Breast Conservation Therapy For Cancer Research Articles

TERTIARY BREAST RECONSTRUCTION: A PROSPECTIVE STUDY ON COSEMETIC OUTCOME AND PERIOPERATIVE COMPLICATIONS

Implant breast reconstruction has seen an upturn over the last decade leading to a rise in referrals of failed prosthetic cases that require salvage by conversion to autologous reconstruction, the most popular being free tissue transfer. This salvage breast reconstruction is complex because of the older patient population with increased comorbidities, effects of previous treatments and inevitable intraoperative challenges. Notable issues include irradiated and scarred skin, severe capsular contracture (CC) and silicone lymphadenopathy. There is also difficulty and potential vascular injury during internal mammary recipient vessel exposure due to scarring, and increased bleeding risk during and after the required capsulectomies. Breast Cancer Conservation therapy cosmetic results BCCT.core computer software program was initially used to assess objectively cosmetic outcomes for lumpectomies but it’s now used for total post mastectomy breast reconstructions. Whilst it is well established that free flap conversion addresses the pain, firmness and cold feel of prosthetic reconstructions (from severe CC) and subjectively improves the cosmetic results, there has hitherto been no objective documentation of the improvement in aesthetic outcomes.

Assessment of breast symmetry in breast cancer patients undergoing therapeutic mammaplasty using the Breast Cancer Conservation Therapy cosmetic results software (BCCT.core).

Therapeutic mammaplasty (TM) is a standard oncoplastic technique utilising aesthetic breast reduction principles to facilitate tumour resection and breast reshaping. Simultaneous contralateral mammaplasties are often performed to maintain symmetry. BCCT.core software, which principally assesses breast symmetry, has been previously employed for evaluating cosmetic results after standard breast conservation therapy and latterly TMs for upper pole tumours. The purpose of this study was to validate this novel tool for TMs in all breast zones. Standardised photographs of 20 consecutive patients who underwent TM were evaluated for symmetry using BCCT.core versus a plastic surgical panel completing a visual analogue scale. Results were rated as (excellent/good/fair/poor). Outcomes between the two methods were compared. Twenty patients aged 37 to 63 years with a median 36G bra size had 22 TMs (18 unilateral, 2 bilateral). Indications were invasive breast cancer (87%) and ductal carcinoma in situ (DCIS) (13%). The median (range) tumour size was 22.5 mm (6-90 mm) with a resection weight of 245.8 g (16-1,079 g). Primary nipple pedicles were superomedial (63%), inferior (21%) and superolateral (16%). Five patients required a secondary glandular pedicle for volume redistribution to maintain breast shape. The BCCT.core software vs. panel symmetry assessments were 37% vs. 39% (excellent), 63% vs. 50% (good) and 0% vs. 11% (fair). Wilcoxon matched-pairs sign rank tests and Spearman rank correlations found the pairings to be statistically significant (P<0.05). Despite small patient numbers, BCCT.core gave comparable findings with the panel and is thus useful for objectively assessing cosmesis of TMs in all breast zones.

Breast reconstruction after breast conservation therapy for breast cancer.

Conservative breast surgery followed by irradiation, often referred to as Breast conserving therapy (BCT), has replaced modified radical mastectomy for the treatment of early stage invasive breast cancer and ductal carcinoma in situ (DCIS). About 10% to 40% of the patients treated with BCT have poor cosmetic outcome results. Small tumours in large breasts can be successfully treated by lumpectomy and radiotherapy, with good cosmetic outcome. However when the tumour breast ratio is higher, the cosmetic outcome can be very disappointing. A surgical conflict arises between optimal oncologic resection and the desire to spare as much tissue as possible to minimize the risk of deformities. In case of a small defect lipofilling can be performed. This technique transplants fat grafts from a donor site to the defect in the breast. In case of larger defects there is the option of oncoplastic surgery. Oncoplastic techniques combine the optimal oncological resection with an adequate reconstruction for optimal cosmetic outcome. Oncoplastic techniques allow the breast surgeon to perform a tumour resection with adequate margins and the plastic surgeon will reconstruct the defect during the same procedure for optimal cosmetic outcome. The use of oncoplastic techniques to reconstruct defects of partial mastectomies (BCT) can be immediate, delayed or immediate delayed. Current breast cancer treatment leads to long-term surivival. It it there for important not only to survive but also life. Therefore the quality of life and good cosmetic outcome is mandatory after breast cancer treatment. Oncoplastic surgery is based on two techniques: volume displacement and volume replacement. The volume displacement techniques use (dermo)glandular flaps of the breast to fill the resection defect. Volume displacement techniques ideally work when the tumour resection can be incorporated in a breast reduction pattern. A similar technique is used on the contralateral breast to match size and shape. The volume replacement techniques use autologous non-breast tissues to compensate the volume loss after tumour resection. Volume replacement techniques are used when a large resection volume is needed in a small breast. Depending on the location and size of the defect many different flaps can be used for partial breast reconstruction.

Breast Cancer Screening With Mammography Plus Ultrasonography or Magnetic Resonance Imaging in Women 50 Years or Younger at Diagnosis and Treated With Breast Conservation Therapy

Younger women (aged ≤50 years) who underwent breast conservation therapy may benefit from breast magnetic resonance imaging (MRI) screening as an adjunct to mammography. To prospectively determine the cancer yield and tumor characteristics of combined mammography with MRI or ultrasonography screening in women who underwent breast conservation therapy for breast cancers and who were 50 years or younger at initial diagnosis. This multicenter, prospective, nonrandomized study was conducted from December 1, 2010, to January 31, 2016, at 6 academic institutions. Seven hundred fifty-four women who were 50 years or younger at initial diagnosis and who had undergone breast conservation therapy for breast cancer were recruited to participate in the study. Reference standard was defined as a combination of pathology and 12-month follow-up. Participants underwent 3 annual MRI screenings of the conserved and contralateral breasts in addition to mammography and ultrasonography, with independent readings. Cancer detection rate, sensitivity, specificity, interval cancer rate, and characteristics of detected cancers. A total of 754 women underwent 2065 mammograms, ultrasonography, and MRI screenings. Seventeen cancers were diagnosed, and most of the detected cancers (13 of 17 [76%]) were stage 0 or stage 1. Overall cancer detection rate (8.2 vs 4.4 per 1000; P = .003) or sensitivity (100% vs 53%; P = .01) of mammography with MRI was higher than that of mammography alone. After the addition of ultrasonography, the cancer detection rate was higher than that by mammography alone (6.8 vs 4.4 per 1000; P = .03). The specificity of mammography with MRI or ultrasonography was lower than that by mammography alone (87% or 88% vs 96%; P < .001). No interval cancer was found. After breast conservation therapy in women 50 years or younger, the addition of MRI to annual mammography screening improves detection of early-stage but biologically aggressive breast cancers at acceptable specificity. Results from this study can inform patient decision making on screening methods after breast conservation therapy.

Diagnostic Performance of and Breast Tissue Changes at Early Breast MR Imaging Surveillance in Women after Breast Conservation Therapy.

Purpose To investigate the diagnostic performance and tissue changes in early (1 year or less) breast magnetic resonance (MR) imaging surveillance in women who underwent breast conservation therapy for breast cancer. Materials and Methods This prospective study was approved by the institutional review board, and written informed consent was obtained. Between April 2014 and June 2016, 414 women (mean age, 51.5 years; range, 21-81 years) who underwent 422 early surveillance breast MR imaging examinations (median, 6.0 months; range, 2-12 months) after breast conservation therapy were studied. The cancer detection rate, positive predictive value of biopsy, sensitivity, specificity, accuracy, and area under the curve of surveillance MR imaging, mammography, and ultrasonography (US) were assessed. Follow-up was also obtained in 95 women by using positron emission tomography (PET)/computed tomography (CT). Background parenchymal enhancement (BPE) changes in the contralateral breast were assessed according to adjuvant therapy by using the McNemar test. Results Of 11 detected cancers, six were seen at MR imaging only, one was seen at MR imaging and mammography, two were seen at MR imaging and US, one was seen at mammography only, and one was seen at PET/CT only. Three MR imaging-depicted cancers were observed at the original tumor bed, and two MR imaging-depicted cancers were observed adjacent to the original tumor. Among two false-negative MR imaging diagnoses (two cases of ductal carcinoma in situ), one cancer had manifested as calcifications at mammography without differentiated enhancement at MR imaging, and the other cancer was detected at PET/CT, but MR imaging results were negative because of marked BPE, which resulted in focal lesion masking. The positive predictive value of biopsy and the sensitivity, specificity, accuracy, and area under the curve for MR imaging were 32.1% (nine of 28), 81.8% (nine of 11), 95.1% (391 of 411), 94.7% (400 of 422), and 0.88, respectively. The sensitivity of surveillance MR imaging (81.8%; 95% confidence interval [CI]: 48.2%, 97.7%) was higher than that of mammography (18.2%; 95% CI: 2.3%, 51.8%) and US (18.2%; 95% CI: 2.3%, 51.8%), with an overlap in CIs. The BPE showed a significant decrease in the group of patients who received adjuvant chemotherapy (43 BPE decreases and four BPE increases) and the group of patients who received hormone therapy (55 BPE decreases and two BPE increases) (P < .0001 for both). Conclusion Early MR imaging surveillance after breast conservation therapy can be useful in patients who have breast cancer, with superior sensitivity compared with that of mammography and US. The BPE tends to be decreased at short-term follow-up MR imaging in patients who receive adjuvant therapy. © RSNA, 2017.

Cosmetic Outcome after Interstitial Brachytherapy Accelerated Partial Breast Irradiation Is Related to the Location of the Lumpectomy Cavity

Cosmetic Outcome after Interstitial Brachytherapy Accelerated Partial Breast Irradiation Is Related to the Location of the Lumpectomy Cavity

Implant-Based Augmentation Mammaplasty Following Breast Conservation Surgery

Implant-based augmentation mammaplasty following breast-conserving cancer therapy (BCT) and radiotherapy has previously been cautioned against given concerns over complications and potential occult recurrence. All patients who underwent BCT and radiotherapy followed by implant-based augmentation mammaplasty were included in the study. Retrospective case-note analysis was performed. In all, 23 delayed implant-based mammaplasty procedures following BCT for breast cancer were performed. Fifteen tumors were located in the superior half of the breast. The median weight of wide local excision was 71.0 g (range, 15-385). All implants were placed in a subglandular position with median volume of 140 mL (range, 80-370). Complications occurred in 10 breasts, and 6 breasts required revisional surgery. Capsular contracture occurred in 4 breasts. No patient developed locoregional recurrence. A questionnaire revealed excellent satisfaction of the patient, and all patients reported that they definitely or probably would recommend the procedure. Delayed implant-based augmentation mammaplasty after BCT and radiotherapy is feasible and gives good aesthetic results with high satisfaction of the patient. This technique is an important addition to the breast conservation surgery algorithm.

Influence of Surgical Technique on Mastectomy and Reexcision Rates in Breast-Conserving Therapy for Cancer

Introduction. Breast conserving surgery (BCS) requires tumor excision with negative margins. Reexcision rates of 30–50% are reported. Ultrasound localization, intraoperative margin pathology, and specimen mammography have reduced reexcisions, but require new equipment. Cavity shave margin (CSM) is a technique, utilizing existing equipment, that potentially reduces reexcision. This study evaluates CSM reexcision impact. Methods. 522 cancers treated with BCS were reviewed. Patients underwent standard partial mastectomy (SPM) or CSM. Data collected included demographics, pathology, and treatments. Results. 455 SPMs were compared to 67 CSMs. Analysis revealed no differences in pathology, intraductal component, or neoadjuvant chemotherapy. Overall reexcision rate = 43%. Most reexcisions were performed for DCIS at margin. SPMs underwent 213 reexcisions (46.8%), versus 16/67 (23.9%) CSMs (P = 0.0003). Total mastectomy as definitive procedure was performed after more SPMs (P = 0.009). Multivariate analysis revealed CSM, % DCIS, tumor size, and race to influence reexcisions. Conclusions. CSM is a technique that reduces reexcisions and mastectomy rates.

Application of mammography in conservation therapy for breast cancer

Among the different x-ray features of breast carcinoma, mass and calcification are the most significant reference parameters in the screening and diagnosis of early carcinoma. Mammographic follow-up after conservation therapy is the other important value of mammography for breast carcinoma. Calcification is the most important sign to show residue or recurrence of conservation therapy. Key words: Radiography; Mastectomy

Breast Reduction in the Irradiated Breast: Evidence for the Role of Breast Reduction at the Time of Lumpectomy

Given the high incidence of breast cancer in our society, it is common to encounter patients with macromastia who desire breast reduction after breast-conserving therapy by lumpectomy and radiation. We hypothesize that radiation leads to a significant increase in postoperative complications after breast reduction. All patients with a history of unilateral breast lumpectomy and radiation who subsequently underwent bilateral breast reduction by a single surgeon from 2004 to 2008 were retrospectively reviewed. Outcomes including cellulitis, wound breakdown, seroma, and need for repeat operations were compared between the radiated and nonradiated breast. The Fisher's exact test was used for statistical analysis. Twelve patients (mean age, 57 years) underwent bilateral breast reduction a mean of 86 months after unilateral lumpectomy and radiation. The nonradiated breasts had no complications postoperatively. The radiated breasts had a significant increase in complications with a total of five breasts (42%, p<0.04) having postoperative complications including cellulitis in two breasts, seroma requiring drainage in five breasts, two cases of fat necrosis, and one case of wound dehiscence. This resulted in two admissions for intravenous antibiotics and two repeat operative procedures. Additionally, three patients had significant breast asymmetry or contour deformities after reduction requiring operative revisions. Breast reduction after radiation leads to a significant increase in complications. Given this data, patients with macromastia undergoing breast conservation therapy for cancer should be considered for reduction at the time of lumpectomy and prior to radiation.

Discolouration of breast skin following breast conservation therapy for breast cancer: a cautionary tale of two patients

Discolouration of breast skin following breast conservation therapy for breast cancer: a cautionary tale of two patients

Is There a Role for Routine Use of MRI in Selection of Patients for Breast-Conserving Cancer Therapy?

Is There a Role for Routine Use of MRI in Selection of Patients for Breast-Conserving Cancer Therapy?

Is There a Role for Routine Use of MRI in Selection of Patients for Breast-Conserving Cancer Therapy?

The role of preoperative bilateral breast MRI in breast cancer patients being considered for breast-conserving therapy has been controversial. We hypothesized that preoperative MRI, along with an active program in MRI-directed biopsies, would lead to a change in multidisciplinary treatment planning for patients being considered for breast-conserving cancer therapy, and it would be associated with reduced rates of margin-positive partial mastectomies. A retrospective review of a consecutive series of patients who were treated for breast cancer at a single center between January 2005 and July 2007 was conducted. Patients in the study were candidates for breast-conserving cancer therapy based on physical examination, mammography, and ultrasonography. All patients were evaluated by a preoperative breast MRI. Analysis included number and result of MRI-directed biopsies, impact of MRI on treatment planning, and incidence of margin-positive partial mastectomy within the series of patients. Seventy-nine female patients were analyzed. Median age was 57 years. MRI led to the performance of 25 MRI-directed biopsies for previously unrecognized suspicious lesions in 21 patients. Forty-four percent of MRI-directed biopsies were positive for cancer. MRI was associated with a change in management in 15 patients (19%) for multicentric ipsilateral cancer (n = 7), a more extensive primary lesion size (n = 6), or contralateral breast cancer (n = 2). Incidence of margin-positive partial mastectomy requiring additional resective operation was very low in this series (10%). Bilateral breast MRI, when used in conjunction with MRI-directed biopsy procedures, can be helpful in planning multidisciplinary treatment of candidates for breast-conserving cancer therapy. By allowing more accurate local staging of tumors, MRI is a tool that can be used to help reduce high reexcision rates for margin-positive partial mastectomies.

Angiosarcoma of the Breast

This article describes the imaging findings, pathologic correlation, and clinical presentation of rare primary and secondary angiosarcomas of the breast. With the increasing use of breast conservation therapy for breast cancer, reports of postirradiation angiosarcoma have increased. Both primary and secondary angiosarcomas may present with bruiselike skin discoloration, which may delay the diagnosis. Imaging findings are nonspecific. MRI may be used to determine lesion extent by showing rapid enhancement and washout in high-grade tumors.

Problems with the Use of Breast Conservation Therapy for Breast Cancer in a Patient with Neurofibromatosis Type 1: A Case Report

Patients with neurofibromatosis type I and breast cancer represent a subset of people who may be considered at high risk for secondary cancers after conventional whole breast radiation therapy and breast conservation surgery. A case of a 49-year-old woman with neurofibromatosis type I is presented. She was diagnosed with a 1.1-cm right breast infiltrating ductal carcinoma. Clinical, diagnostic imaging, and pathologic features are discussed. Her initial treatment plan of breast conserving therapy was thwarted when her sentinel node biopsy was positive for micrometastatic disease in 1/14 lymph nodes. She elected to have a bilateral simple mastectomy. This case addresses the rare dilemma of offering breast conservation therapy as a viable option for patients with neurofibromatosis type I. Current data on radiation-induced secondary cancers such as sarcoma after treatment for breast and other cancers are reviewed.

The Use of Buflomedil in Reduction Mammaplasty for a Previously Irradiated Breast: A Case Report

In recent years, lumpectomy combined with breast irradiation and chemotherapy, as a part of conservation therapy for breast cancer, has well-established results. Little has been published on reduction mammoplasty for breast-irradiated patients. These patients have increased risks of nipple necrosis, wound complications, and delayed healing. Breast reduction techniques that rely on minimum skin undermining combined with the use of buflomedil may prevent major postoperative complications in breast-irradiated patients. Buflomedil was administered intraoperatively and for 14 days after the procedure. The use of buflomedil in reduction mammaplasty for a previously irradiated breast patient has not been heretofore described. The case of a 58-year-old woman who underwent bilateral breast reduction after breast conservation therapy is reported.

Clinical Outcome of Breast Conservation Therapy for Breast Cancer in Hong Kong: Prognostic Impact of Ipsilateral Breast Tumor Recurrence and 2005 St. Gallen Risk Categories

The aim of this study was to evaluate the clinical outcome of breast conservation therapy (BCT) for invasive breast cancers in our predominantly Chinese population. Clinical outcomes of 412 T1-2 invasive breast cancers treated by wide local excision and external radiotherapy from 1994 to 2003 were retrospectively analyzed. Only 7% lesions were first detected by mammograms. Adjuvant tamoxifen and chemotherapy were added in 74% and 45% patients, respectively. The median follow-up was 5.4 years. The 5-year actuarial ipsilateral breast tumor recurrence (IBTR) rate, distant failure-free survival, cause-specific survival, and overall survival were 4%, 92%, 96%, and 98%, respectively. The 5-year distant failure-free survival for the low-risk, intermediate-risk, and high-risk categories (2005 St. Gallen) were 98%, 91%, and 80%, respectively (p = 0.0003). Cosmetic results were good to excellent in more than 90% of the assessable patients. Grade 3 histology (hazard ratio [HR], 4.461; 95% CI, 1.216-16.360; p = 0.024), age (HR, 0.915; 95% CI, 0.846-0.990; p = 0.027), and close/positive final margins (HR, 3.499; 95% CI, 1.141-10.729; p = 0.028) were significant independent risk factors for IBTR. Both St. Gallen risk categories (p = 0.003) and IBTR (HR, 5.885; 95% CI, 2.494-13.889; p < 0.0005) were independent prognostic factors for distant failure-free survival. Despite the low percentage of mammographically detected lesions, the overall clinical outcome of BCT for invasive breast cancers in the Chinese population is comparable to the Western series. The 2005 St. Gallen risk category is a promising clinical tool, but further validation by large studies is warranted.

P220: Predictors of locoregional recurrence to plan breast conservation therapy for breast cancer

Introduction: Since 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal survival after mastectomy and breast conservation therapy, breast conservation therapy undoubtedly represents substantial progress for a better quality of life for women with breast cancer. The outcome of breast conservation therapy at Seoul Asan Medical Center were retrospectively reviewed, and analyses carried out to obtain the 5 year disease free survival rates and significant prognostic factors.

6FDG PET scan evaluation of suspicious breast lesions developing after breast conservation therapy for breast cancer

612 Background: Breast Conservation Therapy (BCT) for early breast cancer is an effective option in selected patients with primary breast cancer. Mammographic evaluation of breast abnormalities developing after BCT can be difficult. Positron Emission Tomography (PET) is a valuable imaging tool in oncology. We investigated the efficacy of PET imaging in predicting the nature of suspicious breast changes following BCT. Methods: All patients with prior BCT with suspicious mammographic or breast examination findings necessitating biopsy evaluation were offered participation. After signed informed consent, PET imaging was performed using F-18 FDG General Electric PET scanner. Breast biopsy was obtained following the PET scan. Pathologic findings were correlated with the PET findings. Results: 33 patients were enrolled in the study between 6/1997 and 11/2003 with 31 patients completing both PET imaging and breast biopsy. The population characteristics at the time of the original breast cancer diagnosis were as follows: (1) Race and age: African Americans 21 (68%) (mean age = 46.8), Caucasian 10(32%) (mean age = 52.8). (2) Tumor size: 7 tumors ≤ 10mm, 11 between 11–20mm, 11 between 21–30mm, and 2 between 31–50mm. (3) Nodal Status: 21(68%) node negative, 10(32%) node positive. (4) Hormone receptor status: 51% negative, 49% positive.Biopsy/PET Results: 58% of the surgical biopsies were negative while 42% were positive (recurrent disease). 58% of PET scans were negative while 42% were positive. There was 1 false negative PET scans and 1 false positive scan. Overall the sensitivity of PET was 92.31%;while specificity was 94.44%. Positive predictive value of PET was 92.31%. PET scan was highly consistent with biopsy results (Kappa Co-efficient k=0.92). The single patient with a negative biopsy following a positive PET scan was found to have wide spread metastatic disease. The single patient with negative PET, but positive disease by biopsy had DCIS. Conclusions: PET imaging appears to be a reliable radiographic approach for the initial evaluation of suspicious breast lesions developing after BCT. No significant financial relationships to disclose.

6FDG PET scan evaluation of suspicious breast lesions developing after breast conservation therapy for breast cancer

612 Background: Breast Conservation Therapy (BCT) for early breast cancer is an effective option in selected patients with primary breast cancer. Mammographic evaluation of breast abnormalities developing after BCT can be difficult. Positron Emission Tomography (PET) is a valuable imaging tool in oncology. We investigated the efficacy of PET imaging in predicting the nature of suspicious breast changes following BCT. Methods: All patients with prior BCT with suspicious mammographic or breast examination findings necessitating biopsy evaluation were offered participation. After signed informed consent, PET imaging was performed using F-18 FDG General Electric PET scanner. Breast biopsy was obtained following the PET scan. Pathologic findings were correlated with the PET findings. Results: 33 patients were enrolled in the study between 6/1997 and 11/2003 with 31 patients completing both PET imaging and breast biopsy. The population characteristics at the time of the original breast cancer diagnosis were as follows: (1) Race and age: African Americans 21 (68%) (mean age = 46.8), Caucasian 10(32%) (mean age = 52.8). (2) Tumor size: 7 tumors ≤ 10mm, 11 between 11–20mm, 11 between 21–30mm, and 2 between 31–50mm. (3) Nodal Status: 21(68%) node negative, 10(32%) node positive. (4) Hormone receptor status: 51% negative, 49% positive.Biopsy/PET Results: 58% of the surgical biopsies were negative while 42% were positive (recurrent disease). 58% of PET scans were negative while 42% were positive. There was 1 false negative PET scans and 1 false positive scan. Overall the sensitivity of PET was 92.31%;while specificity was 94.44%. Positive predictive value of PET was 92.31%. PET scan was highly consistent with biopsy results (Kappa Co-efficient k=0.92). The single patient with a negative biopsy following a positive PET scan was found to have wide spread metastatic disease. The single patient with negative PET, but positive disease by biopsy had DCIS. Conclusions: PET imaging appears to be a reliable radiographic approach for the initial evaluation of suspicious breast lesions developing after BCT. No significant financial relationships to disclose.