Breast-conserving surgery (BCS) for non-palpable lesions is technically demanding, often performed by surgical trainees under supervision. Despite extensive literature evaluating localization techniques, only few studies have directly examined the role of surgeon seniority in determining surgical performance in this specific setting. We conducted a retrospective multicenter analysis (LOCALIZATION01 study, NCT05942105) including 3,195 patients who underwent BCS for non-palpable breast lesions between 2016 and 2024 across 12 Breast Units. Four localization techniques were used: wire-guided (WGL), radioguided occult lesion localization (ROLL), magnetic seed localization (MSL), carbon localization (CL). Outcomes included margin status, calculated resection ratio (CRR), operative time, and complications, stratified by surgeon seniority (attending vs resident). Most procedures were performed by attending surgeons (89.3%, n=2,855) compared to residents (10.7%, n=340). Margin positivity rates didn't differ significantly across localization techniques (e.g., ROLL 3.7% vs 2.3%, p=0.30; MSL 9.4% vs 4.4%, p=0.11, WGL 2.7% vs 5.9 p=0.16, CL 0% vs 9.6% p=0.10). Residents achieved better CRR in ROLL procedures (2.0, IQR 3, [1-47] vs 2.8, IQR 5, [1-78], p=0.006), but had longer operative times, particularly with SLNB (e.g., MSL 60min, IQR 31, [37-98] vs 55min, IQR 20, [18-180], p=0.02). Complication rates were low and comparable between groups. In a supervised setting, surgeon seniority doesn't significantly impact margin status, complication rates, or overall oncologic safety in BCS for non-palpable breast lesions. Localization methods with high reproducibility, such as ROLL and MSL, may mitigate the influence of surgical inexperience. These findings support the safe involvement of trainees in BCS under adequate supervision.

Detection of margin positivity in breast cancer using fluorescence and diffuse reflectance imaging.

ASO Visual Abstract: Complication Profiles of Immediate Implant-Based Versus Deep Inferior Epigastric Perforator Flap Breast Reconstruction Following Nipple-/Skin-Sparing Mastectomy in Patients with Prior Breast-Conserving Surgery and Radiotherapy.

Identification of selection criteria for DIBH in patients with left breast cancer using 3D-CRT and VMAT: An analysis with dosimetric parameters and NTCP models.

ASO Visual Abstract: Breast-Conserving Therapy for Multiple Ipsilateral Breast Cancer After Neoadjuvant Systemic Therapy.

Recent trials suggest omission of sentinel lymph node biopsy (SLNB) for selected early-stage breast cancer patients. However, invasive lobular carcinoma (ILC) is underrepresented, and retrospective data indicate higher rates of nodal metastases, raising concerns about axillary understaging. This study aimed to evaluate the prevalence and predictors of nodal metastases in early-stage, clinically node-negative ILC. This study retrospectively analyzed 491 patients with estrogen receptor (ER)-positive/human epidermal growth factor receptor 2 (HER2)-negative, clinical T1, clinically node-negative ILC who underwent breast-conserving surgery at our institution between 2004 and 2024. The exclusion criteria ruled out neoadjuvant therapy, tumor larger than 2 cm, and metastatic disease at diagnosis or prior breast cancer. Among 491 patients, 392 (79.8 %) were pN0, whereas 99 (20.2 %) had nodal metastases (pN1mi-pN3). Pathologic tumor size was significantly associated with axillary nodal involvement (p = 0.004). In contrast, histologic subtype was not significantly associated with nodal status (p = 0.15), although pleomorphic tumors demonstrated numerically higher rates of nodal involvement than classic invasive lobular carcinoma. Menopausal status was not predictive of nodal positivity (p = 0.96). Approximately one (20.2 %) in five patients with early-stage, clinically node-negative ILC harbors occult axillary nodal metastases. Pathologic tumor size emerged as the primary determinant of nodal involvement. Pleomorphic variants showed a tendency toward higher nodal burden. These findings indicate that omission of SLNB in ILC may carry a risk of axillary understaging with potential therapeutic implications. Pending evidence from prospective studies specifically designed for lobular histology, SLNB should continue to be considered an essential component of axillary evaluation in this subgroup.

There is an increasing utilization of ultrahypofractionation radiotherapy plans in whole breast radiotherapy. This study presents a comparative analysis of ultrahypofractionation using volumetric modulated arc therapy (VMAT) and intensity modulated proton therapy (IMPT) in treatment planning for patients undergoing breast conserving surgery (BCS). CT datasets of twenty patients undergoing BCS, with ten on the left side and ten on the right side, were retrospectively replanned using both VMAT and IMPT techniques. The study included four scenarios: left/right breast only and left/right breast with regional nodes. A total dose of 26 Gy(RBE) was prescribed in 5 fractions. The CTV (clinical target volume) was optimized for IMPT, incorporating a 3 mm setup uncertainty and a 3.5% range uncertainty. The planning target volume (PTV) was used for VMAT optimization and evaluation for both techniques. Dose to the target volume and organs at risk (OARs) between IMPT and VMAT was analyzed. The PTV-D95, along with the V10 and V20 of the ipsilateral lungs, was comparable between VMAT and IMPT plans. The ipsilateral lung Dmean and V5 were significantly lower for the IMPT methods for breast-only radiotherapy and for the right breast with regional nodes. IMPT plans showed significantly reduced Dmean, V5, and V10 doses to the contralateral lung, as well as Dmean and V5 doses to the heart in all subgroups. The Dmean of the heart was less than 1 Gy for the left-sided and less than 0.5 Gy for the right-sided subgroup in IMPT plans. However, the IMPT plans showed a significantly higher Dmax for the skin surface in all subgroups, as well as for the esophagus in the left breast with regional nodes subgroup. IMPT plans significantly reduced radiation exposure to most surrounding OARs compared to VMAT. Clinical outcomes are needed to confirm the potential for reduced late toxicities. However, this benefit was accompanied by an increased skin surface dose and, in specific cases, a higher esophageal dose.

Endoscopic breast-conserving surgery (EBCS) aims to offer improved cosmetic outcomes while maintaining oncologic safety. Although well established in East Asian programs¹⁻³, its use remains uncommon in India⁴. This pilot feasibility series describes early Indian experience with EBCS and sentinel lymph node biopsy (SLNB) performed entirely through a single concealed axillary incision. Three consecutive women with biopsy-proven, clinically node-negative early invasive carcinoma underwent single-incision EBCS with SLNB between January and March 2025. The technique used CO₂ insufflation, a glove-port system, and ultrasonic dissection. Primary outcomes included operative parameters, margin status, sentinel node retrieval, and perioperative complications. Secondary outcomes were seroma, drain duration, pain scores, recovery milestones, and cosmetic satisfaction using a 5-point Likert scale. Follow-up was recorded individually for each patient. All cases were completed endoscopically without conversion. Mean operative time was 145min (range 130-160), and blood loss averaged 60ml. Margins were negative in all three patients. One minor seroma resolved with conservative management. No wound infections, skin necrosis, dimpling, or lymphedema occurred. At a median follow-up of nine months, all patients remained disease-free. Cosmetic satisfaction was high (average Likert 4.6/5), with preserved breast contour and no visible deformity. Single-incision EBCS with SLNB is feasible, safe, and cosmetically favourable in selected Indian patients offering oncologic adequacy. While early outcomes are reassuring, larger series, longer follow-up, and validated PROMs such as BREAST-Q are required to better define the technique's role in routine oncologic practice.

Phyllodes tumours of the breast exhibit a spectrum of biologic behaviour, with a predisposition to recur locally and metastasize distantly in their malignant form. There are limited data regarding the optimal surgical approach. Our systematic review and meta-analysis aimed to determine the impact of breast conserving surgery (BCS) compared to mastectomy on overall survival (OS), disease-free survival (DFS), and local recurrence (LR) for patients with borderline and malignant phyllodes tumours to guide treatment planning. We identified relevant studies from PubMed, MEDLINE, Embase, and Google Scholar using the updated PRISMA Guidelines. Included studies compared breast conservation and mastectomy and reported rates of OS, DFS, and LR for individuals with borderline or malignant phyllodes tumours. A random-effects model was used to pool relative risk data. Heterogeneity was assessed using Cochran's Q statistic. Out of 1950 screened by our search, 13 studies were deemed suitable for inclusion. These studies included 874 patients undergoing breast conservation and 784 undergoing mastectomy. The median follow-up time was 65 months. There was improved OS following BCS in the malignant (pooled RR 0.9, 95% CI 0.85-0.95) and combined borderline and malignant cohorts (pooled RR 0.91, 95% CI 0.86-0.95). There was no difference in DFS in the malignant or combined cohorts. LR risk was increased following BCS in both malignant (pooled RR 2.47, 95% CI 1.64-3.72) and combined cohorts (pooled RR 2.25, 95% CI 1.66-3.04). There was no significant heterogeneity. For individuals with borderline or malignant phyllodes tumours, BCS should be offered, where feasible, as part of an individualised multidisciplinary approach.

Phyllodes tumours (PTs) are infrequent fibroepithelial neoplasms that account for <1% of all primary breast tumours. Local recurrence (LR) rates and distant metastasis vary depending on tumour histology. In this case report, the patient developed a painful growing tumour in the nipple after nipple-sparing mastectomy 17 years before. Local excision was performed with a final diagnosis of borderline PT after 205 months disease-free.The management of surgical margins of PT remains under discussion due to the high risk of LR. Breast-conserving surgery, when feasible, is considered the surgical approach of choice; however, immediate breast reconstruction after mastectomy is a balanced option when the tumour's characteristics are not suitable for conservative surgery. When performing nipple-sparing mastectomy, nipple recurrence is extremely rare but a complication to consider during the patient's follow-up.

Objective: Assessing axillary lymph node metastasis accurately before breast-conserving surgery is essential for guiding surgical decisions and improving diagnostic performance. The study aimed to determine the accuracy of breast magnetic resonance imaging (MRI) in assessing axillary lymph node metastasis in cancer patients undergoing breast-conserving surgery. Material and Methods: A cross-sectional descriptive study was conducted on 76 breast cancer patients with indications for conservative surgery at the Vietnam National Cancer Hospital from June 2020 to May 2021. Patients were assessed for axillary lymph node metastasis using a 1.5 Tesla MRI machine through analysis of parameters of size and morphology on conventional sequences and Diffusion-Weighted Imaging (DWI) sequences. Data were analysed by descriptive statistics and T-test with IBM Statistical Package for the Social Sciences (SPSS) 25.0 software.Results: Short-axis length, short/long axis ratio, cortical thickness, loss of fatty hilum, and eccentric cortical thickening were the parameters with statistically significant differences between the two groups of metastatic and non-metastatic lymph nodes (p-value-value&lt;0.05). The Apparent diffusion coefficient (ADC) index was statistically significant between the two groups, with area under the curve (AUC) values higher than the AUC values of the parameters on conventional magnetic resonance (AUC: 0.874, with the optimal threshold of 1.046x10-3 mm2/s for sensitivity of 78.6%, specificity of 85.5%) (p-value&lt;0.05). Conclusion: Conventional MRI combined with DWI sequences can assess axillary lymph node metastasis in patients undergoing breast-conserving surgery with high sensitivity and specificity. Therefore, to improve treatment quality, it is necessary to assess axillary lymph node metastasis before breast-conserving surgery.

ASO Author Reflections: Increasing Breast Conserving Therapy Rates with Multidisciplinary Clinic-Timing of Consultations is Key.

The use of breast conservation surgery for early-stage breast cancer is common, and adjuvant radiotherapy is often recommended to reduce the risk of ipsilateral breast tumor recurrence. Historical trials have used sequential boost techniques with favorable outcomes with reduction in local recurrence and acceptable cosmetic outcomes. In recent years, there has been renewed interest in incorporating a concurrent tumor bed boost to reduce the number of radiation treatments delivered. This focused review summarizes the literature surrounding the indications, outcomes, and treatment planning considerations for radiation tumor bed boost for early-stage breast cancer patients.

Factors influencing surgical decision-making in breast cancer: A multicenter study in Japan.

The aim of the study was to evaluate the concordance between radiological imaging modalities and pathological findings and to test whether neoadjuvant therapy (NAT) is included in surgical planning, especially in the appropriateness of breast-conserving surgery (BCS). We conducted a retrospective observational study in 280 patients diagnosed with nonmetastatic breast cancer, including [NAT(+): 75 and NAT(−): 205]. Radiological examinations included ultrasonography, mammography, and magnetic resonance imaging before and after NAT. We compared the surgical outcomes, with pathological findings between these groups. In our statistical analyses, we examined the agreement of radiological, surgical, and pathological findings using Pearson chi-square test, Fisher exact test, and the Kappa coefficient. In addition, the data were analyzed using the Python artificial intelligence program and the results were presented. In the study, it was observed that compliance was higher in patients who received NAT compared with those who did not, BCS compliance increased significantly, patients who were not suitable for BCS after NAT became suitable, and there was inconsistency between radiological and pathological findings. Neoadjuvant therapy improves radiological compliance and increases the feasibility of BCS in patients with nonmetastatic breast cancer by effectively reducing tumor size and facilitating more precise surgical planning. Future studies should focus on integrating advanced imaging techniques and molecular profiling to improve treatment strategies and patient outcomes.

MEMS-based near-infrared spectroscopy with AI for real-time breast cancer margin assessment.

BackgroundNearly 40% of breast cancer patients are ineligible for breast-conserving surgery. Immediate implant-based breast reconstruction is a preferred option for these patients. The most severe complication of this procedure is implant loss. Currently, there are no cytokines available to predict implant failure. To identify a drainage biomarker predicting implant loss and evaluate whether dexamethasone irrigation in high-risk cases is associated with reduced implant failure, we designed this study.MethodsA retrospective cohort study was conducted between December 2022 and March 2024, patients undergoing mastectomy with immediate implant-based reconstruction were recruited. We applied protein microarray to analyze cytokines in the drainage fluid from the implant pocket to identify cytokines associated with implant failure.ResultsWe initially selected 3 patients with implant failure and 3 with successful implant outcomes as the cohort for protein microarray analysis. Drainage fluid samples were collected and analyzed at 3 time points: 24 hours postoperatively, at drainage removal and at the onset of implant failure. This analysis identified intercellular adhesion molecule-1 (ICAM-1) as a candidate marker that meets the criteria for predicting implant failure. Subsequently, we validated ICAM-1’s predictive potential in a separate cohort of breast cancer patients who underwent immediate implant-based breast reconstruction between December 2022 and March 2024. Our results demonstrated that ICAM-1 levels in drainage fluid at the time of drainage removal effectively predicted implant failure following immediate breast reconstruction for breast cancer. Additionally, a retrospective analysis revealed that intracavitary irrigation with dexamethasone significantly reduced ICAM-1 level in the drainage fluid and reversed impending implant failure.ConclusionThe data confirmed the potential of ICAM-1 as a predictive factor for breast implant failure. Intracavitary irrigation with dexamethasone was effective to prevent implant loss.

ASO Visual Abstract: Does Multidisciplinary Clinic Impact Rates of Breast Conserving Therapy?

Current intraoperative margin assessment techniques lack the accuracy needed for clinical practice. Indocyanine green fluorescence imaging (ICG-FI) offers a useful technique for detection of tumoral tissue, including breast cancer (BC). There is a great inconsistency in the literature regarding the use of ICG for BC fluorescence imaging mainly concerning ICG dosing and the timing of administration. This study aims to determine the dose and timing of intravenous (IV) ICG administration that provides the optimal diagnostic accuracy for ICG-FI margin assessment during breast-conserving surgery (BCS). This study (BREASTIFLU-1) is a phase II cross-sectional diagnostic accuracy study. It is a five-arm, single-center, prospective, randomized, observational-interventional, open-label study that will include patients with histologically proven early-stage (cT1-T2, cN0-N1) BC who are planned to undergo BCS. Two preoperative timeframes will be used for the administration of five different IV ICG doses in single-dose patient arms. In the intraoperative arms, patients will receive 0.125mg/kg or 0.25mg/kg ICG administered IV at induction anesthesia. In the preoperative arms, patients will receive 0.5mg/kg, 1mg/kg, or 2mg/kg ICG administered 24h before surgery. The primary endpoint is accuracy of the ICG-FI technique for the detection of positive surgical margins. Secondary endpoints include the following: comparison of ICG-FI technique accuracy at different doses and timings, characterization of breast tumor fluorescence, and evaluation of fluorescence intensity of axillary lymph nodes. The trial aims to include 227 patients. Participant recruitment is expected to be complete at the beginning of 2026, and results for the primary outcome are expected to be available in 2026. BREASTIFLU-1 is the first initiative to compare an intraoperative dose of ICG to preoperative ICG administration and is aligned with efforts to standardize the ICG-FI technique. Determining the best dose and timing for IV ICG injection is a crucial step toward using ICG-FI in practice. ICG-FI may provide a relatively easy and quick method to use for reducing the rate of positive margins after BCS. This trial was registered on February15, 2023atClinical Trials Information System EU2023-504024-26-00 and on September10, 2023atClinicalTrials.gov NCT06227338.

ASO Visual Abstract: Commission on Cancer Quality Measure for Omission of Sentinel Lymph Node Biopsy (SNB) in Women Aged 70 Years or Older with Hormone Receptor-Positive (HR+) Invasive Breast Cancer (IBC) Undergoing Breast-Conserving Surgery (BCS): Review of Historical Performance.