Breast Conservation In Patients Research Articles

The incidence of postoperative radiotherapy-induced acute dermatitis in breast cancer and its influencing factors for Chinese women.

PurposeTo investigate the incidence of skin acute reaction and its influencing factors in postoperative breast cancer radiotherapy patients.MethodsOne hundred and seventy three cases of breast cancer patients treated with postoperative radiotherapy were consecutively enrolled from June 1, 2016 to July 31, 2017 in our breast cancer center. Irradiation technology includes conformal intensity-modulated radiotherapy and a conventional two-dimensional one with conventional fraction. Any acute radiation dermatitis was recorded and the influencing factors were analyzed at the end of the radiation treatment.ResultsRadiotherapy-induced acute dermatitis in patients with breast-conserving surgery was relatively mild. Among the 173 patients, 33 cases had no obvious changes in the skin (grade 0); 121 cases had grade 1 skin reactions, manifested as local dark erythema and dry peeling; 29 cases had grade 2 skin reactions, characterized by edema, hyperemia, or erosion part; no grade 3 cases of skin reactions were observed. The incidence of grade 0, grade 1, and grade 2 reactions in all patients was 19.1%, 69.9%, and 11.0%, respectively. The severity of skin acute reaction is independent of the tumor sites, molecular subtypes, patients’ age, and irradiation modalities, but it depends on the surgical types, fields treated, and planned total radiation. There is a trend favoring no chemotherapy over chemotherapy, though p-value is 0.074.ConclusionSkin acute reaction in postoperative radiotherapy breast cancer patients is generally common but mild, and there are quite a few patients who need interruption or cessation of the radiotherapy process. The patients need to be well informed and made aware that any skin reaction will likely be mild, especially for the breast-conserving patients.

Abstract P2-12-16: The use of oncoplastic surgical techniques to increase successful breast conservation in invasive lobular carcinoma of the breast

Abstract Background: Invasive lobular carcinoma (ILC) of the breast differs from invasive ductal carcinoma in its non-cohesive growth pattern. These diffuse tumors pose challenges for accurate size assessment as well as surgical resection. Patients with ILC have higher rates of positive margins and lower rates of successful breast conservation surgery. Oncoplastic surgical techniques such as oncoplastic reduction mammoplasty and lumpectomy with oncoplastic closure can allow for removal of larger areas of breast tissue than lumpectomy alone. Whether or not these techniques improve the success of breast conservation in patients with ILC is unknown. Methods: We queried a prospectively maintained surgical database and identified 384 women treated for ILC at UCSF between 1992 and April 2017. We reviewed pathology and operative reports, and clinical outcomes data, and identified 199 women who had an initial attempt at breast conservation. Data were analyzed in Stata 14.2. Results: Average age was 61 years (range 39-84), and 69% of patients underwent lumpectomy, 16% had lumpectomy with oncoplastic closure, and 15% had oncoplastic reduction mammoplasty. The majority of tumors were hormone receptor positive, Her2 negative, grade 2, T1 or T2, and 28% were node positive. A total of 156 women (78%) had successful breast conservation; of these, 34% had one re-excision, and 1 patient had two re-excisions. Positive margins were seen in 40% of patients overall, and were significantly lower in the lumpectomy with oncoplastic closure group and those who had shave margins taken. Among the patients who underwent lumpectomy only, obtaining shave margins was significantly associated with final negative margins (71% versus 53%, p = 0.033). Patients with oncoplastic reduction mammoplasty had significantly larger average tumor size (4.1 cm), and significantly more tissue removed (167 cm3). LumpectomyLumpectomy with oncoplastic closureOncoplastic reduction mammoplastyP valueTumor size (mean)2.4 cm2.1 cm4.1 cm<0.001Volume tissue excised65 cm383 cm3167 cm3<0.001Positive margins42%19%50%0.022Shave margins50%69%79%0.005Successful breast conservation75%97%77%0.021Re-excision rate among those with successful breast conservation33%26%39%0.571 Conclusions: Tailoring the surgical treatment to tumor size can increase the rate of successful breast conservation surgery for these diffuse, often non-palpable lobular cancers. For the women with the largest tumors, oncoplastic reduction mammoplasty was often recommended. This group likely represents women who were borderline candidates for breast conservation; despite this, oncoplastic reduction mammoplasty allowed 77% to ultimately have successful breast conservation. For the women with smaller tumors, removing additional tissue with shave margins and using oncoplastic techniques for closure when necessary clearly reduced positive margin rates. Surgeons should routinely obtain shave margins when performing partial mastectomy for women with ILC. Citation Format: Wong JM, Piper ML, Ewing C, Alvarado M, Esserman LJ, Sbitany H, Foster RD, Mukhtar RA. The use of oncoplastic surgical techniques to increase successful breast conservation in invasive lobular carcinoma of the breast [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 P2-12-16.

Outcomes after Mastectomy and Lumpectomy in Octogenarians and Nonagenarians with Early-Stage Breast Cancer

Prospective studies have shown equal outcomes after mastectomy or breast conservation in patients with invasive breast cancer; however, many of these studies excluded elderly patients. We identified patients in their eighties and nineties with clinical stage 0 to II breast cancer undergoing mastectomy or lumpectomy with or without radiation from the prospective sentinel lymph node database at Wake Forest Baptist Health and analyzed their treatment and survival. Of 92 patients, 24 (26.1%) underwent mastectomy, 22 (23.9%) lumpectomy with radiation, and 46 (50.0%) lumpectomy alone. Significant differences were noted in tumor size (P = 0.018), nodal status (P = 0.013), and stage (P = 0.011) between the groups. Only 7.6 per cent of patients had chemotherapy, whereas 51.1 per cent took antiestrogen therapy. Recurrence occurred in 11 patients. In univariate analysis, overall survival did not differ by surgery. Age was the only factor that increased risk of death (HR = 1.19, P = 0.028). In this age group, neither tumor factors nor the type of local treatment significantly influenced overall survival. Octogenarians and nonagenarians with early-stage breast cancer undergoing breast-conserving surgery with or without radiation have equivalent survival to patients having a mastectomy.

Short tangential arcs in VMAT based breast and chest wall radiotherapy lead to conformity of the breast dose with lesser cardiac and lung doses: a prospective study of breast conservation and mastectomy patients.

Volumetric modulated arc therapy (VMAT) is modern rotational intensity modulated therapy used for treatment of several sites. The study aimed to analyze partial tangential arc VMAT treatment planning and delivery, including analyzing the cardiac and contralateral breast doses resulting from this technique. A total of 153 consecutively treated breast cancer (conservation as well as mastectomy) patients were taken for this dosimetric study. All patients were planned using partial arc VMAT in the Monaco treatment planning system using two partial arc beams. All patients were divided into seven different categories: (1) all the patients in the study, (2) left sided whole breast and chest wall patients, (3) left Chest wall patients, (4) left whole breast patients, (5) right sided whole breast and chest wall patients, (6) right chest wall patients, and (7) right whole breast patients. We evaluated each treatment plan for PTV coverage and doses to OARs. SPSS version 16.0 software was used for statistical analysis. There were 91 left sided and 62 right sided breast cancer patients in the overall analysis. The percentage of PTV volume receiving 95% of the prescription dose (PTV V95%, mean ± SD) varied in the range of 91.2 ± 5.2-94.8 ± 2.1% with mean dose of 92.4 ± 5.2% for all cases. The (mean ± SD) cardiac dose for all the patients was 289 ± 23cGy. The (mean ± SD) cardiac doses were higher for left sided patients (424 ± 33.8cGy) as compared to right sided patients (123.9 ± 80cGy) (p < 0.001). Cardiac mean doses were higher with arc angles >30° versus 30° (324.5 ± 247.1 vs. 234.4 ± 188.4cGy) (p = 0.001). Similarly contralateral breast mean dose was higher with arc angles >30° versus 30° (126 ± 115 vs. 88.6 ± 76.1cGy) (p = 0.001). However cardiac V20, V30 and V40Gy did not exhibit any statistical difference between the two groups (p = 0.26, 0.057 and 0.054 respectively). This is the first large study of its kind that assesses the dosimetric outcome of tangential partial arc VMAT treatments in a large group of mastectomy and breast conservation patients. Our study demonstrates the efficacy of this technique in dose coverage of PTV as well as in minimizing dose to OARs. Further, based on our results, we conclude that the arc length for the bi-tangential arcs should be 30° since it helps to achieve the most optimal balance between target coverage and acceptable OAR doses.

Abstract P3-13-20: Use of a 3-D bioabsorbable tissue marker in 61 patients over two years

Abstract Background: Breast conservation surgery (BCS) may preserve the breast but many women have less than optimal cosmetic outcomes. Increasingly, this has been addressed by the use of oncoplastic reconstruction.Now, targeting radiation treatment for boost or partial breast irradiation (PBI) using the seroma has become more difficult due to the adjacent tissue rearrangement and resultant “benign” seromas. Since the radiation dose generated increases by the third power of the radius (r3), there is a need to accurately focus radiation therapy to avoid chronic radiation side effects.We have used a 3-dimensional bioabsorbable tissue marker to accurately target the tumor bed while excluding inadvertent seromas caused by oncoplastic procedures. We report on tissue marker implantation on 61 consecutive breast conservation patients in regards to targeting, impact on cosmesis, imaging followup, ease of re-excision, as well as side effects and patient satisfaction. METHODS: Consecutive lumpectomy patients who were candidates for targeted radiation therapy were considered for implantation with the 3-D bioabsorbable marker from May 2014 to June 2016. The tissue marker has a fixed array of 6 titanium clips and was sutured to the site of the excised breast cancer during lumpectomy.The framework of the implant resorbs slowly over time, while the clips remain permanently. All patients had oncoplastic reconstruction with total implant coverage. The marker was utilized for boost or partial breast irradiation (PBI) planning or treatment targeting. Data includes patient demographics, breast size, tumor characteristics, surgical and radiotherapy techniques, follow-up imaging, cosmesis and patient satisfaction. Results:Data on 61 patients with median follow-up 12.7 months was analyzed (range 1.5–25.5). Median age was 62.4 years (range 33-74), 5 of women were postmenopausal and 15% had comorbidities. Cancer histology was in-situ (13%), invasive ductal (84%), invasive lobular (3%) of sizes T0 (13%), T1 (59%), T2 (25%), T3-4 (3%). Laterality and tumor location within the breast were typical. Re-excisions occurred in 11% of patients. No infections occurred in the postoperative period. One infection occurred with chemotherapy and another with repeated aspirations of oncoplastic area.No device was removed for infection, misplacement or patient-generated concerns. No cancer recurrences have been reported. Size of device used reflected size of the tumor; 2X2cm (44%), 2X3cm (34%) and 3X3cm (20%). The device was utilized by radiation oncologists for boost or PBI planning and treatment. Data on ease of setup and boost planning is being collected. Mammography at one year demonstrated marker clips coalescing as the bioabsorbable device dissolves. Evaluation of cosmetic appearance has shown good to excellent cosmesis as judged separately by both physicians and patients (92% and 94%). Conclusions: Initial experience with 61 patients implanted with a novel 3-D absorbable device prospectively followed for an average of 12 months can be used in an array of breast cancer patients without device specific morbidity. Good to excellent cosmesis may be related to the addition of volume to the lumpectomy bed not seen with rearrangement of existing tissues. Citation Format: Kaufman CS, Hall W, Behrndt V, Wolgamot G, Hill L, Zacharias K, Rogers A, Nix S, Schnell N. Use of a 3-D bioabsorbable tissue marker in 61 patients over two years [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-20.

Attitudes towards breast conservation in patients aged over 70 with breast cancer.

BackgroundThe majority of breast conserving surgery (BCS) is performed in younger women. There is little published information about the views of women aged over 70 regarding BCS. The aim of this study was to investigate the attitudes of this age group towards BCS, and factors which may influence their treatment decision-making.MethodsA questionnaire was sent to all patients who were aged 70 or over at the time they had breast cancer surgery in NHS Lanarkshire between 1999 and 2013. This detailed surgical options and recommendations, timing of decision making, treatment expectations, psychological and cosmetic concerns and other factors which may have influenced any decision made e.g. travel for radiotherapy and potential side effects.ResultsResponses were received from 339 patients, 192 of whom had a mastectomy with the remaining undergoing BCS. In the mastectomy group 18 % (35) would have preferred to have BCS had it been an option, with 40 % (76) of group being happy to take neoadjuvant endocrine therapy to try and facilitate this. However, only 14 % (26) of patients would have considered neoadjuvant chemotherapy with the same aim. Almost half (82) of the mastectomy patients said that the risk of local recurrence following BCS was a factor which influenced their decision.ConclusionBCS is something that patients aged over 70 are interested in considering in the same way as younger patients. More than a third of patients requiring mastectomy would be willing to take neoadjuvant endocrine therapy to attempt to downstage their tumour to facilitate BCS.

Attitudes towards breast conservation in patients aged over 70 with breast cancer

Background The majority of breast conserving surgery (BCS) is performed in younger women. There is little published information about the views of women aged over 70 regarding BCS. The aim of this study was to investigate the attitudes of this age group towards BCS, and factors which may influence their treatment decision-making.

Application of latissimus dorsi muscle flap for breast conservation in breast cancer

Breast conserving surgery (BCS) is one of standard treatment approaches in early breast cancer. Although most defect after BCS can be repaired, the cosmetic outcomes are unsatisfactory in the patients with poor tumor/breast ratio. Oncoplastic surgery (OPS) has emerged as a new approach for providing adequate tumor resection without compromise of aesthetic outcomes in BCS. Our purpose is to explore the cosmetic outcomes of applying latissimus dorsi (LD) muscle flap to reshape severe breast conservation deformities in breast cancer. Totally 24 cases of breast cancer were studied. The tumor size was 3.0 - 5.5 cm (median 3.5 cm). All the cases underwent BCS and achieved negative margin by frozen sections examination. Then LD flap reshaping were performed. All the patients received whole breast radiotherapy ± chemotherapy ± endocrine therapy. All the LD flaps were alive without skin necrosis. After a median 23-month follow-up, all the cases were disease-free surviving. The whole breast radiotherapy had no significant effect on the LD flaps. The rate of good cosmetic results was 79.2%. The subjective satisfactory rate of the patients was 96%. Both satisfactory aesthetic outcome and good treatment effect were obtained using LD flap to reshape severe breast conservation deformity. OPS offers tools for breast conservation in patients otherwise destined for mastectomy or poor aesthetic outcome, such as large tumor/breast ratio, nipple-areola complex tumor, ductal carcinoma in situ, neoadjuvant chemotherapy cases and so on.

Changes in brachytherapy-based APBI patient selection immediately before and after publication of the ASTRO consensus statement.

In July 2009, American Society of Radiation Oncology (ASTRO) released a consensus statement (CS) to guide patient selection for accelerated partial breast irradiation (APBI). The goal of this study was to examine how practice patterns changed following the guideline's release. The Surveillance, Epidemiology, and End Results database was queried from 2008 to 2010 for females aged ≥20 years receiving breast conservation via brachytherapy. Among the APBI cohort, characteristics and CS grouping ("suitable," "cautionary," or "unsuitable") of patients receiving APBI in the 18 months before (January 2008 to June 2009) and after (July 2009 to December 2010) guideline publication were analyzed. A total of 87,528 patients undergoing breast conservation therapy were identified. Of this, 4,253 patients (4.9%) received brachytherapy-based APBI. Limiting the analysis to patients not missing data that would affect their CS classification rendered 3,828 patients. The proportion of breast conservation patients receiving brachytherapy-based APBI before and after CS release remained the same (4.9% vs. 4.8%, p = 0.36). Among patients receiving brachytherapy-based APBI, the unsuitable category decreased (15.8 vs. 11.1%, p < 0.01), whereas the suitable category increased (37.7% vs. 42.1%, p = 0.03), and the cautionary category was stable (46.5% vs. 46.7% p = 0.90) after guideline publication. Joinpoint regression analysis failed to reveal that the changes in practice patterns corresponded with the CS publication date. The period before and after publication of the ASTRO CS was associated with a decrease in "unsuitable" patients and an increase in "suitable" patients being treated with brachytherapy-based APBI. This trend began before guideline release and thus cannot be definitively attributed to the ASTRO CS.

Oncoplasty’s Contribution in Breast Cancers: About 48 Cases

Introduction: Oncoplasty has developed for 20 years in order to avoid potentially major deformations of conservative treatment. We report the results of our oncoplastic breast operations. Patients and Methods: We conducted a descriptive and retrospective study of 48 patients treated by oncoplastic technique in the national center of burn and plastic surgery in the U.H. IBN-ROCHD of Casablanca between 2011 and 2014. Patient and tumor characteristics, as well as information on the procedures and complications, were collected from clinical records. Results: Forty-eight cases were reviewed. The tumors were processed for the majority of invasive ductal carcinoma pT2. Seven patients had an inadequate surgical margin. About histology, the rate of recovery for non-positive margins was significantly lower in the CCI alone than that in other types. Morbidity was 14.5% and the average delayed to adjuvant treatment of 72 days. The symmetrization rate was 24%. In terms of oncological results, during a median follow-up of 22 months, the rate of local recurrences was 13%. Conclusion: The oncoplastic operations offer tools for breast conservation in patients and otherwise is destined for mastectomy or poor esthetic outcome. This study shows that the goal of surgical therapy is to identify patients who are suitable for oncoplastic surgery. Proper pre-operative evaluation and diagnosis, surgical planning, adequacy of resection, and pathological evaluation are essential.

Hypofractionated radiotherapy for breast cancers--preliminary results from a tertiary care center in eastern India.

The standard radiotherapy (RT) fractionation practiced in India and worldwide is 50 Gy in 25 fractions over 5 weeks to the chest wall or whole breast followed by tumour bed boost in case of breast conservation (BCS). A body of validated data exists regarding hypofractionation in breast cancer. We here report initial results for 135 patients treated at our center with the START-B type of fractionation. From May 2011 till July 2012, women with all stages of breast cancer (excluding metastatic), who had undergone BCS or mastectomy were planned for 40 Gy in 15 fractions over 3 weeks to chest wall/whole breast and supraclavicular fossa (where indicated) followed by tumour bed boost in BCS patients. Planning was done using Casebow's technique. The primary end point was to assess the acute toxicity and the cosmetic outcomes. Using cosmetic scales; patients were assessed during radiotherapy and at subsequent follow up visits with the radiation oncologist. Of the 135 patients, 62 had undergone BCS and 73 mastectomy. Median age of the population was 52 years. Some 80% were T1 and T2 tumours in BCS whereas most patients in mastectomy group were T3 and T4 tumours (60%). 45% were node negative in BCS group whilst it was 23% in the mastectomy group. Average NPI scores were 3.9 and 4.9, respectively. Most frequently reported histopathology report was infiltrating ductal carcinoma (87%), grade III being most common (58%), and 69% were ER positive tumours, and 30% were Her 2 Neu positive. Triple negative tumours accounted for 13% and their mean age was young (43 yrs.) The maximum acute skin toxicity at the end of treatment was Grade 1 in 94% of the mastectomy group patients and 71% in BCS patients. Grade 2 toxicity was 6% in mast group and 23% in BCS group. Grade 3 was 6% in BCS group, no grade 3 toxicity in mastectomy patients and there was no grade 4 skin toxicity in any case. Post RT at 1 month; 39% of BCS patients had persisting Grade I skin reaction which was only 2% in mastectomy patients. At 3 months post RT, 18% patients had persisting hyperpigmentation. At 6 months 8% patients had persisting erythema in the BCS group only. Some 3% BCS and 8% mastectomy patients had lymph edema till the date of evaluation. Cosmetic outcome in BCS patients remained good to excellent 6 months post surgery and radiotherapy. 1 patient of BCS and 3 patients of mast had developed metastatic disease at the time of evaluation. Hypofractionated RT is well tolerated in Indian population with reduced acute skin toxicity and good cosmetic outcome. Regimens such as these should be encouraged in other centers to increase machine output time. The study is on-going to assess long term results.

Risk of recurrence of ductal carcinoma in situ by oncotype Dx technology: Some concerns

Predicting which patients with ductal carcinoma in situ (DCIS) will develop local disease recurrence: we have been trying to do that for 30 years. But now we can. The Holy Grail has been recovered in the form of Oncotype Dx, or so we have been told.1 A single genetic test capable of identifying the risk of local disease recurrence after breast conservation in patients with mammographically detected DCIS would obviate the need to factor in DCIS grade, size, and margin width, and patient age. The Oncotype Dx DCIS gene signature assay was validated in a registration trial2 that strictly defined a permissible size of ≤25 mm for low-to-intermediate grade tumors and ≤10 mm for high-grade tumors and those with margin widths of ≥3 mm. Unfortunately, most medical oncologists ordering the Oncotype Dx DCIS assay do not appreciate the limitations of the validated results. They order the $4000 test for patients with DCIS of all sizes and all margin widths. The test, if valid, is only valid if the strict protocol required of the Eastern Cooperative Oncology Group (ECOG) E5194 trial is adhered to. A transected DCIS is likely to recur in spite of a low score on the Oncotype Dx assay. A recent example of a 46-year-old woman with a low-risk Oncotype Dx score had 42 mm of disease and 3-mm margins. Her DCIS grade was intermediate with focal necrosis. A Van Nuys Prognostic Index calculation3 results in a total score of 9 (grade score of 2, size score of 3, margin score of 2, and age score of 2). Oncotype Dx provided a 10-year risk of disease recurrence of 15%, whereas the University of Southern California/Van Nuys Prognostic Index projects a local recurrence risk of 40% to 50% without irradiation. The Oncotype Dx assay is in essence a grading system based on gene expression, and is comparable to histologic grading of DCIS. Because it does not factor in a variety of important predictive factors such as age, margin width, extent of DCIS, nuclear grade, and necrosis, it is not likely to be accurate for the majority of patients. No single test, especially one in which other prognostic factors are ignored, can validly estimate the risk of local recurrence among patients with DCIS. The authors made no disclosures. Michael D. Lagios, MD1 Melvin J. Silverstein, MD2 1The Breast Cancer Consultation Service, Tiburon, California 2Department of Breast Surgery, Hoag Memorial Hospital Presbyterian, Newport Beach, California

Accelerated Partial-Breast Irradiation Versus Whole-Breast Irradiation for Early-Stage Breast Cancer Patients Undergoing Breast Conservation, 2003–2010: A Report from the National Cancer Data Base

Previous studies have demonstrated an increase in the utilization of accelerated partial-breast irradiation via brachytherapy (APBI-b), but larger, more contemporary studies examining overall APBI use are lacking. A total of 575,438 nonneoadjuvant American Joint Committee on Cancer stage 0 to II breast conservation patients were selected from the National Cancer Data Base from 2003 to 2010 who underwent either whole-breast irradiation or APBI. Overall, 59,396 patients (10.3 %) underwent APBI. The use of APBI for the entire cohort increased from 3.4 % in 2003 to 12.8 % (p < 0.001) in 2008 and then decreased to 12.4 % in 2010. Three-dimensional conformal radiation increased from 0.8 to 2.2 %, intensity-modulated radiotherapy increased from 0.7 to 1.3 %, and brachytherapy (APBI-b) increased from 2.0 to 8.9 %. The most significant factors associated with APBI use were patient age and facility location. Patients 80-89 years old were 3.8 times more likely to undergo APBI compared to patients 30-39 years old (odds ratio [OR] 3.77, 95 % confidence interval [CI] 3.45-4.10, p < 0.001). Patients living in the West census region were 2.0 times more likely to undergo APBI compared to patients living in the Northeast (OR 2.0, 95 % CI 1.93-2.15, p < 0.001). Using the American Society of Radiation Oncology (ASTRO) guidelines, among patients with noninvasive cancer who received APBI, 95.6 % were categorized as "cautionary" and 4.4 % as "unsuitable." Of the invasive patients, 43.8 % were categorized as "suitable," 47.0 % as "cautionary," and 9.2 % as "unsuitable." The utilization of APBI has stabilized at approximately 12 % starting in 2008. The majority of APBI is delivered using APBI-b, with patient age being the most significant factor associated with APBI use.

Which Eligible Breast Conservation Patients Choose Mastectomy in the Setting of Newly Diagnosed Breast Cancer?

Breast conserving therapy (BCT) and mastectomy offer equivalent survival for women with newly diagnosed breast cancer (BrCa). Despite this, many women eligible for BCT elect mastectomy. Herein, we identify factors associated with choosing ipsilateral mastectomy instead of BCT when mastectomy is not required. Between July 2007 and June 2010, 520 women with BrCa were treated by a single surgeon who prospectively documented patient eligibility for BCT. For patients who did not require mastectomy (n=392), we evaluated associations between treatment choice and potential predictors using odds ratios (ORs) obtained from multivariable logistic regression models. P values≤0.0029 were significant after correction for multiple testing. Of 392 women eligible for BCT, 106 (27%) chose mastectomy and 286 (73%) chose BCT. Multivariate analysis found an increased likelihood of electing mastectomy over BCT for patients with no comorbidities (OR 5.4; P<0.001) and those with previous mastectomy (OR 23.2; P<0.001). MRI and biopsy findings were associated with treatment choice because patients who had a second-site biopsy positive for cancer in the same quadrant as the index tumor were more likely to elect mastectomy compared with patients with no additional MRI abnormalities (OR 4.3; P=0.0027). No association existed on multivariate analysis between choice of mastectomy and patient age, family history, or tumor stage. One in four eligible BCT patients chooses mastectomy. Factors independently associated with choosing mastectomy over BCT include findings of second-site biopsy, previous mastectomy, and absence of comorbidities but not primary tumor characteristics. Further study into a patient’s choice for mastectomy is warranted.

Endocrine Therapy in the Preoperative Setting and Strategies to Overcome Resistance

Endocrine therapy remains the mainstay for treatment of hormone receptor-positive breast cancer in both adjuvant and metastatic settings. Due to the cytostatic property of endocrine therapy, cytotoxic chemotherapy is more commonly used for cytoreduction in preoperative setting to promote breast-conserving surgery. Nevertheless, recent clinical trials demonstrated that preoperative endocrine therapy can also be used to facilitate breast conservation in patients with locally advanced breast cancer, particularly in postmenopausal women with low proliferative tumors. Multiple markers have been shown to be predictive of endocrine responsiveness, including estrogen and progesterone receptor expression as well as other molecular profiles such as the 21-gene recurrence score assay and PAM-50 assay. The preoperative setting offers a unique situation to rapidly prioritize novel treatment combination and to identify the mechanisms of resistance. Several strategies to overcome resistance, including co-targeting other signaling pathways, particularly human epidermal growth factor receptor 2 (HER2), vascular endothelial growth factor receptor (VEGF), and PI3K/Akt/mTOR, are discussed in this review article.

Breast conservation surgery and radiation for a patient with synchronous primary breast cancers and BRCA1/BRCA2 positivity: is mastectomy required?

AbstractThe role of breast conservation in patients expressing BRCA1 and BRCA2 genetic mutations is controversial. A patient who was found to have bilateral synchronous breast cancers and expressed a BRCA genetic mutation was recently evaluated. The patient had a strong desire for breast preservation. This case and a review of the pertinent literature are presented to discuss the role of breast conservation and radiation in patients with BRCA1 or BRCA2 genetic mutations.

Outcome of oncoplastic breast surgery in 90 prospective patients

Background Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007. Methods Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines. Results Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases. Conclusions Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.

Local Therapy in BRCA1/2 Carriers with Operable Breast Cancer: Comparison of Breast Conservation and Mastectomy.

Abstract Background: Women with inherited germline BRCA1/2 mutations have a 55-85% cumulative risk of breast cancer (BC) by age 70. Thus, knowledge of expected outcomes following various treatments is needed to advise these patients should they be diagnosed with BC. It is unclear whether breast conservation (BCT) offers similar rates of tumor control as mastectomy (M) in BRCA1/2 carriers and it is doubtful whether a randomized trial comparing these options could be performed. Thus, this analysis compares the outcomes between similarly staged women with BRCA1/2 mutations treated with BCT vs. M.Methods: Women with deleterious BRCA1/2 mutations diagnosed with operable BC and who consented to longitudinal studies were identified at 10 institutions in the US, Australia, Spain and Israel. Patient, clinical and treatment characteristics were compared between those receiving BCT and those receiving M +/- RT. Time-to-event endpoints included first failure of treatment, diagnosis of contralateral breast cancer (CBC), and overall and BC-specific survival. Cox regression models were constructed to detect significant associations between patient and clinical characteristics and time-to-event endpoints.Results: Clinical characteristics and outcomes for 302 BCT and 353 M patients were compared. With a median F/U of 8.2 years for BCT patients and 8.9 years following M, 15-year local failure as first failure was significantly higher with BCT vs. M (23.5% vs. 5.5%, p&amp;lt;0.0001). Multivariate analysis indicted choice of local therapy as the only factor significantly predicting local recurrence, with a 4.5-fold risk of local failure with BCT compared to M (p&amp;lt;0.0001). Local failure analyses by cohort revealed the presence of a BRCA2 mutation (HR 2.8; p=0.024) and no use of adjuvant chemotherapy (HR 5.4; p=0.0001) as significant predictors within the BCT group; presence of invasive lobular cancer (HR 9.9; p=0.004) was the only significant predictor within the M cohort. No significant differences were seen in distant failure, BC-specific or overall survival by local therapy. 15-year estimates of CBC were 52.1% with BCT; 41.4% with M; and 37.9% with M+RT (p=0.44). Analyses of BCT vs. M +/- RT and surgery +/- RT did not reveal significant differences in CBC by cohort.Conclusions: The higher risk of local failure in BRCA1/2-associated BC treated with BCT compared to M did not translate into an increased risk of distant failure or mortality. RT did not result in a detectable increase in CBC at 15 years above baseline elevated rates. These results at both the involved and contralateral breasts should be discussed when patients with BRCA1/2-associated BC are considering local treatment options. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 959.

The mid-long term outcome of breast-conserving patients with different ages

Objective Breast-conserving surgery has been a standard treatment for relatively small size of breast cancer. Younger breast cancer patients have more desire to conserve their breasts. This study was to investigate the clinicopathological characteristics and prognosis of younger breast cancer patients who received breast-conserving treatment in China.

Neoadjuvant Chemotherapy in Invasive Lobular Carcinoma May Not Improve Rates of Breast Conservation

Patients with invasive lobular carcinoma (ILC) experience a lower pathological complete response rate to neoadjuvant chemotherapy than patients with invasive ductal carcinoma. This study was intended to evaluate the impact of neoadjuvant chemotherapy in ILC on breast-conserving surgery (BCS) rates. Two-hundred eighty-four consecutive patients with pure ILC treated between May 1998 and September 2006 were reviewed. Surgical procedures and long-term outcomes were compared between patients receiving neoadjuvant chemotherapy and those receiving surgery first. Neoadjuvant chemotherapy was administered to 84 patients; 200 patients underwent surgery first. The mean tumor size in the neoadjuvant group (4.9 cm) was significantly larger than in patients who underwent surgery first (2.5 cm, p < 0.0001). In the neoadjuvant group, clinical complete response was seen in 10% and partial response in 59%. Overall BCS rates were 17% in the neoadjuvant group compared with 43% in the surgery-first group (p < 0.0001). When controlled for initial tumor size, there was no difference (all p > 0.05) between the groups in terms of (1) the proportion of patients who underwent an initial attempt at BCS, (2) rate of failure of BCS or (3) the proportion of patients undergoing BCS as their final procedure. With a mean follow-up of 47 months, local recurrence (LR) rates were similar between the two groups (1.2% versus 0.5%, p = 0.5). The use of neoadjuvant chemotherapy does not increase the rates of breast conservation in patients with pure ILC.