Candidates For Conservative Surgery Research Articles

Nipple-Sparing Mastectomy After Neoadjuvant Chemotherapy: Definitive Results with a Long-Term Follow-Up Evaluation.

Nipple-sparing mastectomy (NSM) is increasingly used for women with breast cancer who are not candidates for conservative surgery. The authors previously reported satisfying results with NSM after neoadjuvant chemotherapy (NACT). From 2010 to 2020, 1072 women underwent mastectomy at the authors' institution. In this group, 433 NSMs were performed (40%). The only contraindications to NSM were close proximity to the nipple-areola complex (NAC), bloody discharge, and Paget disease. In 112 cases involving 111 women, NSM followed NACT (group 1), whereas it was performed as primary surgery in 321 instances involving 306 women (group 2). At 5 years, local relapse was 7% in group 1 and 2% in group 2, although in the multivariate analysis, locoregional relapses (LRRs) did not differ between the two groups. An increased incidence of local relapse was associated with higher tumor stage (stage III; p = 0.046) and age younger than 51 years (p = 0.038). For 34 (30.3%) of the 111 women in group 1 with a pathologic complete response (pCR), no LRRs were recorded. Only one NAC recurrence was observed. Overall survival with each tumor stage did not differ between the two groups. No differences in complications were observed. Cosmetic results were satisfying in 83.8% of the cases and did not get worse after NACT. The study data definitively confirm that NSM is safe even after NACT, with good cosmetic results and complications comparable with those in the primary surgery setting. Tumor stage and age were the only independent factors for local relapse. Patients with pCR enjoyed optimal locoregional control.

Mastectomía ahorradora de piel y pezón en carcinoma ductal in situ. Seguridad oncológica a 10 años

ObjectiveThe aim of this study was to assess the oncological safety of nipple-sparing mastectomy (NSM) in patients with ductal in situ carcinoma (DCIS) over a 10-year period. MethodRetrospective observational analysis. A total of 35 NSM were performed in patients with DCIS from 2005 - 2018. We assessed the histological, oncological and morbidity results. ResultsThe most frequent indications were margin involvement after lumpectomy (31.5%), multifocality / multicentricity (22.8%), tumour size >3 cm (8.6%) unfavourable tumour / breast size correlation (8.6%) and patient choice (8.6%). The most commonly used technique was external lateral incision in 11 patients, followed by the Spira technique in 9 patients.DCIS was confirmed in 22 patients and no tumour was found in mastectomy specimen in 11 patients.The complication rate was 22.8%. After a median follow-up of 104 months (SD 69.9) there was no nipple necrosis. In all, 20% of the patients required long-term reintervention. Eleven patients (31.4%) underwent adjuvant treatment (chemotherapy and / or radiotherapy). Only one patient showed local recurrence (2.8%) 28 months after the intervention. One patient developed metastases after 78 months of disease-free survival (DFS). DFS and overall survival rates were 94.3% and 97.22%.Univariate analysis showed two risk factors for recurrence: age <40 years [OR (95% CI) 2.529 (1.230-5.199)] and margin involvement [OR (95% CI) 5.242 (2.041 - 13.464)]. ConclusionNSM is safe and feasible in patients with DCIS who are not candidates for conservative surgery.

Positive margins (R1) risk factors in breast cancer conservative surgery.

BackgroundThe primary goal in conservative breast cancer surgery is the complete excision of the tumor, but at the same time attempting to obtain a satisfactory postoperative esthetic result. The notion of “No Ink on Tumor” that indicates exclusively the presence of tumor cells on the inked surface of the surgical specimen is now the gold standard; however, the problem of the free margin is still a fundamental topic of debate that has not yet found a definitive solution.MethodsOur retrospective analysis takes into account 1440 patients undergoing breast conservative surgery, from October 2004 to November 2018, all treated at the breast unit of our institution.ResultsPositive margins (R1) rate was 10.2% (147 cases out of 1440). Overall survival was 95% at 5 years and 89% at 10 years. No differences in mortality and local recurrence rate between R0 and R1 patients were found. Half of the R1 patients underwent secondary surgery with enlargement of margins, while in the other half we performed direct mastectomy. Among the analyzed variables, age, histological size, histological type, grading, multifocality, lympho-vascular invasion and lymph node status were significantly correlated with the R1 status. The multivariate analysis shows the association of age and surgical technique (oncoplastic) with R1 status.ConclusionFurther studies will allow the creation of a statistical model, for better pre-operative prediction of patients with higher risk of R1 and better selection of patients to be candidates for conservative surgery.

Abstract OT2-02-01: Brazilian randomized study - Impact of preoperative magnetic resonance in the evaluation for breast cancer conservative surgery (BREAST-MRI trial)

Abstract Background: A precise preoperative evaluation of the tumor is essential to improve breast cancer surgical management. Currently, mammography associated with ultrasound and clinical exam are the standard techniques for evaluating extension and tumor localization. However, approximately one third of the lesions in patients eligible for conservative surgical treatment are misevaluated by these methods. Breast magnetic resonance imaging (MRI) has a high sensitivity (95-100%) in detecting invasive neoplasms, and is able to detect occult tumors, multifocal and/or multicentric disease, and contralateral breast cancer more accurately than mammography and ultrasound. Until now, there are only three randomized trials assessing the role of preoperative MRI. These trials have different designs and contradictory results. Trial design: BREAST-MRI is a randomized, open label, unblinded trial designed to compare the accuracy of breast MRI in the preoperative planning of surgical treatment of breast cancer to standard protocol (clinical exam of the breast, mammography and/or breast ultrasound) and the impact of breast MRI on breast cancer outcome. Patients are randomized on a 1:1 basis, stratified for mammary density, into two groups: 1)MRI group: patients are submitted to MRI and standard protocol 2)Control group: standard protocol. First phase: patient recruitment and data collection up until surgery. Second phase: follow-up for five years or until death. Eligibility criteria: women aged 18 years or older with breast cancer stages I to III candidates for conservative surgery (CC). Specific aims: The aim of this study is to evaluate the ability of MRI in selecting patients for conservative treatment of breast cancer. Primary outcomes are: false positive rates, false negative rates, positive predictive value and negative predictive value of MRI in breast cancer CC. Secondary outcomes are: rates of positive margins on pathological examination; reoperation rates; number of conversions to mastectomy; accuracy of MRI according to mammographic density, immunohistochemical subtype and histopathology of the tumor; rates of multicentricity, multifocality and bilateralality of tumors; disease-free survival after 3 and 5 years; and cost-effectiveness of breast MRI. Statistical methods: The calculated total case number for this trial is 372, assuming a recurrence rate of 10% for CC and 1% for mastectomies. The Shapiro-Whilks test will be used to verify if distribution of the quantitative variables follows normal distribution. The baseline population will be analyzed using the t-Student test, or the Mann-Whitney test when appropriate. To test the existence of a possible association between outcomes and the categorized characteristics, chi-square and Fisher's exact test will be performed. Disease progression will be reassessed at 3 and 5 years follow-up, in order to produce a log-rank Kaplan-Meier curve of survival. Present accrual and target accrual: In June 2017, randomizations are at approximately 90% of the target sample size. Citation Format: Dória MT, Mota BS, Reis YN, Ricci MD, Piato JRM, Ferreira VCCS, Shimizu C, Barros N, Filassi JR, Baracat EC. Brazilian randomized study - Impact of preoperative magnetic resonance in the evaluation for breast cancer conservative surgery (BREAST-MRI trial) [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 OT2-02-01.

Radioterapia intraoperatoria de la mama con Intrabeam®: experiencia inicial en nuestro centro

ObjectiveIntraoperative radiotherapy (IORT) in selected patients with breast cancer allows a short and precise treatment on the tumor bed in situ during conservative surgery. We present our initial experience of IORT with the Intrabeam® device. Patients and methodsFrom January 2013 to February 2015, 120 patients with breast cancer were pre-selected for IORT with Intrabeam® according to the TARGIT-A protocol. The indications were as follows: candidates for conservative surgery, age older than 45 years, a histological diagnosis of hormone-dependent infiltrating ductal carcinoma≤3cm and absence of axillary involvement on physical, ultrasound and histological examination. ResultsAmong the selected patients, 34 (28%) did not receive IORT due to the size of the surgical cavity (28 patients) or technical problems (6 patients). Finally, 86 patients (72%) received IORT. The average age was 64 years (SD±8.4). In 22 patients (26%), it was necessary to administer external beam radiotherapy to the whole breast. Thirteen patients (15%) had complications: 3 cases of seroma requiring more than 3 attempts for resolution (4%), 6 cases of abscess-mastitis (7%), 2 cases of hematoma (2%) and 2 cases of partial dehiscence of the surgical wound (2%). There was no severe toxicity (grade iii-iv). The aesthetic result was good or very good in 87% of the patients (n=75). ConclusionIORT with Intrabeam® is a safe and well tolerated alternative versus external radiotherapy in selected patients and provides a good short-term aesthetic result.

Role of hemithyroidectomy in differentiated thyroid cancer.

The incidence of differentiated thyroid cancer (DTC), especially among small tumors, is increasing worldwide, despite the fact that the mortality rate from thyroid cancer remains stable. Total thyroidectomy with or without radioiodine therapy is actually the standard treatment. In the last 2 decades, several studies have shown that lobectomy could be an alternative to total thyroidectomy in low-risk DTC without compromising overall survival. The aim of this article was to assess the role of conservative surgery (hemithyroidectomy) in DTC reviewing the literature data. Recent advances in diagnostic techniques allow treatment to be tailored to patients' needs. The latest consensus guidelines suggest that patients with high-risk tumors should undergo total thyroidectomy, whereas patients with small, low-risk, node-negative DTC may be candidates for conservative surgery. Careful risk evaluation and stratification makes it possible to individualize treatment, avoid overtreatment and guarantee a good long-term prognosis with low recurrence risk. Excellent prognosis of DTC would require large sample sizes and long-term follow-up for prospective trials comparing the outcomes of total thyroidectomy vs. lobectomy; however, there are several remarkable retrospective studies. Based on current clinical data, a conservative surgery might be appropriate for patients with low-risk DTC.

Nipple-Sparing Mastectomy: Are We Compromising Oncologic Safety for Cosmesis?

Randomized trials, such as the National Surgical Adjuvant Breast and Bowel Project B-04 and B-06 clinical trials, provided a foundation for a minimally invasive approach to the surgical management of early breast cancers. Data from these trials resulted in women being offered breast conservation surgery rather than mastectomy. However, there will always be women who are not candidates for conservation surgery or who simply prefer mastectomy. For such patients, the surgical approach to mastectomy has shifted from the disfiguring radical mastectomy of old to skin-sparing mastectomy. Out of the skin-sparing technique evolved the subcutaneous mastectomy, described by Freeman in 1962. Today, the nipple-sparing mastectomy (NSM), as subcutaneous mastectomy is now called, offers an even better cosmetic outcome and has garnered much attention as mastectomy rates overall continue to increase in many parts of the United States. However, the question remains: Does NSM adequately accomplish the goal of mastectomy, which is to remove the entire mammary gland for maximum therapeutic benefit for those with cancer or prophylaxis for those at risk?

Preliminary Experience Using Oncoplastic Techniques of Reduction Mammaplasty and Intraoperative Radiotherapy: Report of 2 Cases

Since 2004 in the Department of Oncological Integrated Surgery at the National Institute for Cancer Research of Genoa, we have applied different techniques of reduction mammaplasty for a subgroup of 26 patients with medium- to large-sized and ptotic breasts who are candidates for conservative surgery. In this series of patients, the choice between different techniques of breast reduction (superior or inferior pedicled or with free areola-nipple graft) depended only on cancer position. The chosen technique minimized reshaping and displacement of residual glandular flaps. In September 2009, the radiotherapists at the Institute began to apply intraoperative radiotherapy (IORT) to early breast cancer, and at the time of this report, more than 200 patients have been treated. This report describes two cases of reduction mammaplasty associated with this new and easily performed radiotherapy option (IORT) and discusses its advantages and cautions. Close collaboration between surgical oncologist, plastic surgeon, and radiotherapist is essential before and during surgery to obtain adequate tumor resection and good aesthetic results and to minimize postoperative complications.

Comparison of open nephroureterectomy and ureteroscopic and percutaneous management of upper urinary tract transitional cell carcinoma

Objectives To compare the outcomes in patients who had undergone either open nephroureterectomy or conservative endoscopic surgery (ureteroscopic or percutaneous management) for upper urinary tract transitional cell carcinoma. Methods We performed a retrospective review of the data for patients treated surgically for upper urinary tract transitional cell carcinoma from 1990 to 2004. The data included patient sex, age at diagnosis, mode of diagnosis, smoking history, history of bladder cancer, type of surgery, complications, and tumor site, size, stage, grade, recurrence, and progression. We also evaluated the recurrence and survival rates. Results Data were analyzed for 97 patients. The median patient age was 68 years. Sixteen patients had a history of bladder tumor. The surgical procedure was open nephroureterectomy in 54 patients, ureteroscopy in 27, and percutaneous endoscopic ablation in 16. The tumor stage, grade, and site were independent prognostic factors for survival in a multivariate analysis ( P <0.05). The 5-year disease-specific survival rate was 81.9% for low-grade tumors and 47.3% for high-grade tumors ( P = 0.0001). A correlation ( P = 0.002) was found between low-grade tumors and superficial tumors. In patients with low-grade tumors (n = 46), the 5-year disease-specific survival rate after nephroureterectomy, ureteroscopy, and percutaneous endoscopy was 84%, 80.7%, and 80%, respectively ( P = 0.89); the corresponding 5-year tumor-free survival rates were 75.3%, 71.5%, and 72% ( P = 0.78). Conclusions Conservative surgery can be recommended as an alternative to nephroureterectomy for low-grade or superficial upper urinary tract transitional cell carcinoma. For patients with high-grade or invasive tumors to be candidates for conservative surgery will require the development of additional prognostic factors (eg, molecular markers). These patients require long-term postoperative surveillance.

Single-Agent Epirubicin as Primary Chemotherapy in T2–T3, N0–N2, M0 Breast Carcinoma: 6-Year Follow-Up

Objective: Single-agent epirubicin was tested as primary chemotherapy treatment in patients with early breast cancer >3 cm. Methods: 100 women with locally advanced breast cancer >3 cm were treated with three cycles of single-agent epirubicin at a dose of 120 mg/m². All patients showing tumor shrinkage to less than 3 cm were considered candidates for conservative surgery (quadrantectomy); in the remaining patients modified radical mastectomy was carried out. Postsurgical treatment consisted of CMF chemotherapy except for postmenopausal node-positive, estrogen-positive patients who were assigned to hormonal treatment with tamoxifen and postmenopausal node-negative, estrogen-positive ones who did not receive any treatment. Results: Quadrantectomy was carried out in 71 patients. At the median follow-up time of 69 months, the relapse rate was 29.6% among patients who underwent quadrantectomy (21 out of 71) and 58.6% among patients who underwent modified radical mastectomy (17 out of 29). Conclusions: Single-agent chemotherapy with anthracyclines could appear to be an effective treatment in inducing a tumor downstaging in patients with early breast cancer >3 cm. This treatment can be administered outside clinical trials in patients who desire to preserve their body integrity. Further prospective, randomized trials are needed in order to validate and better define the role of epirubicin in the neoadjuvant strategy of breast cancer patients.

Stage IA 1 cervical adenocarcinoma: definition and treatment

Objective: To propose a definition for stage IA 1 cervical adenocarcinoma, based on the International Federation of Gynecology and Obstetrics (FIGO) staging system, and to determine if patients meeting criteria might be candidates for conservative surgery. Methods: Two hundred women were diagnosed with early-stage cervical adenocarcinoma from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed, and patients included in this study had microscopically identifiable lesions, up to 3 mm invasive depth, up to 7 mm tumor width, and negative margins if cone biopsy was performed. Results: Twenty-one patients with microinvasive adenocarcinoma met criteria for FIGO stage IA 1 carcinoma of the cervix. The median (range) follow-up was 76 (30–172) months and median (range) patient age was 38 (24–75) years. Definitive treatment included type II or III radical hysterectomy in 16 cases, simple abdominal or vaginal hysterectomy in four cases, and loop electrosurgical excision procedure in one case; one patient received adjuvant pelvic radiation. The histologic subtypes were endocervical adenocarcinoma in 18 cases, adenosquamous carcinoma in two cases, and clear-cell adenocarcinoma in one case. There was no evidence of parametrial invasion or lymph node metastases in any patient who had radical surgery, and there were no disease recurrences. Conclusion: Patients with microinvasive adenocarcinoma who met criteria for FIGO stage IA 1 cervical carcinoma had disease limited to the cervix, and conservative surgery, such as cone biopsy or simple hysterectomy, might offer them definitive treatment.

Conservative surgery and radiation for early-stage breast cancer.

In selected patients with early-stage breast cancer, conservative surgery and radiation represent an alternative equal to mastectomy in terms of local recurrence, distant metastasis, survival, and long-term complications. Patients with early-stage breast cancer who are candidates for conservative surgery and radiation include those whose primary tumor is less than 4 to 5 cm in size without evidence of gross multicentricity or diffuse microcalcifications. Patients with an extensive intraductal component may be appropriate candidates provided that margins of resection are negative. Young age is not a contraindication to the conservative treatment. A preexisting history of collagen vascular disease or prior mantle irradiation for Hodgkin's or non-Hodgkin's lymphoma represents a contraindication to conservative surgery and radiation because of the potential for severe complications. An additional contraindication is the pregnant woman in whom delivery cannot be accomplished before the initiation of radiation. Mammography is essential in the pretreatment evaluation and posttreatment follow-up of the conservatively treated patient. The goal of the pretreatment mammogram is to assess the extent of disease in the ipsilateral breast as well as to evaluate the contralateral breast. In patients who present with microcalcifications, a postbiopsy mammogram before radiation is essential to document complete removal of all malignant-appearing microcalcifications. Mammography is an essential part of the follow-up program in order to detect a recurrence in the treated breast as well as a cancer in the contralateral breast cancer. The optimal interval for follow-up mammography has not been determined, although programs employing mammography on a yearly basis after treatment have been associated with the detection of early recurrences and excellent survival after salvage mastectomy for these recurrences.

Breast-Conserving Surgery and Radiation Therapy: Are They Underused?-Reply

In Reply. —We welcome the opportunity to continue the discussion about the underutilization of breast-conserving surgery and radiation therapy for early invasive breast cancer. The title of our article 1 expresses our interpretation of the study's findings, and we are pleased that it has raised concern among clinicians about the appropriate use of breast-conserving surgery. As stated in the article, we recognize that the analysis was limited by our inability to measure tumor characteristics or patient preference that would determine type of surgery. But we doubt that the majority of the 5364 women with mastectomy (66%) in our study were either unsuitable candidates for conservative surgery or chose that treatment after appropriate counseling. Despite growing scientific evidence in support of the efficacy of breast-conserving surgery and radiation therapy, the time trends indicate essentially no change in breast-conserving surgery for women with stage I disease and a possible decline for women