Ipsilateral Mastectomy Research Articles

Risk Factors for Upper Extremity Impairment after Mastectomy: A Single Institution Retrospective Review.

Patients with breast cancer treated with mastectomy are more likely to develop upper extremity dysfunction compared with those treated with breast-conserving therapy. This study aimed to identify cancer and treatment characteristics that may be risk factors for development of upper extremity dysfunction in patients treated with mastectomy. The authors performed a retrospective chart review of patients at the University of Chicago who were treated with a unilateral or bilateral mastectomy from 2010 to 2020 and developed upper extremity dysfunction based on International Classification of Disease-10 codes. Patients were analyzed by side of body (left or right). Patient demographics and treatment characteristics were extracted from the electronic medical record. In total, 259 patients met criteria and were included in our study. A total of 396 upper extremities were recorded as experiencing dysfunction and were analyzed. Mean age was 60 years (range = 28-96), and mean body mass index was 28.4 (SD = 7.5). An estimated 54% of patients underwent breast reconstruction. After multivariable analysis, chronic upper extremity pain was found to be associated with ipsilateral radiotherapy (P < 0.001) and ipsilateral in situ cancer (0.041). Limited range of motion was found to be associated with ipsilateral invasive cancer (P = 0.01), any ipsilateral mastectomy surgery (P < 0.001), and ipsilateral radiotherapy (P = 0.03). Musculoskeletal dysfunction was found to be associated with no ipsilateral modified radical mastectomy (P = 0.033). No oncological or treatment characteristics were found to be associated with decreased strength or adhesive capsulitis. Furthermore, breast reconstruction (implant or autologous tissue based) was not associated with upper extremity dysfunction. Breast cancer characteristics and treatment modalities may predispose patients treated with mastectomy to developing types of upper extremity dysfunction.

Successful reconstruction using a de-epithelialized rectangular flap on a nipple necrosis site after DIEP flap-based breast reconstruction: a case report

Postmastectomy nipple necrosis is a factor that leads to a poor aesthetic outcome in breast reconstruction because of the unique projective structure of the nipple. We present a case of successful nipple reconstruction using a de-epithelialized rectangular flap. A 45-year-old woman was diagnosed with left breast cancer. She had a vertical scar below the nipple-areolar complex due to previous reduction mammoplasty. She underwent nipple-sparing mastectomy, breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap, and contralateral reduction. After the operation, the nipple gradually necrotized, and full-thickness nipple necrosis was observed on postoperative day 12. For nipple reconstruction, we designed a 38×23 mm rectangular flap from the DIEP flap considering the contralateral nipple diameter (12 mm), protrusion (2 mm), and ipsilateral mastectomy skin flap thickness (15 mm). The area in contact with the mastectomy skin flap was placed in the defect area after de-epithelialization. The reconstruction was successful and the nipple survived with a slight loss of projection. When unexpected nipple necrosis occurs after DIEP-based breast reconstruction, designing a de-epithelialized rectangular flap using the DIEP flap tissue is a feasible reconstructive method to consider.

The Role of Strain Elastography in Evaluating Borderline Axillary Lymph nodes

Background: Axillary lymph node (ALN) enlargement with diffuse cortical thickening and conserved echogenic hilum may represent a diagnostic and therapeutic challenge. Sonographic strain elastography may help the characterization of borderline ALN. Aim: To evaluate the strain elastography of borderline ALN and to calculate a cutoff value of strain ratio (SR) that can identify suspicious ALN with the highest sensitivity and specificity to reduce unnecessary invasive procedures. Subjects and Methods: A prospective study included 45 patients who attended the Breast clinic in Oncology Teaching Hospital with borderline axillary lymphadenopathy (intact hilum and diffusely thickened cortex more than 3mm) who had normal ipsilateral breast, suspicious ipsilateral breast lesion, or who had ipsilateral mastectomy. B-mode sonography and elastography were performed for all participants. Four-point elasticity score (ES), and SR were obtained for the targeted lymph node followed by ultrasound-guided fine need aspirate (FNA) biopsy.. Results: Malignant ALN constituted 20% of the cohort. B mode measurements were not able to differentiate between cytologically confirmed benign and malignant ALN in terms of axis ratio (mean ± standard deviation, 0.46 ± 0.08 vs 0.50 ± 0.12) and cortical thickness (4.88 ± 1.93 vs 6.27 ± 2.46). The mean SR of all samples was 2.66 ± 2.25. Metastatic ALN depicted significantly higher SR (P&lt;0.0001), with 88.9% exhibiting ES score 3 and 4. None of the metastatic ALN had ES score 1. ROC curve was used to investigate the utility of SR as a diagnostic tool. The area under the curve (AUC) was 0.906 with a 95% CI of 0.814-0.997, P&lt;0.001. SR cutoff of 2.1 was chosen with 100% sensitivity and 66.7% specificity. Conclusion: High proportion of borderline ALNs are not malignant. Strain elasticity can improve the risk stratification of such cases and prevent unnecessary invasive procedures. We suggested an algorithm that could better tackle borderline ALN which will need further evaluation

Abstract P3-03-20: The association of preoperative MRI with surgical decision-making in patients with early-stage breast cancer: A multi-institutional analysis

Abstract Background: Lumpectomy with radiation (breast conservation) and mastectomy have equivalent overall survival. However, recent studies suggest that patients undergoing breast conservation have lower rates of recurrence compared to those undergoing mastectomy. A 2013 meta-analysis by Houssami, et al. found that the rate of mastectomy in patients who had preoperative MRI was 16%, twice as high as that in patients who did not have preoperative MRI. A multi-institutional analysis was performed to investigate the possible impact of modern MRI on the surgical management of early-stage breast cancer (ESBC). Methods: A retrospective comparative cohort study included patients with in-situ and invasive breast cancer eligible for breast conservation surgery from two institutions (NY and FL). Patients who received preoperative systemic therapy were excluded. Eligibility for breast conservation was defined as clinical stage Tis-2. Risk factors for the bilateral or multicentric disease were compared between the two groups including breast density, menopausal status, and concerning family history. The rate of ipsilateral mastectomy in lumpectomy-eligible women was compared between patients who did and did not receive preoperative MRI. Chi-square analysis was used to compare rates between groups. P values &amp;lt;0.05 were considered statistically significant. Results: 505 patients diagnosed between 1/2016-4/2019 (NY) and 2/2020-12/2020 (FL) underwent primary surgery for ESBC. 434 did not receive neoadjuvant therapy and were included in the analysis. 292 (67.3%) had preoperative MRI. There was no difference in the proportion of patients who were premenopausal or who met the criteria for genetic testing by family history. The largest dimension on preoperative imaging was similar between the two groups. Patients who had MRI were younger (median age 58 vs. 68, p&amp;lt;0.001) and more likely to have group 3 or 4 breast density (64.5% vs. 27.1%, p&amp;lt;0.001). Patients who underwent preoperative MRI were twice as likely to undergo mastectomy as their first surgery (32.6% vs. 15.3%, p&amp;lt;0.001). The rate of re-excision was similar between the two groups (MRI 13.0% vs. no MRI 10.8% p=0.511). Of note, the final pathologic size of the invasive or in-situ component was similar between the two groups (Table 1). Conclusion: Younger age and greater breast density are associated with preoperative MRI receipt and all three factors likely play a role in choosing mastectomy. Young women with dense breasts represent a unique cohort of patients that may be particularly susceptible to cancer-related worry and anxiety related to additional biopsies, and therefore may be more likely to opt against continued breast imaging. Since approximately 70% of patients with ESBC undergo preoperative MRI, future work should focus on mitigating these challenges to improve shared decision-making. Table 1.Comparison of ESBC Patients Who Did and Did Not Receive MRIMRI (n=292) %, median (IQR)No MRI (n=142)%, median (IQR)p-valueAge58 years (50-65)68 years (60-76)&amp;lt;0.001bPremenopausal27%21%0.108Dense Breasts65%27%&amp;lt;0.001bMeet Criteria for Genetic Testing40%38%0.207Imaging Size13 mm (9-21)12 mm (8-20)0.315Mastectomy as First Surgery33%15%&amp;lt;0.001bPlan for Repeat Surgerya20%24%0.402Re-excision13%11%0.511Pathologic Size (Invasive)13 mm (8-20)13 mm (9-22)0.482Pathologic Size (DCIS)10 mm (5-20)8 mm (3-15)0.093aRepeat surgery includes re-excision, completion mastectomy, and axillary dissectionbDenotes significant p-values. Citation Format: Peter A Borowsky, Seraphina Choi, Orly Morgan, Amy K White, Claudya Morin, Jose Net, Susan Kesmodel, Neha Goel, Yamini Patel, Alexa Griffiths, Joshua A Feinberg, Aaron Kangas-Dick, Charusheela Andaz, Christina Giuliano, Natalie Zelenko, Donna-Marie Manasseh, Patrick Borgen, Kristin E Rojas. The association of preoperative MRI with surgical decision-making in patients with early-stage breast cancer: A multi-institutional 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 P3-03-20.

Incidence of shoulder functional morbidity following ipsilateral mastectomy and latissimus dorsi flap reconstruction

IntroductionThe aim of this study was to investigate the incidence of shoulder morbidity in our cohort of patients with latissimus dorsi flap reconstruction after mastectomy. MethodsThis is a retrospective study of prospectively collected data of 72 patients using validate Oxford shoulder score for function and quickDASH score for disability. Scores were collected preoperatively and at time of final review or study. We also reviewed patient records for patients who had a formal diagnosis of shoulder pathology. Results were analysed with student t-test. ResultsAnalysis of scores showed a statistically significant worsening of both oxford shoulder score (p < 0.005) and quickDASH score (p < 0.005), when pre and post-operative scores were compared. Seven patients had a formal diagnosis of shoulder pathology, and all of them recovered well. There was no significant difference in oxford shoulder score or quickDASH scores between patients with or without shoulder pathology. About 40% patients had some functional loss or disability at 4 years after the surgery. ConclusionOur study shows a high incidence of significant shoulder functional morbidity following latissimus dorsi flap reconstruction but number of patients requiring specific treatment is low. Level of evidenceLevel IV, therapeutic study.

Appropriate treatment receipt after breast-conserving surgery.

Breast-conserving surgery (bcs) and radiation therapy (rt) are the standard of care for early breast cancer, although some women receive ipsilateral mastectomy or adjuvant tamoxifen, both of which can be appropriate alternatives to rt. Objectives of the present study were to determine the proportion of women who are treated appropriately after bcs and to identify factors associated with non-receipt of rt. This retrospective cohort study used Ontario data linked at the Institute for Clinical and Evaluative Sciences to examine 33,718 patients who received bcs during 2004-2010. Primary outcome was rt receipt. The ipsilateral mastectomy rate and patient, surgeon, and setting variables were measured. Of the study patients, 86.1% received either rt or completion mastectomy; in the cohort less than 70 years of age, 90.8% received rt or completion mastectomy. Among patients less than 70 years of age, 3 risk factors for non-receipt of rt were identified: age less than 46 years, treatment in a non-academic institution, and earlier year of initial bcs. Additionally, in the overall cohort, rt non-receipt was associated with high comorbidity, more than 40 km to the cancer centre, income quintile, and breast care specialization. In Ontario, 90.8% of patients less than 70 years of age are appropriately treated for early breast cancer; approximately 1 in 10 do not receive rt or completion mastectomy. Based on those findings, women less than 46 years of age might be at increased risk of recurrence and death because of incomplete treatment. It also appears that academic centres more effectively treat breast cancer; however, breast cancer care appears to be improving over time in Ontario.

Time-varying risks of second events following a DCIS diagnosis in the population-based Vermont DCIS cohort.

Long-term disease-free survival patterns following surgical, radiation, and endocrine therapy treatments for ductal carcinoma in situ (DCIS) are not well characterized in general US practice. We identified 1252 women diagnosed with DCIS in Vermont during 1994-2012 using data from the Vermont Breast Cancer Surveillance System, a statewide registry of breast imaging and pathology records. Poisson regression and Cox regression with time-varying hazards were used to evaluate disease-free survival among self-selected treatment groups. With 7.8years median follow-up, 192 cases experienced a second breast cancer diagnosis. For women treated with breast-conserving surgery (BCS) alone, the annual rate of second events decreased from 3.1% (95% CI 2.2-4.2%) during follow-up years 1-5 to 1.7% (95% CI 0.7-3.5%) after 10years. In contrast, the annual rate of second events among women treated with BCS plus adjuvant radiation therapy increased from 1.8% (95% CI 1.1-2.6%) during years 1-5 to 2.8% (95% CI 1.6-4.7%) after 10years (P < 0.05 for difference in trend compared to BCS alone). Annual rates of second events also increased over time among women treated with BCS plus adjuvant radiation and endocrine therapy (P = 0.01 for difference in trend compared to BCS alone). The rate of contralateral events increased after 10years for all groups with adjuvant treatments. The rate of second events did not vary over time among women who underwent ipsilateral mastectomy (P = 0.62). Long-term risk of a second event after DCIS varies over time in a manner dependent on initial treatment.

The Effect of Receptor Status on Mastectomy and Contralateral Prophylactic Mastectomy Rates in Early Stage Invasive Breast Carcinoma

BackgroundThere is an established relationship between hormone receptor (HR; estrogen and/or progesterone receptors) status, HER2 status, and locoregional recurrence. The purpose of this study was to analyze how HR and HER2 receptor status have influenced the surgical management trends among patients with early stage breast cancer. Patients and MethodsThe National Cancer Database was queried for patients with cT1 to cT3, cN0, and cM0 breast carcinoma from 2004 to 2012. Patients were grouped on the basis of receptor status and surgical management (mastectomy or breast-conserving surgery [BCS]). Multivariable analyses were performed to investigate factors associated with increased odds of receiving mastectomy over BCS. Among a subgroup of patients who underwent ipsilateral mastectomy, analyses were performed to determine any association between contralateral prophylactic mastectomy (CPM) and receptor status. ResultsWe found 280,241 patients who met inclusion criteria for analyzing mastectomy or BCS surgical decision. Patients with HER2-positive (HER2+) tumors (HR+/HER+ and HR−/HER2+) were the most likely to undergo mastectomy (odds ratio [OR], 1.212 and 1.499 respectively, compared with HR+/HER2− patients, each P < .001). HR status alone did not affect ipsilateral surgical management as patients with HR+/HER2− and HR−/HER2− tumors demonstrated similar mastectomy rates (P = .391). Among the 108,018 who underwent mastectomy, 20% underwent CPM. After adjustment, patients with HR+/HER2+, HR−/HER2+, and HR−/HER2− were all more likely to undergo CPM (OR 1.356, 1.608, and 1.358, respectively compared with HR+/HER2− patients, each P < .001). ConclusionThis analysis indicates that patients with early stage breast cancer are more likely to undergo a mastectomy and CPM if they have HER2+ tumors.

Meta-analysis of pre-operative magnetic resonance imaging (MRI) and surgical treatment for breast cancer.

Although there is no consensus on whether pre-operative MRI in women with breast cancer (BC) benefits surgical treatment, MRI continues to be used pre-operatively in practice. This meta-analysis examines the association between pre-operative MRI and surgical outcomes in BC. A systematic review was performed to identify studies reporting quantitative data on pre-operative MRI and surgical outcomes (without restriction by type of surgery received or type of BC) and using a controlled design. Random-effects logistic regression calculated the pooled odds ratio (OR) for each surgical outcome (MRI vs. no-MRI groups), and estimated ORs stratified by study-level age. Subgroup analysis was performed for invasive lobular cancer (ILC). Nineteen studies met eligibility criteria: 3 RCTs and 16 comparative studies that included newly diagnosed BC of any type except for three studies restricted to ILC. Primary analysis (85,975 subjects) showed that pre-operative MRI was associated with increased odds of receiving mastectomy [OR 1.39 (1.23, 1.57); p<0.001]; similar findings were shown in analyses stratified by study-level median age. Secondary analyses did not find statistical evidence of an effect of MRI on the rates of re-excision, re-operation, or positive margins; however, MRI was significantly associated with increased odds of receiving contralateral prophylactic mastectomy [OR 1.91 (1.25, 2.91); p=0.003]. Subgroup analysis for ILC did not find any association between MRI and the odds of receiving mastectomy [OR 1.00 (0.75, 1.33); p=0.988] or the odds of re-excision [OR 0.65 (0.35, 1.24); p=0.192]. Pre-operative MRI is associated with increased odds of receiving ipsilateral mastectomy and contralateral prophylactic mastectomy as surgical treatment in newly diagnosed BC patients.

Abstract P3-17-01: Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ

Abstract Background: Despite evidence that radiotherapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS) halves the risk of recurrence, the benefit of RT in the management of DCIS continues to be a matter of controversy. One argument against the use of RT after BCS is that patients who develop ipsilateral local recurrence (LR) can be salvaged with further breast-conserving surgery such that the omission of RT will lead to high rates of breast preservation while minimizing exposure to RT. Breast preservation is an important determinant of quality of life for women with early stage breast cancer and DCIS. Yet the management of LR and the impact of RT on the resultant long-term risks of bilateral breast preservation in a population of women with DCIS are unclear. We assessed the treatment of LR, the impact of RT on the use of salvage mastectomy and the long-term risks of bilateral breast preservation achieved in a population of women with DCIS treated with BCS alone or BCS+RT. Methods: A population-based analysis of women diagnosed with DCIS from 1994-2003 treated with BCS alone or BCS+RT with pathology review. Treatment and outcomes, including the development of LR and contralateral breast events, were determined by administrative databases with validation by review of operative or pathology reports. Median follow-up was 10.2 years for cases treated by BCS alone, 11.6 years for those treated by BCS+RT. We used a propensity-adjusted Cox proportional hazards model to evaluate factors associated with the use of salvage mastectomy for LR and to evaluate factors associated with any mastectomy. We assessed the risk of long-term breast preservation by calculating the KM 10-year risk of ipsilateral mastectomy and any mastectomy. Results: The population cohort includes 3303 women with pure DCIS;1649 (50%) were treated by BCS alone, 1654 (50%) received BCS+RT. Women treated with RT had more high risk features of DCIS than those treated by BCS alone. LR developed in 343 (21%) women treated by BCS alone and in 257 (15.5%) women treated by BCS+RT (p&amp;lt;0.01). Most women who developed LR received salvage mastectomy, irrespective of age at diagnosis and histology. Salvage mastectomy was used in 57.4% (197/343) of cases that recurred after BCS alone and in 67.6% (173/257) that recurred after BCS+RT. The likelihood of receiving salvage mastectomy for LR was similar in patients initially treated by BCS+RT vs. those initially treated BCS alone. Most (90%) of mastectomies were performed for a LR. Overall, individuals initially treated by BCS+RT had a 29% lower probability of having a mastectomy at 10 years compared to those treated by BCS alone (HR=0.71, 95%CI: 0.60,0.84,p&amp;lt;0.0001). The 10 year mastectomy-free survival rates are 82.7% for women initially treated by BCS alone and 87.3% for those treated by BCS+RT (p=0.0096). Conclusion: Women who received RT after BCS for DCIS experience a greater likelihood of long-term bilateral breast preservation. This is attributable to the lower risks of LR and that most local recurrences after breast-conserving therapy are treated by salvage mastectomy. Long-term breast preservation should be considered in discussions weighing the benefits and risks of RT after conservative surgery for DCIS. Citation Format: Rakovitch E, Nofech-Mozes S, Hanna W, Gu S, Fong C, Tuck A, Sengupta S, Elavathil L, Jani P, Done S, Miller N, Youngson B, Bonin M, Chang M, Paszat L. Long-term rates of breast preservation after breast-conserving therapy for ductal carcinoma in situ [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-17-01.

Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ – The LORD study

BackgroundThe current debate on overdiagnosis and overtreatment of screen-detected ductal carcinoma in situ (DCIS) urges the need for prospective studies to address this issue. A substantial number of DCIS lesions will never form a health hazard, particularly if it concerns non- to slow-growing low-grade DCIS. The LORD study aims to evaluate the safety of active surveillance in women with low-risk DCIS. DesignThis is a randomised, international multicentre, open-label, phase III non-inferiority trial, led by the Dutch Breast Cancer Research Group (BOOG 2014-04) and the European Organization for Research and Treatment of Cancer (EORTC-BCG 1401). Standard treatment will be compared to active surveillance in 1240 women aged ⩾45years with asymptomatic, screen-detected, pure low-grade DCIS based on vacuum-assisted biopsies of microcalcifications only. Both study arms will be monitored with annual digital mammography for a period of 10years. The primary end-point is 10-year ipsilateral invasive breast cancer free percentage. Secondary end-points include patient reported outcomes, diagnostic biopsy rate during follow-up, ipsilateral mastectomy rate and translational research. FeasibilityTo explore interest in and feasibility of the LORD study we conducted a survey among EORTC and BOOG centres. A vast majority of EORTC and BOOG responding centres expressed interest in participation in the LORD study. The proposed study design is endorsed by nearly all centres.

Breast Reconstruction in a Previously Explanted Patient: An Interesting Anatomical Anomaly

Breast Reconstruction in a Previously Explanted Patient: An Interesting Anatomical Anomaly

Disease-free survival by treatment after a DCIS diagnosis in a population-based cohort study

Randomized trials have demonstrated the efficacy of radiation and tamoxifen in reducing risk of second events after breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS), but the comparative effectiveness of mastectomy, BCS, and adjuvant treatments have not been established in community practice. We examined disease-free survival (DFS) among 1,676 DCIS cases diagnosed during 1995-2006 in the population-based Wisconsin In Situ Cohort study. Information on patient and tumor characteristics, treatments, and second breast cancer events were collected via a comprehensive review of data from patient interviews, the statewide cancer registry, and pathology reports. Breast cancer DFS was evaluated according to treatment while adjusting for patient and tumor characteristics. After an average of 7.1 years of follow-up, 143 second breast cancer events occurred. Overall 5-year DFS was similar among women treated with ipsilateral mastectomy (95.6 %; 95 % CI 93.5-97.0) compared to women treated with BCS and radiation (94.8 %; 95 % CI 92.8-96.1), though women receiving BCS without radiation experienced poorer overall DFS (87.0 %; 95 % CI 80.6-91.5). Women treated with tamoxifen in addition to BCS and radiation had a similar risk of a second breast event, although the hazard ratio (HR) suggested a potential benefit (0.70, 95% CI 0.41-1.19). Women treated with BCS, radiation, and tamoxifen had comparable risk of a second event as those treated with ipsilateral mastectomy (HR = 1.20; 95 % CI 0.71-2.02). In this population-based sample, the use of BCS with radiation and tamoxifen resulted in high DFS rates comparable to those achieved by ipsilateral mastectomy.

Lifestyle Factors and the Risk of a Second Breast Diagnosis after DCIS in the Wisconsin In Situ Cohort

Abstract Purpose: Certain tumor factors have been associated with increased likelihood of a second breast diagnosis after treatment for ductal carcinoma in situ (DCIS) breast cancer. However, little information exists on modifiable lifestyle factors that affect prognosis after DCIS and may be useful for survivors in reducing their risk of a second breast cancer event. Methods: We examined the longitudinal association between body mass index (BMI), physical activity, and alcohol intake and risk of a second breast diagnosis among 1,925 DCIS survivors first diagnosed in 1997–2006 and enrolled in the Wisconsin In Situ Cohort. Data were collected during biennial patient interviews and diagnosis information was validated via pathology report. BMI, physical activity, and alcohol intake were examined over time using Chi-square and ANOVA methods. Cox proportional hazards regression was used to estimate the risk of a second diagnosis after adjustment for patient, tumor, and treatment factors. Repeated measures were incorporated to make use of exposure measurements taken at each post-diagnosis interview. Results: Over an average of 6.6 years of follow-up, 162 second breast cancer diagnoses were reported. Significant trends of increasing BMI and decreasing physical activity were observed over time since diagnosis (p &amp;lt; 0.001). For all women, a significant linear trend of increasing risk of a second diagnosis was found over increasing categories of post-diagnosis alcohol intake (p-trend 0.02). Among women treated with ipsilateral mastectomy, a reduction in risk was suggested with increasing post-diagnosis physical activity (HR 0.67, 95% CI 0.45, 1.02 for each additional hour/week). Among postmenopausal women, higher categories of post-diagnosis BMI were associated with increasing risk, although these results were of borderline significance (p-trend 0.09). Conclusion: This study is the first to examine the association of physical activity and alcohol intake with second breast diagnoses in an exclusively DCIS population. Our results suggest that DCIS survivors may reduce their risk of a second diagnosis by engaging in physical activity and reducing their alcohol consumption.

Abstract P1-02-01: Flat epithelial atypia diagnosed on breast core biopsy: what next?

Abstract Background: Historically, atypical ductal hyperplasia (ADH) identified on breast core biopsy has been associated with a 20% upgrade to malignancy at surgical excision. Recent literature has suggested a downward trend in such upgrade rates, possibly related to the use of larger gauge core biopsy devices. It is still unclear if this applies to other high-risk lesions, such as flat epithelial atypia (FEA). As core biopsy techniques and imaging have improved, it is critical to review the correlation between FEA diagnosed on core biopsy and malignancy at final surgical excision. Methods: We performed a retrospective chart review of our institution's medical record from 2009 to 2011 to identify all patients who (1) underwent breast core biopsy, (2) were initially diagnosed with FEA without malignancy (in situ or invasive carcinoma), and (3) proceeded with surgical excision at our institution. Results: Of the 726 breast core biopsies performed between 2009 and 2011, we identified 14 patients who met our inclusion criteria. Three patients were upgraded to malignancy following surgical excision (21%). The median age was 53.5 years, and the average breast cancer risk assessment scores were 3.5% 5-year and 18.9% lifetime. All patients underwent pre-biopsy mammogram, and four were further evaluated with ultrasound; no patients underwent a breast MRI. All of the imaging abnormalities were initially classified as BI-RADS 4, including five masses/densities and nine with suspicious calcifications. Only one patient reported the lesion as palpable on presentation and this was eventually upgraded to malignancy. All patients underwent image-guided core biopsies, including 13 stereotactic, vacuum-assisted and one ultrasound-guided, vacuum-assisted. Nine patients had 9-gauge core needle biopsies, while the remaining four patients had 11, 12, or 14-gauge needle biopsies, and this did not vary between years. Following surgical excision, three of the 14 patients (21%) were upgraded pathologically to ductal carcinoma in situ (DCIS; n=1) or invasive ductal carcinoma (n = 2). All three of these patients had 9-gauge core biopsies prior to surgical excision. Of note, four patients also had concurrent ADH on initial biopsy, although none of these were pathologically upgraded to malignancy. Of the upgrades, one patient proceeded with a definitive lumpectomy (negative sentinel lymph node biopsy) and one underwent bilateral mastectomy. The third patient is planning to undergo ipsilateral mastectomy for a subsequent diagnosis of multi-centric breast disease, including identification of an ipsilateral DCIS lesion distant from the primary lesion. Conclusions: The use of a larger gauge core biopsy needle (e.g. 9-gauge) may yield superior tissue sampling and should likely be considered as the standard of care in the evaluation of image-detected breast abnormalities. In addition, biopsy results should not be considered definitively non-malignant when a high-risk lesion is identified. While there may be a trend towards not excising some of these high-risk lesions, we believe that a core biopsy demonstrating FEA still warrants surgical excision. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-02-01.

Increasing rates of contralateral prophylactic mastectomy – A trend made in USA?

BackgroundNumerous recent studies conducted in the USA reported a considerable rise in the rates of contralateral prophylactic mastectomy (CPM) in early-stage breast cancer (BC). However, this aggressive surgical approach only showed an evidence-based improvement in prognosis for a small subgroup of high-risk BC patients. We present the first European study reporting CPM rates in an unselected cohort of patients with BC. Patients & methodsThe data of 881 patients (≤80 years) who underwent surgery for stage I–III BC from 1995 to 2009 at the University of Basel Breast Center was analyzed. ResultsCPM was performed in 23 of 881 patients (2.6%). Of the entire patient population, 37.5% underwent ipsilateral mastectomy and of those, only 7.0% chose to undergo CPM. Importantly, there was no trend over time in the rate of CPM. Women who chose CPM were significantly younger (54 vs. 60 years, p < 0.001), had more often a positive family history (39.1% vs. 24.4%, p = 0.032) and tumors of lobular histology (30.5% vs. 13.9%, p = 0.035). ConclusionsOur analysis of CPM rates in BC patients, conducted at a European University breast center, does not show the considerably rising CPM rates observed in the USA. We hypothesize that different medico-social and cultural factors, which are highlighted by a different public perception of BC and a different attitude toward plastic surgery, determine the varying CPM rates between the USA and Europe.

Selecting Individualized Treatment for Patients With Ductal Carcinoma in Situ of the Breast: The Search Continues

Selecting Individualized Treatment for Patients With Ductal Carcinoma in Situ of the Breast: The Search Continues

P2-13-06: Feasibility of Fast-Track Germline Genetic Analyses for Localized Breast Cancer Patients and Its Impact on Local Management.

Abstract Background Patients with BRCA1-BRCA2 germline mutation who developed a first breast cancer (BC) have a high risk to develop a second BC, especially if aged less than 40 at first diagnosis. Thus, a positive BRCA test may influence the therapeutic management and orients towards non conservative surgery to reduce new BC occurrence. We set up a fast-track process to get BRCA1/2 and sometimes p53 mutation results within the shortest possible interval, in recently diagnosed BC patients whose probability to be mutation carriers was high (&amp;gt; 20%). Methods: Between 05/02/2009 and 03/01/2011, 61 patients diagnosed with localized BC requesting neo-adjuvant or adjuvant chemotherapy and whose personal or familial history fulfilled BRCA1/2 or P53 genetic testing criteria, were proposed genetic counselling. After a first multisciplinary team meeting (MT), genetic testing was proposed and performed according to usual genetic counselling rules. Psychological support was offered at every step of the process. Patients were informed that their test would be analysed as part of a fast-track process and were aware of the potential consequences of a positive test. Results were communicated and discussed during a second MT, when initial therapeutic plan was eventually changed. Results: All women who were referred to the genetic clinic for fasttrack testing accepted the analysis. The mean age at diagnosis was 38 (range 26–55). The whole process (from 1st genetic consultation till disclosure consultation) was completed in a median interval of 99 days (range 19–245). All pts received appointment within 5 days, when results were available. 50% pts postponed for more than 15 days their disclosure appointment (range 0–113 days). One patient (pt) declined result disclosure. 18 pts (30%) were found to be carrier of a deleterious mutation (13 BRCA1, 4 BRCA2, 1 p53). Variants of unknown significance (UV) in BRCA1 or BRCA2 genes were identified in another 4 patients. In 18 cases, surgery type initially proposed was changed because of the presence of the germline mutation: all pts were proposed ipsilateral mastectomy eventually associated to immediate reconstruction as often possible, as well as controlateral mastectomy. Final surgery turned to bilateral mastectomy in 3 patients with deleterious BRCA mutation and in one suspect UV 14 patients with mutation accepted the change, but four BRCA2 and one BRCA1 mutation carriers refused mastectomy or bilateral mastectomy. Radiotherapy was cancelled in a p53 mutation carrier. Conclusion: This data show that genetic testing might be considered as a part of therapeutic decision. Moreover, 22% (4/18) opted for a simultaneous controlateral prophylactic mastectomy. On the other hand, some women did not change their mind with mutation knowledge (4/18, 22%). Psychological impact of this procedure is currently retrospectively assessed by a self-questionnaire, fulfilled by mail. Analyses will be available for the meeting. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-13-06.

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

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

Abstract A28: DCIS disease-free survival in the population-based Wisconsin In Situ Cohort

Abstract Ductal carcinoma in situ (DCIS) now makes up 20% of new breast cancer diagnoses. Women diagnosed with DCIS face an increased risk of developing invasive breast cancer. A number of randomized trials have demonstrated the effectiveness of radiation and tamoxifen in reducing the risk of invasive cancer after a DCIS diagnosis. However, few population-based studies have examined disease-free survival according to treatment in community practice. We examined disease-free survival in the Wisconsin In Situ Cohort (WISC) Study, a longitudinal study of health outcomes among a large population-based cohort including 1959 DCIS cases enrolled between 1995 and 2006. Data on the initial DCIS diagnosis, treatments, second breast cancer events, and prognostic factors were collected from the statewide cancer registry, patient interviews, and pathology reports. Multivariate Cox proportional hazards regression was used to evaluate disease-free survival in relation to treatment while adjusting for prognostic patient and tumor characteristics. After an average of 7.0 years of follow-up, 133 second breast cancer events occurred. The overall five-year disease-free survival rate was 94.6% (95% CI: 93.3–95.6%). Use of mastectomy declined over time, from 46% of DCIS cases in 1995–1997 to 30% of cases in 2004–2006. Tamoxifen use increased from 14% in 1995–1997 to 47% in 2004–2006. Overall five-year disease-free survival rates were 100% for women undergoing a bilateral mastectomy, 94.7% for women undergoing ipsilateral mastectomy, 95.4% for women treated with breast conserving surgery (BCS) and radiation, 89.9% for women treated with BCS only, and 86.5% for women receiving no further treatment beyond biopsy. These differences were driven mainly by variation in rates of ipsilateral events, whereas five-year disease survival for contralateral events was above 96% regardless of treatment type. No statistically significant differences were observed for any type of second event according to tamoxifen use. These results of this study provide population-based data that can be used to guide treatment choice for DCIS. Citation Information: Cancer Prev Res 2011;4(10 Suppl):A28.