Breast-conserving Approach Research Articles

Injectable Nano-in-Gel Vaccine for Spatial and Temporal Control of Vaccine Kinetics and Breast Cancer Postsurgical Therapy.

Breast cancer is the most commonly diagnosed cancer, and surgical resection is the first choice for its treatment. With the development of operation techniques, surgical treatment for breast cancer is evolving toward minimally invasive and breast-conserving approaches. However, breast-conserving surgery is prone to an increased risk of cancer recurrence and is becoming a key challenge that needs to be solved. In this study, we introduce a one-shot injectable nano-in-gel vaccine (NIGel-Vax) for postoperative breast cancer therapy. The NIGel-Vax was constructed by mixing protein antigens with PEI-4BImi-Man adjuvant and then encapsulated in a hydrogel made with oxidized dextran (ODEX) and 4-arm PEG-ONH2. Using 4T1 tumor-extracted proteins as antigen, the NIGel-Vax achieved a 92% tumor suppression rate and a 33% cure rate as a postoperative therapy in the 4T1 tumor model. Using the tumor-associated antigen trophoblast cell-surface antigen 2 (TROP2) protein as the antigen, NIGel-Vax achieved a 96% tumor suppression rate and a 50% cure rate in triple-negative breast cancer (TNBC) models. This design provides an encouraging approach for breast cancer postoperative management.

Can breast cancer be reirradiated?

Salvage mastectomy is still the standard procedure for ipsilateral breast tumor recurrence. A second breast-conserving approach with re-irradiation is considered nowadays feasible in selected patients, with good results in terms of local control and tolerance. In this work we summarize the different radiation techniques and their results in order to define recommendations to help groups starting to consider this approach in their institutions. Although the difficulty due to the low rate of breast cancer recurrences after first breast conserving therapy, further clinical trials are needed to confirm these results.

1331 An Observational Study Investigating the Role of Therapeutic Mammoplasty in Breast Tumours Greater Than 40mm

Abstract Aim For large breast tumours, therapeutic mammoplasty (TM) provides a breast-conserving approach to the conventional mastectomy. The prevalence and outcomes following TM in larger breast tumours is relatively unknown. This study aims to analyse the short-term outcomes and local recurrence rate following TM for breast tumours of varying sizes. Method Single-centre retrospective analysis of data from all patients undergoing a TM between June 2016-October 2019. Variables reviewed included age, imaging, tumour size, pre-operative histology, adjuvant chemotherapy and radiotherapy, post-operative pathology, post-operative complications, and recurrence rates. Results 192 patients undergoing a TM procedure were included, 126 (66%) patients had tumours <40mm and 66 (34%) patients had tumours >40mm. The average age of participants was 61 years with a mean follow-up of 31 months. The mean size of tumours >40mm was 56.8mm, of these patients 15% had positive margins, 2 (3%) patients required a further mastectomy and 8 (12%) underwent margin re-excisions. In lesions >40mm there were six episodes (9%) of T-junction delayed wound healing with two requiring surgical management, two episodes (3%) of wound infections requiring antibiotics and four episodes (6%) of seroma with one requiring surgery for an infected seroma. Two patients were found to have metastatic disease and no patients were found to have local recurrence at the most recent follow-up. Conclusions Our study demonstrated TM offers a surgical option with suitable cosmetic and oncological outcomes for women with early breast tumours above 40mm. These results warrant further study into the long-term outcomes for patients undergoing TM with tumours >40mm.

Oncoplastic surgery: A suitable alternative to conventional breast conserving surgery in low - Middle income countries; a retrospective cohort study

IntroductionBreast Conserving Surgery (BCS) with whole breast radiation is now standard of care as a safer alternative to Mastectomy in terms of loco-regional recurrence and long-term survival. Despite this, a frequent pitfall of conventional BCS is positive surgical margins and need for second surgery with a reported frequency of 12–59 % in literature. Oncoplastic Surgery can be a safer, more cost effective alternate to conventional BCS owing to its higher rate of negative surgical margins (4–6% vs 12–59 %) and better cosmetic results. We aim to prove utility of Oncoplastic surgery for Low-Middle income countries. ObjectiveThe aim of this study was to determine Oncoplastic Surgery as a more appropriate alternative to Conventional Breast Conserving Surgery for Low-Middle Income countries in terms of its lower positive margins and re-excision rates. MethodologyA retrospective comparative single center study by reviewing patient's medical records from August 2016 to June 2020 was conducted. Rate of positive margins and re-excisions along with mean volume of resection specimen, mean tumor size and quadrant dealt by both surgical procedures were compared. ResultsOut of 421 patients 249 patients underwent oncoplastic surgery and were compared with 173 patients who had conventional breast conserving surgery. Positive margins were seen in 5 patients (2 %) in OPS group whereas in 31 (17.9 %) patients in BCS group (p value < 0.001). Therefore, 2 from OPS group and 17 from BCS group underwent re-excision (p value < 0.002).None in OPS group while 7 out of 17 patients in BCS group underwent mastectomy as second procedure. Mean tumor size in OPS group was 2.26 cm ± SD 1.66 and in BCS group was 1.94 cm ± SD 1.28. Majority of Lobular carcinoma and Ductal carcinoma in-situ, multifocal, upper inner and central quadrant tumors and those unresponsive to neo-adjuvant therapy were treated by Oncoplastic techniques. ConclusionOncoplastic surgery has shown promising results as a safer tool to deal with large, complex tumors, lesions in difficult anatomical locations, multifocal or progressing on neo-adjuvant therapy. With its low Re-excision rates, it is a better alternative to traditional Breast Conserving approach for overburdened and resource limited health care system of Low-Middle Income countries. Multi-center, prospective trials are needed to determine its feasibility.

The Effect of Hospital Volume on Outcomes of Patients with Occult Breast Cancer.

With limited data in regards to management, occult breast cancer (OBC) poses a challenging surgical scenario. Current surgical management includes axillary lymphadenectomy (ALND) with or without mastectomy. We sought to investigate the impact of hospital volume on surgical approach and survival outcomes of patients with OBC. Patients with cT0N+ breast cancer were selected from the National Cancer Data Base (NCDB, 2004-2014). Primary outcome was overall survival (OS), calculated using Kaplan-Meier methods compared according to hospital volume: community cancer center (CC), comprehensive community cancer center (COMP), and academic center (AC). Secondary outcome was the rate of modified radical mastectomy (MRM). We identified 574 patients with OBC, 11.1% were treated at a CC, 51.8% at a COMP, and 37.0% at an AC. Patients treated at CC had lower socioeconomic status compared with COMP or AC (23.1%, 14.1%, 19.3%; p = 0.005, respectively). There was no difference in access to radiation therapy (p = 0.888) or neoadjuvant chemotherapy (p = 0.221). Patients treated at CC had worse OS compared with COMP or AC (87.04, 105.29, 108.06 mo, p = 0.026, respectively). There was an increased rate of MRM at CC compared with COMP or AC (54.7%, 41.2%, 30.5%, p = 0.003, respectively). A direct association seems to exist between hospital volume and outcomes of patients with OBC. Patients with OBC treated at AC were more likely to undergo breast-conserving approaches and had better survival than those treated at CC.

Risk Factors for Local Relapse and Inferior Disease-free Survival After Breast-conserving Management of Breast Cancer: Recursive Partitioning Analysis of 2161 Patients

BackgroundThe purpose of this study was to analyze risk factors for ipsilateral in-breast relapse and inferior disease-free survival (DFS) after standard adjuvant whole-breast radiotherapy (± boost and systemic treatment) as part of a multimodal breast-conserving approach. Patients and MethodsDecision trees were built through recursive partitioning analysis (RPA). The median follow-up for all 2161 patients was 114 months (9.5 years). ResultsLocal relapse in the treated breast was uncommon (actuarial rates after 5 and 10 years were 2.7% and 5.8%, respectively). In RPA, the first split was related to age (52 years), with younger patients having a significantly higher risk of local relapse. The younger patients were stratified further by lymph node ratio (LNR). In patients older than 52 years, lack of endocrine treatment was associated with significantly higher risk. DFS was 80.7% at 10 years. The first split was caused by LNR, and the group with unfavorable LNR (> 0.20) could not be stratified further. Ten-year DFS in this group was as low as 50.6%. Patients with favorable LNR (0-0.20) could be stratified by additional risk factors, in particular primary tumor size. ConclusionRPA is a suitable method to assign patients with early stage breast cancer to different risk groups, both regarding local relapse and DFS. Although age was a major risk factor for local relapse after breast-conserving management, LNR was associated with both endpoints. The systemic treatment approaches used in this study failed to provide satisfactory DFS in patients with LNR > 0.20 and 2 other subgroups.

Prognostic Factors, Treatment, and Outcomes in Early Stage, Invasive Papillary Breast Cancer: A SEER Investigation of Less Aggressive Treatment in a Favorable Histology.

Invasive papillary breast cancer (IPBCA) represents 0.5% of invasive BCA, and is thought to carry a favorable prognosis. This population-based study reports on prognostic factors, treatment, and outcomes of early-stage IPBCA to explore whether there is any evidence to support less aggressive treatment. IPBCA cases from 1990 to 2009 of the recent Surveillance, Epidemiology, and End Results were analyzed. Inclusion criteria included patients with stage T1-2, N0 IPBCA. Univariate and multivariate analyses were performed using the variables of treatment, stage, race, hormone receptor status, grade (G1-3), and age. Treatment modalities included lumpectomy alone (LA), lumpectomy with radiation treatment (LRT), and mastectomy alone (MA). Among 10,485 patients, median follow-up was 56 months. Five and 10-year overall survival (OS) were 93.1% and 76.8%, respectively. Patients treated with LRT had superior mean OS 16.8 versus 14.9 years for MA (P=0.0004) and 14.2 years for LA (P=0.0003). Improved OS also correlated with lower histologic grade (P<0.0001), lower T-stage (P<0.0001), and younger age (P<0.0001). Black patients had the worst OS (12.7 y, P<0.0001). LRT is associated with superior OS for early-stage invasive papillary BCA patients, when compared with LA or MA in this population-based study. The findings support the standard of care breast conservation approach for patients with invasive papillary BCA. Other prognostic factors associated with worse OS include increased age, higher T-stage, higher histologic grade, and black race.

212. Difficult mastectomies subsequent to unsuccessful breast conserving operations of peripheral cancers: When oncoplastic approach meets the history of surgery

Background: Oncoplastic techniques allow adequate local control with excellent cosmetic outcomes in more and more breast cancer patients. When breast conservation approach is unsuccessful, subsequent mastectomy is performed, usually with ease. However, in peripheral cancers choosing mastectomy incision to remove tumour bed all together with scars produced by prior oncoplasty can be a surgical challenge. The aim of the study was to investigate what incisions had been used in those difficult cases.

Should triple-negative breast cancer (TNBC) subtype affect local-regional therapy decision making?

The more aggressive biologic characteristics and the current lack of targeted therapy for triple-negative breast cancer (TNBC) make local-regional management decisions challenging for physicians. TNBC is associated with patients of younger age, black race and BRCA1 mutation carriers. Distinctions between BRCA1-associated and sporadic TNBC include increased lifetime risk of ipsilateral and contralateral breast cancer after breast cancer therapy (BCT) for BRCA carriers, which is not shared by sporadic TNBC. However, the presence of a BRCA mutation should not preclude a breast-conservation approach in patients who are otherwise appropriate candidates for BCT. Data suggest that local-regional relapse (LRR) at baseline after BCT appears to be comparable for TNBC and the HER2-positive subgroups, but is about 50% greater than luminal tumors. LRR appears to be similarly increased after mastectomy; thus, TNBC should not be a contra-indication for BCT. Recent hypothesis-generating data suggest less LRR after BCT (where radiation is routinely delivered) than with mastectomy for early-stage TNBC. To date, no specific local-regional guideline recommendations for TNBC exist. Level I outcome data for TNBC using accelerated partial breast irradiation (APBI) and hypofractionated whole-breast irradiation (hWBRT) are lacking. TNBC should be treated with APBI only on clinical trials. Although hWBRT may be considered in TNBC, its association with younger age, advanced disease and use of systemic chemotherapy often precludes its use for this subtype. Until definitive treatment strategies are validated in large datasets and confirmed in randomized trials, TNBC subtype, in and of itself, should not direct local-regional management treatment decisions.

Methods for the Aesthetic Evaluation of Breast Cancer Conservation Treatment: A Technological Review

Breast-conserving approaches aim to attain better aesthetic results in addition to local control and achieving survival rates equivalent to mastectomy in patients with breast cancer. While the oncologic outcome of breast conserva- tion procedures is easily estimated objectively by disease-free and overall survival rates, the cosmetic outcome has no standard of evaluation. Although breast conservation techniques have been widely studied, different forms of evaluation and heterogeneous working practices have contributed to different aesthetic results. As this scenario suggests, the evalua- tion of aesthetic results should be mandatory in any institution performing breast cancer treatment, contributing to the im- provement of current strategies by enabling the identification of variables which have a significant impact on the final aes- thetic result. In the process of assessing cosmetic outcomes there are several important issues that should be considered: which factors have a crucial impact on the cosmetic outcome of Breast Cancer Conservation Treatment (BCCT); which parameters or features should be evaluated in the cosmetic assessment of BCCT; how patients are evaluated; which scales are used in this evaluation; which methods and technological solutions are available for the evaluation of cosmetic results of BCCT. In this paper we try to discuss all these questions, with an emphasis on the objective methods and corresponding tech- nologies used in the aesthetic evaluation of BCCT. The most relevant publications related to the mentioned topics are pre- sented, critically analysed and put in chronological perspective. Current and future trends are also discussed.

Surgical Margins in Breast Conservation

Significant progress has been made in the diagnosis and treatment of breast cancer during the past 30 years. The increased availability of screening mammography has resulted in a higher percentage of woman being diagnosed with early stage disease allowing the option of breast conservation therapy to be more widely available. Long-term follow-up studies clearly demonstrate equivalent survival with breast conservation surgery (lumpectomy) and radiotherapy versus total mastectomy [1–3]. The importance of obtaining clear lumpectomy surgical margins has been well established in minimizing the risk of local recurrence [4]. Unfortunately there is a lack of uniform guidelines in terms of what constitutes an adequately clear lumpectomy margin. Substantial debate about bigger margins being better continues [5]. This has led to wide variations in lumpectomy margin reexcision rates from 15 to 47% [6]. These additional surgical procedures cause significant patient distress, utilize health care resources, and can adversely affect cosmesis. From the patient perspective, they may wonder why we did not get it right the first time. They want their cancer gone while maintaining a normal appearance. This special issue highlights the areas of controversy and demonstrates current best practices and emerging novel approaches towards optimal breast conservation approach. The goal is to improve our ability to provide breast-conserving approaches for breast cancer while avoiding multiple surgical procedures, minimizing recurrence risk while obtaining excellent cosmesis. We have chosen 6 of 16 submissions to be published in this special issue. Each paper was evaluated by at least two expert reviewers and revised according to review comments. P. Ananthakrishnan et al. provide an excellent comprehensive review article on all aspects involved in optimizing breast conservation. They include discussion of preoperative breast imaging, lesion localization, impact of tumor biology and systemic therapy, intraoperative lesion identification and margin assessment techniques, the role of margin ablation and oncoplastic techniques. They also discuss the promise of ductal anatomy mapping toward the goal of validating the “Sick lobe hypothesis” [7, 8] which may allow for more accurate identification of breast tissue to be targeted for excision. R. Emmadi and E. L. Wiley provide an excellent review from the pathology perspective of the different approaches to margin assessment. They explore issues of specimen processing, fixation, cutting techniques, and reporting. They well explain the reasons for the reporting variations between institutions and the need for standardization. J. L. Baker et al. present a scholarly review of our current understanding of the issue of atypical ductal hyperplasia (ADH) as it relates to surgical margins. They highlight the large interobserver variability among pathologists in differentiating ADH from low-grade ductal carcinoma in situ (DCIS). The issue of whether ADH is a precursor lesion to DCIS is explored. R. J. Rivera et al. report on a 21-site multicenter clinical trial evaluating the performance of the MarginProbe intraoperative device. This device is based on radiofrequency spectroscopy to assess adequacy of lumpectomy margins. They analyzed volume or resection and reexcision rates in the device group versus usual surgical standard of care (SOC). They demonstrate the reexcision rate of 14.1% in the device group versus 29.9% with SOC. Increased resection volume was 2.6% using the device. M. M. Chang et al. provide a comprehensive overview of oncoplastic breast reduction. This is a complete review of the techniques including indication, patient selection, practical pointers, and their experience including a low (3.3%) rate of margin failure. They stress the importance of a coordinated team approach between breast surgical oncology, plastic surgery, breast imaging, and radiation oncology. Lastly, G. H. T. Au et al. present an exciting research paper on margin assessment using a Quantum-Dot Molecular probe in a mouse model. This employs nanoparticle monoclonal antibodies with molecular imaging. Their concept has a potential advantage over optical imaging and radiofrequency spectroscopy in that it is not affected by tissue heterogeneity. It also can display and differentiate very small (100–200 cells) spots. Timeline of 30 minutes is practical for intraoperative use. This early work is an highly innovative approach to a practical issue. These papers present a great deal of important information and well explore the current state of the art, controversies and future directions towards the important goal of optimizing breast conservation with particular attention to margin issues.

Refining the Use of Endocrine Therapy for Ductal Carcinoma in Situ

Refining the Use of Endocrine Therapy for Ductal Carcinoma in Situ

Breast conservation surgery: state of the art.

Breast conservation surgery is available to the vast majority of women with breast cancer. The combination of neoadjuvant therapies and oncoplastic surgical techniques allows even large tumours to be managed with a breast-conserving approach. The relationship between breast size and the volume of tissue to be excised determines the need for volume displacement or replacement. Such an approach can also be used in the management of carefully selected cases of multifocal or multicentric breast cancer. The role of novel techniques, such as endoscopic breast surgery and radiofrequency ablation, is yet to be precisely defined.

Prognostic factors for local recurrence following breast-conserving treatment in young women

Breast cancer is a rare disease in young women. Its incidence has remained remarkably constant over the last decades, contrary to what has happened in older patients. Age is a major prognostic factor for local control after breast-conserving treatments, which does not seem to be entirely explained by the poor prognostic features that are more commonly associated with breast cancers in young women. A better knowledge of the prognostic factors for local control, and, whenever possible, those pertaining specifically to the young age group, is key, not only to better select the patients who would benefit the most from a breast-conserving approach but also to enhance the local control when this option has been elected. These prognostic factors can be related to the patient, the tumor and the treatment they receive. Finally, we will present a perspective of what the future could hold, both in terms of the selection of the patients and of a more customized therapeutic approach.

Breast conservation in locally advanced breast cancer in developing countries: Wise or waste

Breast conservation as an additional benefit was beyond the initial expectations of the investigators who pioneered neoadjuvant chemotherapy (NACT). In recent years an increasing number of patients with locally advanced breast cancer (LABC) are being treated with NACT, followed by breast conservation surgery with axillary dissection and radiation as a part of the multimodality management. Breast conservation has not been the standard of care for women with LABC, owing to concerns of increased chances of local recurrence, and possible survival disadvantage and psychological trauma from experiencing a recurrence of malignancy. LABC is still a common form of presentation of breast cancer in developing countries. Strict adherence to treatment protocols and regular follow-ups for years may not be practical for a large majority of patients hailing from the regions most affected by LABC. Defaulters often thus have a heavy price to pay. Hence lies the importance of carefully selecting LABC patients for a breast conservation approach from others that would have a higher risk of locoregional recurrence. Can we extrapolate the lessons learnt in early breast cancer to LABC and offer selected patients with LABC breast conservation therapy? Would the local control and survival results with conservative therapy be comparable to those obtained using mastectomy, or does the increased tumor burden in LABC necessitate ablative surgery in all women? This review aims to address these important questions.

Axillary Surgery in DCIS: Is Less More?

As our understanding of the biology of ductal carcinoma in situ (DCIS) has increased, the management approach to the axilla has evolved. DCIS, by definition, cannot metastasize, and it has been known for many years that nodal metastases, presumed to be due to unrecognized invasion, are extremely uncommon. In a National Cancer Database review of 10,946 patients with DCIS undergoing axillary dissection between 1985 and 1991, only 3.6% were found to have axillary metastases, and this number is even lower when only cases of screen-detected DCIS are considered. The major impetus for nodal staging in DCIS today is the recognized sampling error that occurs when needle biopsy techniques are used for diagnosis. In 1998, a joint committee of the American College of Surgeons, American College of Radiologists, and College of American Pathologists developed a standard for the diagnosis and management of DCIS which concluded that axillary dissection was unnecessary for the majority of patients with DCIS. Consideration of a level I dissection to avoid a second surgical procedure for patients undergoing mastectomy for extensive or high-grade DCIS was recommended. When these guidelines were updated in 1992, they reflected both the emergence of sentinel node biopsy as an axillary staging technique and the low likelihood of identifying invasive carcinoma with nodal disease in localized DCIS by recommending that axillary staging in patients treated with breastconserving approaches be reserved for those found to have invasion on final pathologic evaluation. In patients undergoing mastectomy, sentinel node biopsy for axillary staging was recommended for surgeons experienced in the technique; for those who were not, a level I axillary dissection was suggested. In this issue of the Annals of Surgical Oncology, Porembka et al. use Surveillance, Epidemiology, and End Results (SEER) data from 1988 through 2002 to analyze axillary management in patients with DCIS. Based on their analysis of 23,502 patients, they conclude that there is persistent and excessive utilization of axillary nodal assessment, particularly axillary dissection, in patients with DCIS. The data as presented is alarming, with 21% of those having surgery between 1998 and 2002 undergoing lymph node assessment. In the group that had breast-conserving surgery (BCS), 67% of the nodal procedures were axillary dissections; in the mastectomy group, 87% had axillary dissection. There are several important caveats to these observations. First, the SEER database, while an excellent source of high-quality, population-based cancer data, may not be an ideal source for analyzing the nuances of axillary surgery. SEER coding rules state that, if axillary nodes are present in a mastectomy specimen, the procedure should be coded as a modified radical mastectomy rather than a simple mastectomy. The removal of a few level 1 axillary nodes in order to ensure removal of the axillary tail of the breast is not uncommon, and certainly does not constitute a therapeutic axillary dissection, although it would be coded as such by SEER rules. Thus, the most accurate assessment of the use of axillary dissection is obtained from the subset of women undergoing BCS. Based on the authors’ statement that 70% of the 10,637 women treated in the 1998–2002 timeperiod hadBCS, and that 589 had axillary staging, this results in about 395 axillary dissections, or 5% of the total group. The second major issue regarding this work is that the time period under study was the same time period in which the sentinel node biopsy technique was being validated, refined, and disseminated. Two major Published online August 5, 2008. Address correspondence and reprint requests to: Monica Morrow, MD; E-mail: morrowm@mskcc.org

Paget’s Disease of the Breast: There Is a Role for Breast-Conserving Therapy

The optimal surgical management of Paget's disease of the breast remains to be defined. Mastectomy has been the standard of care, but several institutions have recently advocated breast-conserving surgery, particularly for patients with minimal disease. In an effort to develop rational treatment guidelines, we examined our institutional experience with Paget's disease of the breast. Patients with Paget's disease of the breast who had surgical therapy at our institution between 1949 and 1993 were reviewed. In addition to patient and tumor characteristics, charts were reviewed for treatment modalities, locoregional recurrence patterns, and survival. Subgroups were compared for differences in survival in both univariate and multivariate analyses. A total of 104 patients met the study criteria. The most common presenting symptoms were nipple discharge and eczematous changes of the nipple/areola complex. Ninety-seven patients (93.2%) had an underlying invasive or noninvasive cancer associated with Paget's disease. Ninety-two patients (88.5%) underwent mastectomy, and 12 (11.5%) had a breast-conserving procedure. On univariate analysis, patients with age <60 years at diagnosis, stage II disease, positive lymph nodes, invasive disease, or a palpable mass had significantly lower 10-year disease-specific and recurrence-free survival. There were four locoregional recurrences (three after mastectomy and one after breast conservation). There were no significant differences in overall, disease-specific, or recurrence-free survival according to the type of surgery. Paget's disease of the breast is almost always associated with an underlying breast cancer. Breast-conserving approaches result in local control and survival rates similar to those achieved with mastectomy.

Impact of core biopsy on the management of screen-detected ductal carcinoma in situ of the breast.

Screen-detected ductal carcinoma in situ (DCIS) usually presents as clinically impalpable microcalcification. Although core biopsy is well established as a diagnostic modality for invasive breast cancers, few reports address its impact on the management of screen-detected DCIS. We examined the sensitivity of core biopsy in diagnosing screen-detected DCIS, as well as its role in facilitating one-step surgery in the community, especially a breast-conserving approach. Through the Monash BreastScreen database, we reviewed the management of 148 patients diagnosed with pure DCIS over a 4-year period. Particular attention was paid to the sensitivity and surgical margin status of 63 patients who underwent initial assessment with core biopsy, compared to patients who underwent excisional biopsy or fine needle aspiration cytology (FNAC). Core specimens in 63 patients yielded positive histology in 57 (90%), allowing for breast-conserving surgery in 45 and mastectomy in 12. Negative margins were obtained in 73% of those treated by breast-conserving surgery, compared to 51% negative margins among those who underwent excisional biopsy initially. Overall, 45 of 57 patients with a positive core biopsy histology (79%) underwent one-step surgery. Those assessed by FNAC had a 48% incidence of non-diagnostic/benign cytology. Core biopsy facilitates one-step surgery for screen-detected DCIS, and potentially reduces the number of surgical procedures. Stereotactic core biopsy for suspicious microcalcifications should replace hookwire-guided excisional biopsy and FNAC as the diagnostic modality of choice.

Treatment of Breast Cancer in Countries with Limited Resources

Early and accurate diagnosis of breast cancer is important for optimizing treatment. Local treatment of early stage breast cancer involves either mastectomy or breast-conserving surgery followed by whole-breast irradiation. The pathologic and biologic properties of a woman's breast cancer may be used to estimate her probability for recurrence of and death from breast cancer, as well as the magnitude of benefit she is likely to receive from adjuvant endocrine therapy or cytotoxic chemotherapy. Ovarian ablation or suppression with or without tamoxifen is an effective endocrine therapy in the adjuvant treatment of breast cancer in premenopausal women with estrogen receptor (ER)-positive or ER-unknown breast cancer. In postmenopausal women with ER- and/or progesterone receptor (PR)-positive or PR-unknown breast cancer, the use of tamoxifen or anastrozole is effective adjuvant endocrine therapy. The benefit of tamoxifen is additive to that of chemotherapy. Cytotoxic chemotherapy also improves recurrence rates and survival, with the magnitude of benefit decreasing with increasing age. Substantial support systems are required to optimally and safely use breast-conserving approaches to local therapy or cytotoxic chemotherapy as systemic therapy. Locally advanced breast cancer (LABC) accounts for at least half of all breast cancers in countries with limited resources and has a poor prognosis. Initial treatment of LABC with anthracycline-based chemotherapy is standard and effective. Addition of a sequential, neoadjuvant taxane thereafter increases the rate of pathologic complete responses. Neoadjuvant endocrine therapy may benefit postmenopausal women with hormone receptor-positive LABC. After an initial response to neoadjuvant chemotherapy, the use of local-regional surgery is appropriate. Most women will require a radical or modified radical mastectomy. In those women in whom mastectomy is not possible after neoadjuvant chemotherapy, the use of whole-breast and regional lymph node irradiation alone is appropriate. In those women who cannot receive neoadjuvant chemotherapy because of resource constraints, mastectomy with node dissection, when feasible, may still be considered in an attempt to achieve local-regional control. After local-regional therapy, most women should receive additional systemic chemotherapy. Women with LABC that has a positive or unknown hormone receptor status benefit from endocrine therapy with tamoxifen. The treatment of LABC requires multiple disciplines and is resource intensive. Efforts to reduce the number of breast cancers diagnosed at an advanced stage thus have the potential to improve rates of survival while decreasing the use of limited resources.

The diagnosis and management of ductal carcinoma in-situ of the breast.

The widespread utilization of screening mammography has produced a shift in the stage of breast cancer at diagnosis in the US: Currently, 12% to 15% of newly diagnosed breast cancer cases annually are ductal carcinoma in-situ (DCIS). The diagnosis is made, in at least 90% of patients, with mammography. Only about 10% of patients will have a palpable mass. The accurate characterization and visualization of calcifications typically requires magnification of mammographic imaging. The morphology of the calcifications is generally considered to be the most important factor in differentiating benign from malignant formations. Round and uniform shapes are more likely to be benign, while linear and heterogeneous morphologies are associated with DCIS. Following a complete mammographic work-up, most suspicious lesions are potential candidates for a stereotactic core needle biopsy. Ten percent to 50% of patients initially diagnosed with atypical ductal hyperplasia by needle biopsy have subsequently been surgically diagnosed with cancer near the biopsy site. Due to this relatively high incidence of co-existent carcinoma, a needle biopsy diagnosis of atypical ductal hyperplasia necessitates subsequent surgical excision. The most important change in our thinking about DCIS was from a monolithic view, conceiving of DCIS as a single disease highly likely to invade if left untreated, to the realization that DCIS represents a non-obligate precursor with a variable risk of progression, depending on a combination of factors, such as histology, lesion, size, and margin status. In discussing treatment options, patients should understand that local recurrence following total mastectomy is rare and that this is the procedure of choice for disease that cannot be adequately encompassed with a breast-conserving approach. If the patient and her surgeon are in agreement about proceeding with a breast-conserving approach, there needs to be a clear understanding of the incidence and implications of local recurrence. In all such discussions with newly diagnosed patients, however, it is essential to emphasize the excellent prognosis with this disease, irrespective of the surgical approach.