Breast Conservation In Patients Research Articles

ThP1.3 - Oncoplastic Surgery and Magseed Markers: A five-year snapshot of ambition and evolution in breast conserving surgery

Abstract Aim Oncoplastic surgery and localisation markers allow breast conservation in patients who might previously have been treated with mastectomy. We aimed to evaluate breast conservation across a five-year period spanning widening adoption of oncoplastic conservation, and the introduction of Magseed localisation. Method All patients diagnosed with breast cancer or DCIS, screening or symptomatic, in NHS Lanarkshire during the first 6 months of 2017 and 2022 were reviewed. These dates were chosen to eliminate the effects of Covid-19 on practice as much as possible. Results 531 patients (244 in 2017; 287 in 2022) were diagnosed within the study period. Groups were comparable for age (median 62 (32-96) and 61 years (28-94); P=0.4), and tumour size (median 19 (3-150) and 21 mm (4-123); P=0.4). Breast conservation as first operation rose from 69.1% to 85.5%. Use of localisation also increased, from 52.7% of procedures using wires in 2017, to 71.2% using one or more Magseeds in 2022 (P<0.001). Oncoplastic breast conservation rose from 3% to 7% of procedures. Re-excision rates remained in line with national outcomes (20.4% in 2017 and 20.0% in 2022); and ‘failure’ of breast conservation resulting in completion mastectomy also reduced from 8.0% to 4.7%. Overall mastectomy rate (+/- reconstruction) fell from 36% to 18% (P<0.001). A reduction in mastectomy for multifocal or diffuse disease requiring localisation or bracketing was also observed, from 56.2% to 35.5%, though this didn’t reach statistical significance (P=0.13). Conclusion Increasing success in breast conservation has coincided with greater adoption of oncoplastic breast conservation and novel localisation technology. Reassuringly, this has not resulted in an increase in re-excision, nor completion mastectomy rate.

A clinical perspective on oncoplastic breast conserving surgery.

Breast conserving surgery (BCS) plus radiation treatment is the favored alternative for mastectomy in patients with breast cancer. To allow for breast conservation in patients with large invasive tumors and poor response to neoadjuvant systemic treatment (NST) or patients with extensive ductal carcinoma in situ (DCIS), oncoplastic breast conserving surgery (OPBCS) techniques are introduced. OPBCS allows for breast conservation in a selective group of breast cancer patients who initially would have been treated with mastectomy due to the unfavorable tumor-to-breast ratio. With OPBCS, the oncological tumor excision is combined with plastic surgical breast conservation techniques without compromising oncological safety and maintaining aesthetic outcomes by preserving the shape of the breast. OPBCS should however not be applied to all breast cancer patients and the selection of patients who benefit from OPBCS and the timing of OPBCS are best discussed in a multidisciplinary team (MDT). Caution is required in patients with higher risk of positive margins [e.g., multifocal breast cancer, invasive lobular carcinoma (ILC), larger tumors and DCIS]. In these patients, delayed OPBCS is recommended to facilitate re-excision and maintain excellent breast conserving rates. Despite proven benefits in selected patients, the increase in the adoption of OPBCS is relatively low. This article provides a clinical perspective on OPBCS.

Blood flow on ultrasound imaging is a predictor of lump margin status in breast-conserving patients: a retrospective matching study

PurposeThis study investigated the relationship between breast ultrasound features and lump margin status in breast-conserving patients.MethodsA single-institution database and medical records system were searched to identify patients who had undergone breast-conserving surgery between 2015 and 2022. Patients were divided into case and control groups based on their postoperative margin status, and different matching methods [case–control matching (CCM) and propensity score matching (PSM)] were used to match the cases and controls at a ratio of 1:1.ResultsBefore matching, patients with positive margins were more likely to have a tumor with increased blood flow (OR = 2.90, 95% CI 1.83–4.61, p < 0.001) and microcalcifications (OR = 2.22, 95% CI 1.44–3.42, p < 0.001). Among the 83 pairs of CCM subjects, patients with positive margins were prone to increased blood flow (p = 0.007) and crab sign (p = 0.040). In addition, there was a significant difference in blood flow (p = 0.030) among PSM subjects. After adjusting for the unbalanced factors, the same results were obtained.ConclusionsUltrasound blood flow significantly predicts the status of breast-conserving margins, but further studies are required to verify our findings.

Organ-sparing treatment for breast cancer

This article reviews literature on organ-sparing and oncoplastic surgeries for breast cancer. Initially, we performed organ-sparing surgeries in patients with stage I—IIA breast cancer and then compared outcomes with those in patients after radical mastectomy. Since there were no differences in both overall and relapse-free survival between the groups, we started to perform organ-sparing surgeries in women with locally advanced breast cancer after neoadjuvant therapy who achieved complete or partial response. Oncoplastic resections were used to achieve good aesthetic results and also for patients in whom classical organ-sparing resection would inevitably result in a poor cosmetic outcome due to the tumor location. In recent years, the technique of extreme oncoplastic breast resection has emerged as a promising option that extended the scope of indications to organ-sparing treatment. In particular, it allows breast conservation for patients with multicentric, multifocal tumors, and tumors &gt;50 mm. All organ-sparing and oncoplastic operations first of all improve the quality of life of breast cancer patients.

Combining a Chest Wall Perforator Flap and Bioabsorbable Implant to Facilitate Oncoplastic Breast-conserving Surgery

Oncoplastic breast conservation is classically divided into two approaches: volume displacement and volume replacement (VR). These approaches are important to use when more than 20% of the breast is removed to avoid deformity. Smaller, nonptotic breasts require VR strategies from flaps based off of local chest wall perforators. When larger volumes are required, a flap based off the thoracodorsal artery can be used. Although this flap can replace larger volumes, it usually requires a position change with increased operative time, patient morbidity, and longer recovery while also exhausting a major reconstructive modality. In an effort to avoid this increased operative complexity, we have found that combining a local chest wall perforator flap and bioabsorbable implant, which has been previously shown to be safe and effective in reconstructing partial mastectomy defects, allows for a simpler VR strategy in patients who might otherwise require a more extensive thoracodorsal artery-based flap surgery or a mastectomy. Here, we present 10 cases where we combined flaps based off the lateral, anterior or medial intercostal artery perforators or lateral thoracic artery perforator with a bioabsorbable implant to successfully perform oncoplastic breast conservation in patients who might otherwise be marginal candidates for VR using a local chest wall perforator flap.

ASO Visual Abstract: The Presence of Non-classic LCIS is Not a Contraindication to Breast Conservation in Patients with Concomitant Invasive Breast Cancer or DCIS.

ASO Visual Abstract: The Presence of Non-classic LCIS is Not a Contraindication to Breast Conservation in Patients with Concomitant Invasive Breast Cancer or DCIS.

Presence of Non-classic LCIS Is Not a Contraindication to Breast Conservation in Patients with Concomitant Invasive Breast Cancer or DCIS.

Non-classic lobular carcinoma in situ (NC-LCIS) represents a spectrum of lesions, histologically distinct from classic LCIS (C-LCIS) and ductal carcinoma in situ (DCIS). Several studies have reported on the safety of breast conservation (BCS) in patients with DCIS or invasive breast cancer and concomitant C-LCIS, yet there are no data addressing this question for patients with concomitant NC-LCIS. We evaluated local recurrence (LR) after BCS in patients with DCIS or invasive cancer and concomitant NC-LCIS. We searched institutional databases using natural language processing to identify patients with DCIS or invasive breast cancer and concomitant NC-LCIS treated with BCS between 2000 and 2015. Charts were reviewed to collect demographics, disease and treatment details, and recurrence events. All results represent descriptive analyses. We identified 71 patients with DCIS (n = 13) or invasive cancer (n = 58) and concomitant NC-LCIS treated with BCS. Median patient age was 59 years (33-77 years), and median invasive tumor size was 1.2 cm (0.1-6.9 cm); 62% of DCIS and 79% of invasive cancer patients had hormone receptor (HR)-positive disease. Among DCIS patients, seven (54%) received radiation and none hormonal therapy. Among those with invasive cancer, 52 (90%) received radiation, 17 (29%) received chemotherapy and 44 of 55 with HR-positive disease (78%) received hormonal therapy. At median follow-up of 79 months (1-265 months), the LR rate was 8% and 2% among patients with DCIS and invasive cancer, respectively. NC-LCIS is rarely present in association with DCIS or invasive cancer, and it does not appear to impact LR outcomes following BCS.

Comparing single or dual tracing modality on sentinel lymph node biopsy from patients who plan to omitting axillary lymph node dissection referring to the criteria of Z0011 trial: a retrospective study.

Axillary lymph node dissection (ALND) can be omitted in the part of the breast-conserving patients with positive sentinel lymph nodes (SLNs) since Z0011 trial has presented. Nevertheless, to date, no studies revealed the influence of different tracing modalities (single tracer versus dual tracers) for sentinel lymph node biopsy (SLNB) on axillary management referring to Z0011 trial criteria. This study aimed to assess whether different tracing modalities of SLNB have impact on axillary management referring to Z0011 trial criteria. The clinical data of breast-conserving patients who underwent SLNB guided by combination of methylene blue (MB) and indocyanine green(ICG) were retrospectively analyzed in our center. The numbers of metastatic (positive) SLNs guided by the single tracer and the dual tracer were compared by self-control study. 127 patients with 1-2 metastatic SLNs dyed by MB [(recorded as MB(+))]were retrieved from our database between 2016 and 2020. In these cases, 53 patients contained 86 SLNs, which were ICG staining but MB negative staining (recorded as ICG(+)/MB(-)). In addition, 16 patients contained 20 metastatic SLNs with ICG(+)/MB(-). There were six patients finally excluded patients (6/127, 4.7%) who initially met the criteria of Z0011 trial, because the further detection of ICG(+)/MB(-) SLNs led the total numbers of positive SLNs over two. The difference was statistically significant. Single tracing modality may underestimate the positive SLN numbers compared to dual tracing modality. Different tracing modalities of SLNB will significantly affect Axillary management referring to Z0011 trial criteria.

Abstract P3-18-02: Breast conservation plus radiotherapy provides superior survival benefit than mastectomy in triple negative breast cancer: A propensity matched national cancer database analysis

Abstract Background: Triple-negative breast cancer (TNBC) is an aggressive breast cancer subtype with a higher risk of locoregional and distance recurrence. Consequently, this population was considered poor candidate for breast conservation (BCT). Our study aim was to determine whether BCT plus radiotherapy (RT) was equivalent to mastectomy for TNBC after adjustment of selection bias of demographic and clinical characteristics. Methods: The National Cancer Database was queried for women diagnosed as primary unilateral invasive clinical T1-2N0-2 TNBC from 2004-2016. Patients who underwent mastectomy or breast conservation (partial mastectomy plus radiation) were included. A 1:1 propensity match with replacement was performed to compare breast conservation vs. mastectomy. Overall survival was analyzed using stratified multivariable Cox proportional hazard regression analysis.Results: Of 59,599 clinical T1-2N0-2 TNBC patients, 26,325 (44.2%) underwent mastectomy and 33,274 (55.8%) were treated with BCT. BCT patients were older (median age 59 vs. 54, p&amp;lt;0.001), had smaller tumors (cT1 61.7% vs. 42.9%, p&amp;lt;0.001) and node negative (cN0 85.8% vs. 73.7%, p&amp;lt;0.001). Propensity matching reduced the bias between mastectomy and breast conservation groups and generated 30,980 pairs for analysis. Median follow-up times were 41 months (range 6.97-95.8) and 39 months (range, 0.62 -94.06) for BCT and mastectomy groups, respectively. After matching, BCT+RT was associated with significantly higher OS compared to mastectomy ( 86.8% vs. 79.7%, p&amp;lt;0.001). The survival advantage was also present in multivariate cox regression after controlling age, race, insurance, facility type, clinical T and clinical N stage.Conclusions: Using both propensity matching and multivariate cox regression controlling for potential confounders, BCT+RT survival was superior to mastectomy in a retrospective analysis of a large cancer database. Citation Format: Lifen Cao, Christopher W Towe, Megan E Miller, Alberto J Montero, Robert Shenk. Breast conservation plus radiotherapy provides superior survival benefit than mastectomy in triple negative breast cancer: A propensity matched national cancer database analysis [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 P3-18-02.

Breast-conserving in centrally located breast cancer patients confirmed safe by SEER based study.

Due to the lack of high-level data, there is still controversy over the oncological safety of breast conservation in patients with centrally located breast cancer. This study aimed to assess the safety of breast-conserving surgery in patients with centrally located breast cancer based on the data from the Surveillance, Epidemiology, and End Results (SEER) database. We collected data for all cases diagnosed with breast cancer who underwent breast-conserving surgery from 2012-2014 in the SEER database. The primary outcome of our study was disease-specific survival (DSS) and overall survival (OS). The PSM was used to eliminate the effects of non-random statistics. Chi-square test, Kaplan-Meier method and Cox proportional hazards regression model on univariate and multivariate analysis were used to analyze the data. Data from 79,214 patients who had undergone breast-conserving surgery were analyzed in this study, including those with breast cancer in the central region (n=3,128) and outside the central region (n=76,086). The DSS of central breast cancer patients and outside the central breast cancer patients was 58.1 months versus 58.0 months (P>0.05), respectively, while the OS of the 2 groups was 58.0 months versus 58.0 months (P>0.05), respectively. Breast cancer in the central region should not be contraindicated for breast conserving surgery and breast-conserving surgery can benefit a wider range of patients.

ASO Visual Abstract: The Impact of Radiotherapy Delay in Breast-Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures

ASO Visual Abstract: The Impact of Radiotherapy Delay in Breast-Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures

The Impact of Radiotherapy Delay in Breast Conservation Patients Not Receiving Chemotherapy and the Rationale for Dichotomizing the Radiation Oncology Time-Dependent Standard into Two Quality Measures.

The Commission on Cancer/National Quality Forum breast radiotherapy quality measure establishes that for women < 70 years, adjuvant radiotherapy after breast conserving surgery (BCS) should be started < 1 year from diagnosis. This was intended to prevent accidental radiotherapy omission or delay due to a long interval between surgery and chemotherapy completion, when radiation is delivered. However, the impact on patients not receiving chemotherapy, who proceed from surgery directly to radiotherapy, remains unknown. Patients aged 18-69, diagnosed with stage I-III breast cancer as their first and only cancer diagnosis (2004-2016), having BCS, for whom this measure would be applicable, were reviewed from the National Cancer Database. Among 308,521 patients, the median age was 57.0 years, and > 99% of all patients were compliant with the measure. The cohort of interest included 186,650 (60.5%) patients not receiving chemotherapy, with a mean age of 57.9 years. Of these, 90.5% received external beam radiotherapy (EBRT) and 9.5% brachytherapy. Among them, 24.9% started radiotherapy > 8 weeks after surgery. In a multivariable model, delay from surgery to radiotherapy increased the hazard ratios for overall survival to 9.0% (EBRT) per month and 3.0% (brachytherapy) per week. While 99.9% of patients undergoing BCS without chemotherapy remain compliant with the current quality measure, 25% have delays > 8 weeks to start radiation, which is associated with impaired survival. These data suggest that the current quality measure should be dichotomized into two, with or without chemotherapy, in order to impel prompt radiotherapy initiation and maximize outcomes in all patients.

Effect of auto flash margin on superficial dose in breast conserving radiotherapy for breast cancer.

PurposeTo investigate the dose‐effect of Auto Flash Margin (AFM) on breast cancer's superficial tissues based on the Treatment Planning System (TPS) in the breast‐conserving radiotherapy plan.MethodsA total of 16 breast‐conserving patients with early stage breast cancer were selected, using the X‐ray Voxel Monte Carlo (XVMC) algorithm. Then, every included case plan was designed using a 2 cm‐AFM (the value of AFM is 2 cm) and N‐AFM (without AFM). Under the condition of ensuring the same configuration of #MU and collimator, the absorbed dose after a simulated inspiratory motion was calculated again using the new plan center, which moved backward to the linac source. The dose difference between the measurement points between AFM and N‐AFM groups was compared.ResultsIn the dose results, PTVV50Gy of the AFM group was superior to that of the N‐AFM group, PTVD2%, PTVDmean, Lung_IpsiV20Gy, Lung_IpsiDmean, and BodyDmax. Also, the dose results of the N‐AFM group were significantly higher than those of the AFM group. However, there was no significant difference between Lung_ContraV5Gy, HeartDmean, and Breast_ContraV10Gy in the two groups. In the collimator alignments at the same angle between groups, the AFM group formed an apparent air region outside the collimator compared with the N‐AFM group. In the XVMC algorithm feature parameter, the AFM group had less #MU, higher QE, and slightly longer optimization time. The #segments of both groups were close to the 240 control points preset by the plan. The validation results of EBT3 film in both groups were more significant than 95%, meeting the clinical plan's application requirements. The difference in film results between groups was mainly reflected in the dose distribution at the near‐source. 4DCT was used to summarize the maximum and minimum inspiratory motion distances of 7.31 ± 0.45 and 3.42 ± 0.91 mm respectively.ConclusionsThese results suggest that the AFM function application could significantly reduce the possibility of insufficient tumor target caused by inspiratory motion and ensure sufficient tumor target exposure.

Extreme Oncoplasty: Breast Conservation in Patients with Large, Multifocal, and Multicentric Breast Cancer.

IntroductionExtreme Oncoplastic Breast Conservation Surgery (EOBCS) is offered in selected patients with multifocal or multicentric breast cancer (MFMC). Recent evidence has suggested that EOBCS may be a valuable resource for patients with MFMC who may avoid the risk associated with mastectomy in favour of the benefits of breast conservation without risking their oncological outcomes. Our study examined the practice of EOBCS in two regional breast units in Glasgow, United Kingdom.Materials and MethodsA prospectively collected database of 50 patients treated with EOBC in two breast units in Glasgow between 2007 and 2018 were evaluated, and clinical outcomes were observed.ResultsFifty patients (median age 55) underwent EOBCS, of which 43 (86%) had invasive disease. Median tumour size was 55mm (50–90) and multifocal disease was identified in 22 (44%) patients. Nine patients (18%) were found to have positive margins and underwent a second procedure, with 6 (12%) proceeding to mastectomy. Five-year disease free survival rate was 91.5%, while cancer-specific survival was 95.7%.ConclusionEOBCS is oncologically safe in short-term follow-up. Large scale studies are required to confirm these preliminary results, in order to offer EOBCS as a valid option to patients with advanced or multifocal breast cancer.

Patient-reported outcomes among women with unilateral breast cancer undergoing breast conservation versus single or double mastectomy.

More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer. We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal-Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point. 203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15months, it was significantly lower in BM patients than in BCT patients. Women who felt "very" confident and "very" informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15months. While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.

Evaluation of left ventricular systolic function and synchrony in patiests with early left breast cancer after breast conserving radiotherapy by layer-specific strain technique

Objective To evaluate the left ventricular systolic function and synchronization of patients with early left breast cancer after breast conserving radiotherapy by layer-specific strain technique. Methods Thirty-six patients with early left breast cancer who underwent breast surgery and radiotheraphy in Affiliated Tumor Hospital of Zhengzhou University from January 2018 to January 2019 were selected for this study. The layered strain technique was respectively applied to collect two-dimensional dynamic ultrasonic cardiograms one week before radiotherapy, one week after radiotherapy, and six months after radiotherapy. The EchoPAC 201 software was applied to analyze and obtain the global longitudinal peak strain(GLPS) and peak stain dispersion(PSD) of the epicardial layer(epi), the middle layer(mid) and endocardial layer(endo) of 17 left ventricular segments. The differences of every parameter before and after radiotherapy were compared, and the correlation of PSD and other parameters was analyzed. Results Compared with one week before radiotherapy, the absolute values of LPSepi, LPSmid, LPSendo, and GLPS all reduced significantly one week and six months after radiotherapy, and PSD increased significantly (P<0.05). Compared with one week after radiotherapy, the LPS absolute value of every layer and GLPS obviously reduced after six months, PSD obviously increased, the difference had statistical significance (P<0.05). PSD and GLPS displayed negative correlation one week after radiotherapy (r=-0.420, P<0.05), PSD and GLPS displayed negative correlation six months after radiotherapy (r=-0.641, P<0.05). Conclusions Layered strain technique can noninvasively and quantitatively evaluate the early changes of global and layered longitudinal peak strain and systolic synchrony of left ventricle in left breast cancer breast-conserving radiotherapy patients, and provides a new noninvasive test method for evaluating radioactive myocardial injury, and it has a certain guiding value to early clinical intervention and treatment of cardiovascular complications. Key words: Breast cancer, early; Radiotherapy; Layer-specific strain; Peak strain dispersion

Surgical margins for borderline and malignant phyllodes tumours.

Phyllodes tumours represent less than 1% of all UK breast neoplasms. Histological features allow classification into benign, borderline or malignant, which has a significant impact on prognosis and recurrence. Currently, there is no consensus for the optimal surgical excision margin. This systematic review aims to provide a comparative summary of outcomes (local recurrence, metastasis and survival) for borderline and malignant phyllodes tumours resected with either ≥1cm or <1cm margins. MEDLINE and Embase were systematically searched (1990 to July 2019), in line with PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa scale. Ten retrospective studies were included (Newcastle-Ottawa scale mean score: 5.6, range: 8-4). Nine reported local recurrence rates, four reported distant metastasis and four reported survival. Meta-analysis pooling demonstrated no statistically significant difference between <1cm and ≥1cm margins in terms of local recurrence rates (relative risk [RR] 1.43, 95% confidence interval [95% CI] 0.70 - 2.93; p=0.33, n=456), distant metastasis (RR 1.93, 95% CI 0.35 - 10.63; p=0.45, n=72) or mortality (RR 1.93, 95% CI 0.42 - 8.77; p=0.40, n=58) for borderline and malignant tumours. Additionally, two studies demonstrated no significant difference in local recurrence for borderline tumours excised with <0.1cm margins compared to ≥1cm. Current evidence suggests that margins <1cm may provide adequate tumour excision. This could enable breast conservation in patients with smaller breast-to-tumour volume ratios, with improved cosmetic outcomes and patient satisfaction. A prospective, multi-institutional trial would be appropriate to further elucidate the safety of smaller margins.

Oncoplastic Central Partial Mastectomy and Neoareolar Reduction Mammoplasty with Immediate Nipple Reconstruction: An Initial Report of a Novel Option for Breast Conservation in Patients with Subareolar Tumors.

Breast-conserving therapy (BCT) has been associated with better quality of life and cosmetic outcomes than mastectomy. However, subareolar cancers abutting the nipple-areolar complex (NAC) present a unique cosmetic and oncologic challenge. Oncoplastic central partial mastectomy and neoareolar reduction mammoplasty with immediate nipple reconstruction is a novel technique that can permit BCT for these patients. This study enrolled consecutive patients with central tumors during 2017-2018 who underwent central partial mastectomy reconstructed with neoareolar reduction mammoplasty and immediate nipple reconstruction. Patient demographics, imaging and pathology size, margin width, mastectomy and reexcision rates, and cosmesis were evaluated. The study identified 23 sequential patients. The average patient age was 60.5 ± 12.3years, and the average body mass index was 29.4 ± 5.7kg/m2. The mean lesion size was 51.5 ± 43.0mm on preoperative imaging, and the average disease span shown by the final pathology was 59.5 ± 45.3mm. "No ink on tumor" was achieved for 22 patients (95.7%). In 13 patients (56.5%), the margins were inadequate for ductal carcinoma in situ (DCIS) (n = 12) or invasive cancer (n = 1). Good to excellent cosmetic results were achieved for 21 patients (95.5%). Complications occurred for six patients (26.1%), including three patients with ischemia of the reconstructed NAC. The single-stage operation described in this report can allow patients with cancers abutting the NAC to consider BCT. This technique allows patients to avoid mastectomy and to minimize the number of operations required for reconstruction while maximizing cosmetic outcomes. In the study cohort, the presence of extensive DCIS resulted in a significant need for reexcision, which could be performed successfully without compromise to cosmetic outcome.

A Prospective Phase I trial of Concurrent Cisplatin (CIS) and Radiation Therapy (RT) in Women with Stage II and III Triple-negative Breast Cancer (TNBC)

Patients with TNBC experience a higher rate of both in breast and regional nodal recurrence. CIS is an effective systemic chemotherapy in TNBC, and is also a radiation sensitizer. This prospective, phase Ib trial was designed to assess safety and toxicity and establish the recommended phase 2 dose of concurrent CIS with adjuvant RT for women with stage II and III TNBC. Eligible patients had stage II or III TNBC. Any prior preoperative or adjuvant chemotherapy was permitted except CIS or carboplatin. Patients receiving preoperative therapy could not have a complete pathologic response. CIS was initiated at 10 mg/m2intravenously once weekly, then escalated in a classic 3 + 3 design by 10 mg/m2at each dose level until a dose of 40 mg/m2, or maximum tolerated dose (MTD), was reached. Breast conservation (BCT) and mastectomy (M) patients were accrued in separate parallel cohorts in dose-escalation followed by a 10 patient expansion at the MTD for each group. During the escalation phase, all patients in each dose level were observed throughout the 8-week dose limiting toxicity (DLT) window prior to dose escalation. RT was delivered with conventional once-daily fractionation (1.8-2.0 Gy) to the breast or chest wall to 50-50.4 Gy followed by a 10 Gy lumpectomy site cone down (BCT) or 6-10 Gy incision boost (M) at the discretion of the radiation oncologist. Regional nodal radiation was also at the discretion of the treating physician (46-50.4 Gy). Fifty-five patients were accrued from 2013-2018. Four experienced a DLT. In the BCT cohort, one patient developed tinnitus at the maximum dose level of 40 mg/m2resulting in a cisplatin delay. This was therefore the BCT MTD. In the M cohort, three experienced a DLT. One patient, receiving 30 mg/m2CIS, was hospitalized for a grade 3 urinary infection. Two additional patients had DLTs at 40 mg/m2: one grade 3 neutropenia, and the other tinnitus, both resulting in delays in CIS. As a result, 30 mg/m2was the MTD for the M cohort. Two patients had breaks in radiation, (one day and three days; both hospitalized for infection). The most common adverse events in both cohorts were dermatitis (45% grade 2, 2% grade 3), leukopenia (15% grade 2, 15% grade 3), fatigue (15% grade 2), nausea (11% grade 2), ototoxicity and thrombocytopenia (each 7% grade 2). Only one patient (BCT cohort at 30 mg/m2) experienced grade 3 radiation dermatitis; there were no grade 4 skin reactions. CIS was held (16%) or discontinued early (7%) in 13 patients. Median follow-up was 29.1 months. Three-year disease-free survival was 71% in the BCT cohort, and 70% among M patients. Adjuvant radiation therapy with concurrent CIS is feasible with the MTD of 30 mg/m2and 40 mg/m2IV weekly in M and BCT patients, respectively. Additional study is necessary to determine the long-term benefits of concurrent treatment in this high-risk population.

Extreme oncoplasty: Expanding indications for breast conservation

IntroductionPresence of multiple lesions and/or tumor span ≥5 cm are traditional indications for mastectomy. Patient desire for breast conservation has increased the interest in extreme oncoplastic breast conserving surgery (EOBCS) to avoid mastectomy; however, perioperative outcomes in this population have not been well described. MethodsThis is an observational cohort of breast cancer patients with multiple lesions and disease span ≥5 cm who underwent EOBCS. Patient demographics, disease span, margin width, mastectomy and re-excision rates, and cosmesis were evaluated. ResultsOne hundred-eleven patients underwent EOBCS between 2012 and 2017. Eighty-two patients presented with multifocal or multicentric disease with an average of 3.2 lesions per breast spanning 57.1 ± 23.6 mm. Eighteen patients presented with unifocal tumors measuring an average of 67.6 mm (range 50–160 mm) on imaging. Eleven patients with an imaging size of <5 cm had a disease span ≥5 cm on final pathology. No tumor on ink occurred in 87 (78.3%) patients. Fifty-seven (51.4%) patients had additional surgery for inadequate margins. Fifteen (12.6%) patients elected to have mastectomy while 42 (37.8%) patients opted for re-excision. Good to excellent cosmetic results were reported in 95% of patients who ultimately achieved breast conservation. Recurrence rate was 1.1% in patients who completed EOBCS and adjuvant radiation therapy. ConclusionEOBCS can allow for breast conservation in patients who are traditionally counseled to undergo mastectomy. Although the re-excision rate was significant, most patients ultimately achieved breast conservation with adequate margins. Further study is warranted to determine the long-term oncologic outcomes of this approach.