Resection Of Breast Cancer Research Articles

Fabrication of tumor targeting rare-earth nanocrystals for real-time NIR-IIb fluorescence imaging-guided breast cancer precise surgery

The near-infrared fluorescence imaging has been integrated into the operating room to guide tumor resection, potentially reducing the positive margin rates in breast-conserving surgery (BCS). Relative to the widely used first near-infrared fluorescence imaging, imaging in the second near-infrared (NIR-II) region possesses higher contrast and deeper tissue penetration, particularly in the NIR-IIb window, offering many new opportunities for imaging-guided BCS. Here, we fabricated the c(RGDfC) functionalized erbium-based rare-earth nanoparticles (ErNPs@cRGD) with superior optical property in NIR-IIb region. Owing to deeper tissue penetration and efficient tumor targeting, ErNPs@cRGD-based NIR-IIb fluorescence imaging achieved enhanced signal-to-background ratios in tumor visualization, which was able to guide more complete tumor resection, identify multiple microtumors and distinguish malignant lesions from normal tissues in various mice models. Based on these, this NIR-IIb imaging strategy for surgical navigation can significantly reduce positive margin rates and improve prognosis, laying a foundation for the clinical resection of breast cancer.

Comparison of nine methods of immediate breast reconstruction after resection of localized breast cancer: A cost‐effectiveness Markov decision analysis of prospective studies

Women undergoing immediate breast reconstruction without radiation therapy have reconstruction methods available with uncertain long-term costs associated with complications requiring surgery and revisions. We evaluated cost-effectiveness of nine methods of immediate breast reconstruction for women with localized breast cancer. Markov modeling was performed over 10-years for unilateral/bilateral breast reconstructions from healthcare/societal perspectives. PubMed, Embase, Cochrane, Scopus, and CINAHL were searched to derive data from 13,744 patients in 79 prospective studies. Complications requiring surgery (mastectomy necrosis, total/partial flap necrosis, seroma, hematoma, infection, wound dehiscence, abdominal hernia, implant removal/explantation) and revisions (fat necrosis, capsular contracture, asymmetry, scars/redundant tissue, implant rupture/removal, fat grafting) were evaluated over yearly cycles. Reconstructions included: direct-to-implant (DTI), tissue expander-to-implant (TEI), latissimus dorsi flap-to-implant (LDI), latissimus dorsi (LD), pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, deep inferior epigastric perforator/superficial inferior epigastric artery (DIEP/SIEA), thigh-based, or gluteal based flaps. Outcomes were incremental cost-effectiveness ratios (ICER) and net monetary benefits (NMB). Willingness-to-pay thresholds were $50,000 and $100,000. From a healthcare perspective for unilateral reconstruction, compared to LD, the ICER for DTI was -$42,109.35/quality-adjusted life-years (QALY), LDI was -$25,300.83/QALY, TEI was -$22,036.02/QALY, DIEP/SIEA was $8307.65/QALY, free TRAM was $8677.26/QALY, pedicled TRAM was $13,021.44/QALY, gluteal-based was $17,698.99/QALY, and thigh-based was $23,447.82/QALY. NMB of DIEP/SIEA was $404,523.47, free TRAM was $403,821.40, gluteal-based was $392,478.64, thigh-based was $387,691.70, pedicled TRAM was $376,901.83, LD was $370,646.93, DTI was $339,668.77, LDI was $334,350.30, and TEI was $329,265.84. All nine methods of immediate breast reconstruction were considered cost-effective from healthcare/societal perspectives. LD provided the lowest costs, while DIEP/SIEA provided the greatest effectiveness and NMB.

Pyoderma Gangrenosum after Breast Cancer Resection: A Less-invasive and Early Treatment Using the Skin around Ulcers

Summary:Surgical invasion is a risk factor of pyoderma gangrenosum (PG). A total of 25% of postoperative PG cases were reported to occur after breast surgeries, including bilateral breast reduction and breast reconstruction following cancer resection. Immunosuppressive therapy and less-invasive wound therapy are necessary; however, the complete healing of ulcers takes 5.1 months on average. We herein report a case of skin grafting under a surgical concept of less-invasive and short-term treatment. An 82-year-old woman complained of a high fever and severe pain at her breast wounds after bilateral breast cancer resection. Although we performed emergency debridement surgery to remove the necrotic tissue, suspecting surgical site infection and inflammation, her high fever persisted. She was diagnosed with PG because of the physical findings of characteristic painful, sterile ulcerations, bullae and pustules, and the pathological abundance of neutrophils in the absence of infection and vasculitis. Oral administration of prednisolone 30 mg/day improved the symptoms, and we applied negative-pressure wound therapy (NPWT) from day 16 following debridement surgery. After the gradual reduction of oral steroid intake to 12.5 mg/day, we performed skin grafting surgery. To limit the surgical invasion, we used the surplus skin around the ulcers. Split-thickness mesh skin grafts were fixed by NPWT to avoid the use of tie-over sutures. We achieved short-term treatment of PG with a less-invasive surgical strategy using skin around the ulcers and NPWT.

Abstract P1-02-10: Breast tumor measurement after neoadjuvant chemotherapy using the 8th edition of the American Joint Committee on cancer staging system: Impact on estimates of tumor size and discrepancies with residual cancer burden class

Abstract Background: In the 8th Edition of the American Joint Committee on Cancer Staging System (yAJCC) for breast cancer after neoadjuvant chemotherapy (NAC), tumor size is based on the largest focus of residual tumor, excluding treatment-related fibrosis. The goal of this study was to assess the impact of strict adherence to yAJCC criteria on residual breast tumor size and discrepancies between yAJCC stage and Residual Cancer Burden (RCB) class. Design: Breast cancer resections after NAC from 2016-2020 were identified in the Anatomic Pathology laboratory information system. Stage IV, pT4b, pT4d, pCR, neoadjuvant endocrine therapy alone and no response to NAC were exclusion criteria. Tumor size, ypT category and focality were reassessed using current yAJCC criteria and compared to the original reports. A median of 29 slides per case were reviewed (range, 9-113). Results: A total of 189 cases met inclusion criteria, including 58 (31%) TNBCs, 50 (26%) HER2+ and 81 (43%) hormone receptor-positive/HER2-negative (HR+/HER2-). The reassessed tumor size and ypT category differed from the original report in 113 (60%) and 107 (57%) cases, respectively. In all of these cases the tumor size or ypT category was smaller/lower on review. The 107 cases with lower ypT categories included 41% of TNBCs, 62% of HER2+ and 64% of HR+/HER2- (p=0.02) In the original report, 36 (19%) cases were classified as multifocal versus 131 (69%) after review (p=0.00001). yAJCC staging based on the reassessed ypT categories differed from the original report in 38 (20%) cases (all down-staged). There were 77/189 (41%) cases with yAJCC/RCB Class discrepancies in the original reports versus 95/189 (50%) after slide review (p=0.08). The yAJCC/RCB discrepant cases in the original reports included 47% of TNBCs, 38% of HER2+ and 38% of HR+/HER2- versus 47% of TNBCs, 48% of HER2+ and 54% of HR+/HER2- after review (p=0.62). The higher proportion of discrepancies among HR+/HER2- after review did not reach statistical significance (p=0.06). Conclusions: Strict adherence to 8th Ed. yAJCC criteria for measurement of the residual breast tumor after NAC resulted in smaller tumor size, lower ypT category, lower yAJCC stage and more tumors classified as multifocal. Changes in ypT category occurred more often among HER2+ and HR+/HER2- than TNBC. There was no significant change in the frequency of yAJCC/RCB discrepancies. Citation Format: Dawn Harter, Siobhan M O'Connor, Johann D Hertel, Benjamin C Calhoun. Breast tumor measurement after neoadjuvant chemotherapy using the 8th edition of the American Joint Committee on cancer staging system: Impact on estimates of tumor size and discrepancies with residual cancer burden class [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-02-10.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Postoperative outcomes of cancer surgery in patients with and without kidney failure with dialysis therapy: a matched-pair cohort study.

ABSTRACTBackgroundThe difference in outcomes of cancer surgery between patients with and without kidney failure with dialysis therapy (KFDT) remains uncertain.MethodsUsing 2010–18 data in a national inpatient database in Japan, we identified patients who had undergone resection of colorectal, lung, gastric or breast cancer. We matched selected patient characteristics, type of cancer, surgical procedure and hospital of up to four patients without KFDT to each patient with KFDT. We assessed 30-day mortality and postoperative complications.ResultsThrough matching, we identified 2248 patients with KFDT (807 with colorectal, 579 with lung, 500 with gastric and 362 with breast cancer) and 8210 patients without KFDT (2851 with colorectal, 2216 with lung, 1756 with gastric and 1387 with breast cancer). Postoperative complications occurred in a higher proportion of patients with KFDT than of those without KFDT after colorectal {20.3% versus 14.6%; risk difference (RD): 5.7% [95% confidence interval (95% CI) 2.6%–8.8%]}, lung [18.0% versus 12.9%; RD: 5.1% (95% CI 1.6%–8.4%)], gastric [25.0% versus 13.2%; RD: 11.8% (95% CI 7.6%–16.2%)] and breast cancer surgery [7.5% versus 3.5%; RD: 3.9% (95% CI 1.1%–6.9%)]. Patients with KFDT had a higher 30-day mortality than those without KFDT after gastric cancer surgery [1.6% versus 0.3%; RD: 1.3% (95% CI 0.1%–2.3%)]. Heart failure and ischemic heart disease occurred more frequently in patients with KFDT.ConclusionsPatients with KFDT had higher rates of postoperative complications and 30-day mortality; however, RDs varied between cancer types. The higher rates of postoperative complications in patients with KFDT were mainly attributable to cardiovascular complications.

Indocyanine green guided resection of non-palpable breast cancer

Screening tests and national programs of early detection of breast cancer have been widely implemented worldwide, subsequently increasing the number of cases diagnosed in incipient stages, when the lesion has no clinical expression. In such cases a proper identification of the lesion is mandatory in order to achieve a radical result of the surgical procedure. Therefore, attention was focused on identifying the best imagistic methods regarding the accomplishment of an exact identification of the lesion which could further provide an adequate surgical resection and a proper oncological outcome and, in the meantime to provide the possibility of achieving a good cosmetic result. The aim of this paper is to study the role of indocyanine green as part of the therapeutic armamentarium which provides a correct identification of non-palpable breast lesions.

Frequency of Chromosomal Translocations Are Significantly Higher in Therapy Related Myeloid Neoplasm As Compared to Primary MDS

Background: Myelodysplastic syndromes (MDS) are a heterogeneous group of disorders with variable outcomes. Acquired chromosome abnormalities in patients with myelodysplastic syndromes (MDS) are among the most valuable determinants of prognosis. However, chromosomal translocations are rare in MDS, and their prognostic implication is not well known. To elucidate factors driving chromosomal translocations in MDS, we compared the frequency of MDS patients with and without prior exposure to DNA damaging cytotoxic therapies.Methods: We evaluated diagnostic bone marrow metaphase cytogenetic data of MDS patients enrolled in South Australian MDS/AML registry data. Appropriate Institutional Review Board approval was obtained. Diagnosis and subclassification of MDS were done according to World Health Organization (WHO) 2016 criteria and risk stratified according to the revised International Prognostic Scoring System (R-IPSS) (Greenberg et al., 2012). Standard G-banding method was used for cytogenetic analysis.To decipher changes induced by cytotoxic therapy (CT) from that of myeloid neoplasm in general, we compared cytogenetic profile of three carefully selected cohorts: (i) tMN, in which a myeloid neoplasm occurred in a cancer survivor following exposure to cytotoxic (n = 206, 15.5%); (ii) myeloid neoplasm developing in unrelated cancer survivors with NO prior exposure to CT (a diagnosis of primary MN and another cancer; pMN+Ca) (n =148, 12%). This would include myelodysplastic syndrome or acute myeloid leukemia diagnosed in patients managed with surgical resection of breast cancer and NO exposure to CT; (iii) primary MDS without preceding independent cancer and/or exposure to CT (pMDS) (n = 893,72.5%)Results: The median age of 1247 patients analyzed was 72.50 (IQR 64.9 to 79) and 64% patients were male. Majority of patients were diagnosed with pMDS (n=893; 72.5%), while 206 (15.5%) and 148 (12%) were classified as t-MN and pMN+Ca respectively.Ten percent (114/1247) patients harbored translocations at the time of diagnosis. The most frequent chromosomes involved in translocation are chromosome 1 (37/114, 34.5%), 3 (15/114, 13.8%), 5 (6/114= 5.3%) (Fig.1A). Most common chromosome partners for translocation with chromosome 1 were chromosome 3, 7 and 21.The frequency of chromosomal translocations in patients with monsomal (55/114, 48%) and complex (70/114, 61%) karyotype were higher than patients without. There is a clear relationship in incidence of chromosomal translocations with increasing IPSS-R scores. The frequency of translocations in the Very high risk IPSS-R risk category was significantly higher compared to patients with Very low risk category (27% vs.1.1%).Importantly, frequency of chromosomal translocations was significantly higher in t-MN as compared pMN+Ca and P-MN patients who were not exposed to DNA damaging cytotoxic therapies prior to their diagnosis (17% vs. 4% vs. 8%, P=0.0004; Fig 1B). Notably, the survival of patients with chromosomal translocation was significantly poorer as compared to patients without translocation (Fig.1C). Poor OS of patients with translocation is most probably due to association with complex karyotype (Fig.1D).Conclusion: This comprehensive analysis demonstrates that chromosomal translocations are observed in 10% of MDS patients. Chromosomal translocations are significantly higher in patients who had prior exposure to cytotoxic therapy as compared to patients without. [Display omitted] DisclosuresHiwase: Novartis: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees.

802 Preservation of a Reconstructed Breast Whilst Undertaking Total Sternal Resection for Metastatic Breast Cancer with a Pedicled Latissimus Dorsi Flap and a Methyl Methacrylate Mesh Sandwich

Abstract Background Sternal resection and reconstruction are a complex and challenging procedure that requires a multidisciplinary approach and input from both thoracic and plastic surgeons. Limited data exist on sternal resection and reconstruction for secondary breast malignancies. The goals of sternal and anterior chest wall reconstruction are to maintain chest wall integrity, rigidity, and the negative pressure necessary for respiratory and cardiac functions, protect intrathoracic contents, and restore the chest wall contour. Case Presentation A 40-year-old lady developed a solitary sternal metastatic lesion three years after her initial diagnosis with BRCA2 positive breast cancer. She had previously undergone left mastectomy, axillary clearance and implant reconstruction followed by right prophylactic mastectomy and implant reconstruction. She also had neoadjuvant chemotherapy and adjuvant chest wall radiotherapy. Her solitary sternal metastasis was managed with curative intent by complete sternal resection and a combined alloplastic and autologous sternal reconstruction with methyl methacrylate sandwiched between a polypropylene mesh and covered with a pedicled latissimus dorsi flap. The flap was successfully tunnelled under the previous implant-based breast reconstruction capsule. The surgical margins were clear, there were no post-operative complications and no further disease. The patient achieved good cosmetic outcomes. Conclusions We describe the first case of breast implant preservation whilst undertaking total sternal resection for an isolated sternal metastasise and reconstruction with a pedicle latissimus dorsi flap and methyl methacrylate mesh sandwich. We advocate combined approach with thoracic and plastic surgery, which allows a safe single stage procedure.

Comprehensive Nursing can Relieve the Negative Emotions of Patients undergoing Breast Cancer Resection and Reduce Postoperative

To explore the effect of comprehensive nursing on adverse emotions and postoperative complications of breast cancer patients undergoing mastectomy. Altogether 180 patients who received treatment in our hospital from May 2017 to May 2019 were selected as the research participants and divided into group A and group B. Among them, 100 cases in group A received comprehensive nursing, 80 cases in group B received routine nursing. The surgical indications, upper limb function, serum NGF, TK1 and CA15-3 expression level, VAS score, SAS, SDS score, quality of life SF-36 score were detected, and the incidence rate of postoperative complications and nursing quality score were compared. Compared with group B, group A had less postoperative bed time, intraoperative blood loss, length of hospital stay, better recovery of upper limb function, lower expression levels of serum NGF, TK1 and CA15-3, lower VAS score, SAS and SDS score, higher quality of life SF-36 score, lower incidence of postoperative complications and higher nursing quality score. Comprehensive nursing can relieve the negative emotions of patients undergoing breast cancer resection and reduce the incidence of postoperative complications.

Incremental Spending Associated with Low-Value Treatments in Older Women with Breast Cancer.

In most women ≥ 70 years old with hormone-receptor-positive breast cancer, axillary staging and adjuvant radiotherapy provide no survival advantage over surgery and hormone therapy alone. Despite recommendations for their omission, sentinel lymph node biopsy (SLNB) and adjuvant radiotherapy rates remain high. While treatment side effects are well documented, less is known about the incremental spending associated with SLNB and adjuvant radiotherapy. Using a statewide multipayer claims registry, we examined spending associated with breast cancer treatment in a retrospective cohort of women ≥ 70 years old undergoing surgery. 9074 women ≥70 years old underwent breast cancer resection between 2012 and 2019, with 78% (n = 7122) receiving SLNB and/or adjuvant radiotherapy within 90 days of surgery. Women undergoing SLNB were more likely to receive radiation (51% vs. 28%; p < 0.001 and OR = 2.68). Average 90-day spending varied substantially based upon treatment received, ranging from US$10,367 (breast-conserving surgery alone) to US$27,370 (mastectomy with SLNB and adjuvant radiotherapy). The relative increases in 90-day treatment spending in the breast-conserving surgery cohort was 65% for SLNB, 82% for adjuvant radiotherapy, and 120% for both treatments. SLNB and adjuvant radiotherapy have significant spending implications in older women with breast cancer, even though they are unlikely to improve survival.

Radiomics features on ultrasound imaging for the prediction of disease-free survival in triple negative breast cancer: a multi-institutional study.

To explore the predictive value of radiomics nomogram using pretreatment ultrasound for disease-free survival (DFS) after resection of triple negative breast cancer (TNBC). A total of 486 TNBC patients from 3 different institutions were consecutively recruited for this study. They were categorized into the primary cohort (n = 216), as well as the internal validation cohort (n = 108) and external validation cohort (n = 162). In primary cohort, least absolute shrinkage and selection operator logistic regression algorithm was used to select recurrence-related radiomics features extracted from the breast tumor and peritumor regions, and a radiomics signature was constructed derived from the grayscale ultrasound images. A radiomic nomogram integrating independent clinicopathological variables and radiomic signature was established with uni- and multivariate cox regressions. The predictive nomogram was validated using an internal cohort and an independent external cohort regarding abilities of discrimination, calibration and clinical usefulness. The patients with higher Rad-score had a worse prognostic outcome than those with lower Rad-score in primary cohort and two validation cohorts (All p < 0.05).The radiomics nomogram indicated more effective prognostic performance compared with the clinicopathological model and tumor node metastasis staging system (p < 0.01), with a training C-index of 0.75 (95% confidence interval (CI), 0.71-0.80), an internal validation C-index of 0.73 (95% CI, 0.69-0.78) and an external validation 0.71 (95% CI,0.66-0.76). Moreover, the calibration curves revealed a good consistency for survival prediction of the radiomics model. The ultrasound-based radiomics signature was a promising biomarker for risk stratification for TNBC patients. Furthermore, the proposed radiomics modal integrating the optimal radiomics features and clinical data provided individual relapse risk accurately. The radiomics model integrating radiomic signature and independent clinicopathological variables could improve individual prognostic evaluation and facilitate therapeutic decision-making, which demonstrated the incremental value of the radiomics signature for prognostic prediction in TNBC.

Impact on survival of primary tumor resection in patients with metastatic breast cancer: preliminary results of a retrospective analysis.

Treatment of de-novo metastatic breast cancer is usually centered around systemic therapy, with local therapy (surgery and radiation therapy) largely reserved for palliation in patients with significant symptoms from primary tumor. The efficacy of locoregional treatment like surgery and/or radiotherapy is still controversial and the debate about surgical resection of primary tumor (PT) in de novo metastatic breast cancer (MBC) patients persists. All patients with de-novo MBC undergone surgical treatment between January 2015 and January 2020 at the Multidisciplinary Breast Center of the IRCCS A. Gemelli University Polyclinic Foundation in Rome were included in this study. The primary endpoint was overall survival (OS) after PT resection, the secondary endpoint was progression free survival (PFS). The survival analyses were done using Kaplan-Meier method. Patients and tumor characteristics were analyzed in an exploratory modality in order to identify prognostic factor. Forty-five patients received resection of the primary breast cancer (26 mastectomy and 19 breast conserving surgery). Median age of diagnosis was 53 years old (range 25-75 years old). Median follow-up was 25.67 months. The median OS was not reached with 75% of patients alive over 2 years from PT resection. The median PFS was not reached with 64% of patients alive over 2 years from PT resection. For both PFS and OS only the triple negative (TN) immunophenotype appears to be a prognostically unfavorable factor in multivariate analysis. In view of the low number of disease progression events and deaths, although our results are preliminary, surgical treatment of primary breast cancer in metastatic setting seems to be an option after systemic therapies in luminal and HER2 positive breast cancer. Randomized prospective trials for each immunophenotype are necessary in order to confirm this evidence.

An In Vivo Mouse Model of Total Intravenous Anesthesia during Cancer Resection Surgery.

Anesthesia is a routine component of cancer care that is used for diagnostic and therapeutic procedures. The anesthetic technique has recently been implicated in impacting long-term cancer outcomes, possibly through modulation of adrenergic-inflammatory responses that impact cancer cell behavior and immune cell function. Emerging evidence suggests that propofol-based total intravenous anesthesia (TIVA) may be beneficial for long-term cancer outcomes when compared to inhaled volatile anesthesia. However, the available clinical findings are inconsistent. Preclinical studies that identify the underlying mechanisms involved are critically needed to guide the design of clinical studies that will expedite insight. Most preclinical models of anesthesia have been extrapolated from the use of anesthesia in in vivo research and are not optimally designed to study the impact of anesthesia itself as the primary endpoint. This paper describes a method for delivering propofol-TIVA anesthesia in a mouse model of breast cancer resection that replicates key aspects of clinical delivery in cancer patients. The model can be used to study mechanisms of action of anesthesia on cancer outcomes in diverse cancer types and can be extrapolated to other non-cancer areas of preclinical anesthesia research.

Comprehensive or specialty-specific cancer care in the United States: A story of continuing underperformance.

6577 Background: “Textbook oncologic outcome” (TOO) is a composite measure representing the “ideal” outcome for patients undergoing cancer surgery and is associated with improved survival. Using TOO as the primary outcome, we asked whether hospitals are high-performing across multiple cancer types. Methods: Patients undergoing potentially curative breast, colon, rectal, lung, or pancreatic cancer resection were identified within the National Cancer Database (2010-2016). Organ-specific TOO was defined as: adequate lymph node yield, R0 resection, non-length of stay outlier, no hospital readmission, no 90-day postoperative mortality, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the risk-adjusted TOO rate for each hospital stratified by cancer type. Results: Among 1,094,550 cancer resections (breast = 690,442; colon = 213,918; lung = 121,771; rectum = 40,315; pancreas = 28,104), 434 hospitals performed ≥10 resections for each cancer type. Only 11 hospitals (2.5%) ranked in the top quartile for adjusted TOO rate for all five cancer types. Of the 323 hospitals (74.4%) that ranked in the top quartile for one cancer type, 149 hospitals (46.1%) also ranked in the bottom quartile for another cancer type. There was a weak correlation between hospital rankings across cancer types with the strongest correlations between colon and rectal cancer (R2= 0.148) and lung and pancreatic cancer (R2= 0.098). Conclusions: Most U.S. hospitals do not provide high-quality care across cancer types with respect to TOO. Perhaps this knowledge should be used to guide referral for oncology care.

Factors Associated With Breast Cancer Surgery Delay Within a Coordinated Multihospital Community Health System: When Does Surgical Delay Impact Outcome?

BackgroundMultiple factors influence the time elapsed between diagnosis of breast cancer and surgical extirpation of the primary tumor. The disease-free interval between resection of primary breast cancer and first evidence of recurrence is predictive of mortality. We aimed to determine patient, disease, and treatment factors associated with a delay in time to surgery (TTS) and identify the point when prolonged TTS negatively impacts disease-free survival. Patients and MethodsCancer registry and electronic medical record data for patients with breast cancer who underwent surgery as first course of treatment during 2006–2016 were retrospectively reviewed. Patients undergoing surgery in ≤30 vs. 31–60 vs. >60 days of initial diagnosis were compared. Kaplan–Meier survival analyses with Cox proportional hazards were performed to evaluate impact of time from breast cancer diagnosis to definitive therapeutic surgery on breast cancer recurrence or death (all-cause). ResultsOverall, 4462 patients were analyzed, 43.4% of whom underwent surgery beyond 30 days. The following factors were associated with TTS >30 days: age <50, non-Hispanic White race/ethnicity, commercial or health exchange/Medicaid insurance, diagnosis of noninvasive disease (i.e., ductal carcinoma in situ), had breast magnetic resonance imaging before definitive surgery, underwent total mastectomy (especially if immediate reconstruction, particularly if autologous, was performed), and did not receive adjuvant therapies (P < .001 for all). After adjusting for relevant variables, significant predictors of recurrence/death included a TTS >60 days, increased patient age, higher breast cancer stage, and triple-negative biomarker expression. ConclusionRisk of recurrence or death is not compromised until TTS exceeds 60 days after initial breast cancer diagnosis.

Differentiation of breast tissue types for surgical margin assessment using machine learning and polarization-sensitive optical coherence tomography.

We report an automated differentiation model for classifying malignant tumor, fibro-adipose, and stroma in human breast tissues based on polarization-sensitive optical coherence tomography (PS-OCT). A total of 720 PS-OCT images from 72 sites of 41 patients with H&E histology-confirmed diagnoses as the gold standard were employed in this study. The differentiation model is trained by the features extracted from both one standard OCT-based metric (i.e., intensity) and four PS-OCT-based metrics (i.e., phase difference between two channels (PD), phase retardation (PR), local phase retardation (LPR), and degree of polarization uniformity (DOPU)). Further optimized by forward searching and validated by leave-one-site-out-cross-validation (LOSOCV) method, the best feature subset was acquired with the highest overall accuracy of 93.5% for the model. Furthermore, to show the superiority of our differentiation model based on PS-OCT images over standard OCT images, the best model trained by intensity-only features (usually obtained by standard OCT systems) was also obtained with an overall accuracy of 82.9%, demonstrating the significance of the polarization information in breast tissue differentiation. The high performance of our differentiation model suggests the potential of using PS-OCT for intraoperative human breast tissue differentiation during the surgical resection of breast cancer.

Clinically relevant dual probe difference specimen imaging (DDSI) protocol for freshly resected breast cancer specimen staining

BackgroundRe-excision rates following breast conserving surgery (BCS) remain as high as ~ 35%, with positive margins detected during follow-up histopathology. Additional breast cancer resection surgery is not only taxing on the patient and health care system, but also delays adjuvant therapies, increasing morbidity and reducing the likelihood of a positive outcome. The ability to precisely resect and visualize tumor margins in real time within the surgical theater would greatly benefit patients, surgeons and the health care system. Current tumor margin assessment technologies utilized during BCS involve relatively lengthy and labor-intensive protocols, which impede the surgical work flow.MethodsIn previous work, we have developed and validated a fluorescence imaging method termed dual probe difference specimen imaging (DDSI) to accurately detect benign and malignant tissue with direct correlation to the targeted biomarker expression levels intraoperatively. The DDSI method is currently on par with touch prep cytology in execution time (~ 15-min). In this study, the main goal was to shorten the DDSI protocol by decreasing tissue blocking and washing times to optimize the DDSI protocol to < 10-min whilst maintaining robust benign and malignant tissue differentiation.ResultsWe evaluated the utility of the shortened DDSI staining methodology using xenografts grown from cell lines with varied epidermal growth factor receptor (EGFR) expression levels, comparing accuracy through receiver operator characteristic (ROC) curve analyses across varied tissue blocking and washing times. An optimized 8-min DDSI methodology was developed for future clinical translation.ConclusionsSuccessful completion of this work resulted in substantial shortening of the DDSI methodology for use in the operating room, that provided robust, highly receptor specific, sensitive diagnostic capabilities between benign and malignant tissues.

English

The incidence of breast cancer has increased significantly over recent years.1 Surgery is the gold standard treatment for most cases, and general anaesthesia (GA) is the preferred anaesthetic technique. However, regional anaesthesia may be an alternative to GA in multimodal regimens in high-risk patients to avoid GA-related cardiovascular or pulmonary side effects.2 The use of neuraxial techniques [thoracic epidural or thoracic paravertebral block (TPVB)] or an intercostal nerve block can therefore be suggested.3 However, novel approaches that are easier, safer, and more effective have been proposed to overcome possible complications and difficulties of these techniques. One approach, the pectoral nerve (Pecs) II block, is a fascial plane block that has shown promising results in anterolateral chest wall 2 analgesia.3,4 The aim of this technique is to block the pectoral nerves, intercostobrachial, intercostals3- 6 and the long thoracic nerve.4 The Pecs block II has been used successfully as part of the multimodal regimen for postoperative analgesia, but not yet as a primary anaesthetic technique in breast surgery.3 Here, we describe breast cancer resection with ultrasound (US)-guided Pecs block II and sedation in two high-risk elderly patients. Both patients provided written consent for publication of the case reports and related images. Here, we present two breast cancer resection cases with multiple comorbidities who underwent ultrasound-guided Pecs II blocks under sedation. Additional analgesic and / or local anaesthetic infiltration was required for parasternal region pain (simple mastectomy, Case 1) and axillary region pain (sentinel node biopsy, Case 2). However, Pecs II blocks may not block the anterior cutaneous intercostal nerve branches or the intercostobrachial nerve in operations involving the medial part of the breast or extending to the axilla.

Human Serum Albumin Decorated Indocyanine Green Improves Fluorescence-Guided Resection of Residual Lesions of Breast Cancer in Mice.

ObjectiveAchieving negative resection margin is critical but challenging in breast-conserving surgery. Fluorescence-guided surgery allows the surgeon to visualize the tumor bed in real-time and to facilitate complete resection. We envisioned that intraoperative real-time fluorescence imaging with a human serum albumin decorated indocyanine green probe could enable complete surgical removal of breast cancer in a mouse model.MethodsWe prepared the probe by conjugating indocyanine green (ICG) with human serum albumin (HSA). In vitro uptake of the HSA-ICG probe was compared between human breast cancer cell line MDA-MB-231 and normal breast epithelial cell line MCF 10A. In vivo probe selectivity for tumors was examined in nude mice bearing MDA-MB-231-luc xenografts and the FVB/N-Tg (MMTV-PyMT) 634Mul/J mice model with spontaneous breast cancer. A positive-margin resection mice model bearing MDA-MB-231-luc xenograft was established and the performance of the probe in assisting surgical resection of residual lesions was examined.ResultsA significantly stronger fluorescence intensity was detected in MDA-MB-231 cells than MCF 10A cells incubated with HSA-ICG. In vivo fluorescence imaging showed that HSA-ICG had an obvious accumulation at tumor site at 24 h with tumor-to-normal tissue ratio of 8.19 ± 1.30. The same was true in the transgenic mice model. The fluorescence intensity of cancer tissues was higher than that of non-cancer tissues (58.53 ± 18.15 vs 32.88 ± 11.34). During the surgical scenarios, the residual tumors on the surgical bed were invisible with the naked eye, but were detected and resected with negative margin under HSA-ICG guidance in all the mice (8/8). Recurrence rate among mice that underwent resection with HSA-ICG (0/8) was significantly lower than the rates among mice with ICG (4/8), as well as the control group under white light (7/7).ConclusionsThis study suggests that real-time in vivo visualization of breast cancer with an HSA-ICG fluorescent probe facilitates complete surgical resection of breast cancer in a mouse xenograft model.