Surgery For Invasive Breast Cancer Research Articles

Impact of Resident and Fellow Participation on Surgical Outcomes in Breast Conserving Surgery for Invasive Breast Cancer

Few studies examine the impact of surgical trainee involvement on tumor-free margins in breast conserving surgery (BCS). Our objective was to investigate the impact of resident and fellow involvement on positive margins rates following BCS for invasive breast cancer (BC). We identified female patients who had BCS for BC between January 2005 to December 2015. Tertiary care hospital. Around 1089 patients were identified from a prospectively maintained database. Of 1089 patients, mean age was 63 (range 43-99) years. Around 768 patients (70.1%) required preoperative localization, and 328 patients (29.9%) had a palpable cancer. Nonpalpable cancers had a smaller volume of specimen tissue excised (p = 0.0005) compared to palpable cancers, and no significant difference was observed in the positive margin rate between the nonpalpable group compared to the palpable group (24.7% nonpalpable vs. 25.3% palpable, p = 0.88). Nonpalpable cancer positive margin rates were 23.9% (n = 102/427) for cases performed by an attending surgeon, 25.0% (n = 15/60) with a junior resident (PGY 2-3), 28.6% (n = 8/28) with a senior resident (PGY 4-5), and 25.7% (n = 65/253) with a fellow, which were not statistically significant (p = 0.89). Palpable cancer positive margin rates were 27.6% (n = 47/170) for cases performed by an attending, 13.9% (n = 5/36) with an intern (PGY-1), 40.9% (n = 9/22) with a junior resident, 0% (n = 0/8) with a senior resident, and 23.9% (n = 22/92) with a fellow, which were also not significantly different (p = 0.07). Resident and fellow participation in BCS for BC does not appear to impact the rate of positive margins.

Dynamic contrast-enhanced and diffusion-weighted MRI of invasive breast cancer for the prediction of sentinel lymph node status.

Although sentinel lymph node biopsy (SLNB) is the current standard for identifying lymph metastasis in breast cancer patients, there are complications of SLNB. To evaluate preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted imaging (DWI) of invasive breast cancer for predicting sentinel lymph node metastasis. Retrospective. In all, 309 patients who underwent clinically node-negative invasive breast cancer surgery FIELD STRENGTH/SEQUENCE: 3.0T, DCE-MRI, DWI. We collected clinicopathologic variables (age, histologic and nuclear grade, extensive intraductal carcinoma component, lymphovascular invasion, and immunohistochemical profiles) and preoperative MRI features (tumor size, background parenchymal enhancement, internal enhancement, adjacent vessel sign, whole-breast vascularity, initial enhancement pattern, kinetic curve types, quantitative kinetic parameters, tumoral apparent diffusion coefficient [ADC], peritumoral maximal ADC, and peritumoral-tumoral ADC ratio). Multivariate logistic regressions were performed to determine independent variables associated with SLN metastasis, and the area under the receiver operating characteristic curve (AUC) was analyzed for those variables. 41 (13.3%) of the patients showed SLN metastasis. With MRI, tumor size (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.06-1.17), heterogeneous (OR, 5.33; 95% CI, 1.71-16.58), and rim (OR, 15.54; 95% CI, 2.12-113.72) enhancement and peritumoral-tumoral ADC ratio (OR, 72.79; 95% CI, 7.15-740.82) were independently associated with SLN metastasis. Clinicopathologic variables independently associated with SLN metastasis included age (OR, 0.96; 95% CI, 0.92-0.99) and CD31 (OR, 2.90; 95% CI, 1.04-8.92). The area under the curve (AUC) of MRI features (0.80; 95% CI, 0.73-0.87) was significantly higher than for clinicopathologic variables (0.68; 95% CI, 0.60-0.77; P = 0.048) and was barely below statistical significance for combined MRI features with clinicopathologic variables (0.84; 95% CI 0.78-0.90, P = 0.057). Preoperative internal enhancement on DCE-MRI and peritumoral-tumoral ADC ratio on DWI might be useful for predicting SLN metastasis in patients with invasive breast cancer. 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2020;51:615-626.

The use of contralateral prophylactic mastectomy among elderly patients in the United States.

Previous studies have reported increased rates of contralateral prophylactic mastectomy (CPM) in the United States among women with unilateral breast cancer. These trends have primarily focused on younger breast cancer patients. Given the growing aging population in the United States, we sought to determine whether CPM use is also increasing in elderly patients. This population-based study identified patients in the surveillance epidemiology and end results (SEER) data. We determined the rate of CPM as a proportion of all surgically treated patients and as a proportion of all mastectomies. We compared the unadjusted CPM rates over the study period using the Cochrane-Armitage test for trend. We used a logistic regression model to test for the factors associated with CPM utilization. We identified 261,281 patients ≥ 65years who underwent surgical treatment for breast cancer. For all patients treated with surgery for invasive breast cancer, the use of CPM increased from 1 in 2004 to 3% in 2014 (200% increase). Among mastectomy patients, the use of CPM increased from 3 in 2004 to 7% in 2014 (133% increase). Young age, non-Hispanic white race, lobular histology, higher grade, increased stage, negative lymph node status, and recent year of diagnosis were significantly associated with increased CPM rates. For elderly patients the use of CPM has continued to increase in the United States. These observations warrant concern in light of increasing evidence that CPM does not improve oncological outcomes and is associated with increased morbidity in older patients.

Breast-Contour-Preserving Procedure as a Multidisciplinary Parameter of Esthetic Outcome in Breast Cancer Treatment in The Netherlands

BackgroundThe rate of breast-conserving surgery (BCS) is used as an esthetic outcome parameter, while other treatments contribute also, such as neoadjuvant chemotherapy (NAC) enabling BCS or immediate breast reconstruction (IBR). This study explores these efforts to preserve the patient’s breast contour.Patients and MethodsAll patients who underwent surgery for invasive breast cancer in The Netherlands between January 2011 and December 2015 were selected from the Dutch national breast cancer audit (n = 61,309). The breast-contour-preserving procedures (BCPP) rate was defined as the rate of primary BCS, BCS after NAC, or mastectomy with IBR. BCPP rates were calculated and compared by year of diagnosis, age categories, and individual hospitals.ResultsThe rate of primary BCS remained stable (53%) while the BCPP rate increased from 63% in 2011 to 71% in 2015 due to an increase in patients receiving BCS after NAC and mastectomy with IBR. Primary BCS rates increased with age (from 17% in patients aged < 30 years to 63% in patients aged 60–69 years), while the proportion of patients undergoing mastectomy with IBR decreased from 44% in patients < 30 years to 1% in patients ≥ 70 years. The BCPP rate was similar for all age groups except for patients > 70 years. BCPP rates varied between the different hospitals in The Netherlands, ranging from 47 to 88%.ConclusionsThe chance of preserving the breast contour for patients with breast cancer has increased substantially over recent years. BCPP provides a comprehensive parameter of esthetic outcome of breast cancer surgery.

Sentinel lymph node biopsy in microinvasive ductal carcinomain situ

Microinvasive breast cancer is an uncommon pathological entity. Owing to the rarity of this condition, its surgical axillary management and overall prognosis remain controversial. A database was analysed to identify patients with microinvasive ductal carcinoma in situ (DCIS) who had surgery for invasive breast cancer at the European Institute of Oncology, Milan, between 1998 and 2010. Women who had undergone axillary staging by sentinel lymph node biopsy were included in the study. Of 257 women with microinvasive breast cancer who underwent sentinel lymph node biopsy (SLNB), 226 (87·9 per cent) had negative sentinel lymph nodes (SLNs) and 31 had metastatic SLNs. Twelve patients had isolated tumour cells (ITCs), 14 had micrometastases and five had macrometastases in sentinel nodes. Axillary lymph node dissection was performed in 16 of the 31 patients with positive SLNs. After a median follow-up of 11 years, only one regional first event was observed in the 15 patients with positive SLNs who did not undergo axillary lymph node dissection. There were no regional first events in the 16 patients with positive SLNs who had axillary dissection. Good disease-free and overall survival were found in women with positive SLNs and microinvasive DCIS. This study is in line with studies showing that SLNB in microinvasive DCIS may not be useful, and supports the evidence that less surgery can provide the same level of overall survival with better quality of life.

Abstract P1-11-21: Analysis of cognitive function in elderly HER2-positive breast cancer patients receiving either trastuzumab monotherapy or trastuzumab plus chemotherapy as a postoperative adjuvant treatment: A cognitive function sub-study of a randomized, open-label, phase 3 clinical trial (RESPECT trial)

Abstract OBJECTIVE: The effect of trastuzumab(Tmab) or chemotherapy on cognitive function has not been fully understood, especially in elderly breast cancer patients. The RESPECT trial compared 1-year(yr) Tmab monotherapy with Tmab plus standard chemotherapy as adjuvant therapy in elderly patients with HER2-positive breast cancer. The primary objective was to verify the noninferiority of 1-yr Tmab monotherapy compared to Tmab plus chemotherapy in terms of disease-free survival, and the planned analysis showed that the difference of restricted mean survival time between two groups at 3 yrs was 0.45 months (Sawaki at ASCO2018). The goal of this report was to assess the impact of the treatment groups on longitudinal cognitive function. PATIENTS AND METHODS: The study was performed with patients from 99 hospitals in Japan. Elderly women with HER2-positive, stage I-IIIA invasive breast cancer surgery treated with clear resection margins were randomly assigned to either receive 1-yr Tmab or 1-yr Tmab plus standard chemotherapy. 15 institutions participated in the cognitive sub-study. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) at baseline and at 1 and 3 yrs after treatment. The primary outcome was the amount of change in the MMSE score from the baseline. A linear mixed-effects model was used for comparisons of change in the MMSE score between groups, controlling for time and baseline score. Secondary outcomes were the proportion of both suspected mild dementia (MMSE≤27) and dementia (MMSE≤23) at each time point. RESULTS: Between October 2009 and October 2014, 275 patients were enrolled in the RESPECT trial, and 57 patients were enrolled in the cognitive function sub-study with 2 patients subsequently excluded. The 55-patient sub-study comprised 29 patients assigned to the Tmab monotherapy group and 26 patients assigned to the Tmab plus chemotherapy group. Primary analysis revealed that change in the MMSE score was not significantly different between the two groups (difference −0.6 at 1 yr and −0.9 at 3 yrs; p=0.136), whereas the baseline score was the only significant factor that had an effect on the amount of change in the MMSE score (p&amp;lt;0.001). The proportions of suspected mild dementia at baseline, and at 1 yr and 3 yrs were 15.4, 32.0, and 41.7% in the Tmab monotherapy group, and 45.8, 17.6, and 28.6% in the Tmab plus chemotherapy group. The proportions of suspected mild dementia at baseline were significantly higher in the Tmab plus chemotherapy group (p=0.04). The proportions of suspected dementia at baseline, and at 1 yr and 3 yrs were 0%, 0%, and 4.2% in the Tmab monotherapy group, and 4.2%, 0%, and 4.8% in the Tmab plus chemotherapy group. There were no significant differences in the proportions of suspected dementia between the treatment groups at each time point. CONCLUSION: Postoperative chemotherapy for elderly breast cancer patients was considered to have little effect on the onset of dementia during the follow-up period of 3 yrs. Further long-term observation is necessary to obtain a significant conclusion. Citation Format: Takahashi M, Sawaki M, Hagiwara Y, Uemura Y, Kawahara T, Shimozuma K, Ohashi Y, Saito T, Baba S, Kobayashi K, Mukai H, Taira N. Analysis of cognitive function in elderly HER2-positive breast cancer patients receiving either trastuzumab monotherapy or trastuzumab plus chemotherapy as a postoperative adjuvant treatment: A cognitive function sub-study of a randomized, open-label, phase 3 clinical trial (RESPECT trial) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-21.

Re-Excision Rates in Breast-Conserving Surgery for Invasive Breast Cancer after Neoadjuvant Chemotherapy with and without the Use of a Radiopaque Tissue Transfer and X-ray System

Background: Significant re-excision rates in breast-conserving surgery (BCS) after neoadjuvant systemic chemotherapy may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Devices allowing an exact topographic localisation of the lesion in the resected tissue could reduce re-excision rates by optimising the intraoperative detection of involved margins. Methods: 80 patients with invasive breast cancer receiving BCS after neoadjuvant chemotherapy were included in this non-randomized case-control study. 40 patients with specimen radiography performed in a standard approach (control group) were compared to 40 patients with use of a radiopaque tissue transfer system (study group). Results: 19/80 (23.75%) patients required re-excision because of involved margins; among those, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p = 0.023). Conclusion: Our analysis provides a rationale for the routine use of a radiopaque tissue transfer system for specimen radiography in BCS after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates.

Pretreatment MRI features associated with diagnostic accuracy of post-treatment MRI after neoadjuvant chemotherapy

To investigate whether pretreatment magnetic resonance imaging (MRI) features are associated with diagnostic accuracy of post-treatment MRI for predicting pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in patients with breast cancer. From January 2005 and December 2016, 221 consecutive patients (mean age, 50 years; range, 20-81 years) who had undergone NAC, breast MRI before and after NAC, and surgery for invasive breast cancer were enrolled. Pretreatment and post-treatment MRI images were reviewed. Radiological complete response (rCR) was defined as the absence of both early and late enhancement on MRI after NAC. The association of pretreatment MRI features and post-treatment MRI diagnostic accuracy was assessed by using logistic regression analysis. Among 221 patients, 60 (27.1%) underwent pCR after NAC. The diagnostic accuracy of post-treatment MRI was 84.2% (186/221). False-positive diagnosis occurred in 21 cases and false-negative diagnosis occurred in 14 cases. Of pretreatment features, the presence of peritumoural oedema (odds ratio, 3; 95% confidence interval [CI]: 1.1, 8.0; p=0.03) and HER2 (human epidermal growth factor receptor 2)-positive status (odds ratio, 3.4; 95% CI: 1.2, 9.9; p=0.02) were significantly associated with false-positive MRI results. Dense fibroglandular tissue (odds ratio, 10.8; 95% CI: 1.1, 105.2; p=0.04), presence of rim enhancement (odds ratio, 7.5; 95% CI: 1.2, 38.3; p=0.02) and oestrogen receptor (ER)-positive status (odds ratio, 6.3; 95% CI: 1.2, 32.5; p=0.03) were significantly associated with false-negative MRI results. Pretreatment MRI features and cancer subtypes may be associated with diagnostic accuracy of post-treatment MRI after NAC in patients with breast cancer.

Abstract P2-12-06: Re-excision rates in breast conserving surgery for invasive breast cancer after neoadjuvant chemotherapy with and without the use of a radiopaque tissue transfer and X-ray system

Abstract Background: Published re-excision rates after breast conserving surgery for invasive breast cancer vary between 20 and 50%. In patients after neoadjuvant chemotherapy even higher re-excision rates may result from difficulties in defining the surgical target particularly in cases with excellent treatment response. Specimen radiography is reducing re-excision rates, however, defining involved margins is often difficult using standard approaches. Devices allowing horizontal and vertical examination and an exact topographic localization of the lesion in the resected tissue could reduce re-excision rates by an intraoperative detection of involved margins. Methods: 80 patients with invasive breast cancer receiving breast conserving surgery after neoadjuvant chemotherapy and an indication for wire marking by mammography were included in this analysis. All tumors were marked with titanium clips prior to chemotherapy. In 40 patients specimen radiography was performed in a standard approach (control group), in 40 patients a tissue transfer and X-ray system based on a non-radiopaque board with radiopaque topographic markers and a stand for cranio-caudal X-rays was used (study group). A univariate analysis was carried out to evaluate the association between the use of the radiopaque tissue transfer system and the re-excision rate using a logistic regression model. Calculations were performed using the XLSTAT Biomed Software (Version 19.03, Addinsoft, NY, USA.). Results: 19/80 patients (23.75%) required re-excision because of involved margins; among those patients, 14/40 (35%) were in the control group and 5/40 (12.5%) in the study group. The association between the use of the radiopaque tissue transfer system and the lower re-excision rate was statistically significant (p=0.023). Conclusion: Our analysis provides a rationale for the use of a radiopaque tissue transfer system for specimen radiography in breast conserving surgery after neoadjuvant chemotherapy for invasive breast cancer in order to reduce re-excision rates. Based on these results we are planning a study including also patients receiving primary surgery. Citation Format: Kolberg H-C, Akpolat-Basci L, Stephanou M, Wetzig S, Cubuk Y, Gerharz J, Liedtke C. Re-excision rates in breast conserving surgery for invasive breast cancer after neoadjuvant chemotherapy with and without the use of a radiopaque tissue transfer and X-ray system [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 P2-12-06.

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

The Society of Surgical Oncology and American Society of Radiation Oncology consensus statement was the first professional guideline in breast oncology to declare "no ink on tumor" as a negative margin in patients with stages I/II breast cancer undergoing breast-conservation therapy. We sought to analyze the financial impact of this guideline at our institution using a historic cohort. We identified women undergoing re-excision after breast-conserving surgery for invasive breast cancer from 2010 through 2013 using a prospectively maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis. Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with ductal carcinoma in situ. A subcohort of 83 patients (32.7%) who underwent breast-conservation therapy for stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure, per the Society of Surgical Oncology and American Society of Radiation Oncology guideline. The majority had invasive ductal carcinoma (n= 70 [84.3%]) and had invasive disease (n= 45 [54.2%]), and/or ductal carcinoma in situ (n= 49 [59.0%]) within 1 mm of the specimen margin. Seventy-nine patients underwent 1 re-excision and 4 patients underwent 2 re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations. Implementation of the Society of Surgical Oncology and American Society of Radiation Oncology consensus guideline holds great potential to optimize resource use. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Additional analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

Racial Differences in Utilization of Breast Conservation Surgery: Results from the National Cancer Data Base (NCDB).

Whether rates of breast-conservation surgery (BCS) vary based on race and ethnicity has not been clearly elucidated on a national leve. The National Cancer Data Base (NCDB) was used to identify women who underwent surgery for invasive breast cancer during 2010 and 2011. The effect of race and ethnicity on BCS rates was determined, independent of patient demographics, tumor-related variables, and geographic region. There were 299,827 patients with known race and ethnicity who underwent definitive breast surgery. BCS rates by race were as follows: 135,065/241,236 (56.0%) for whites, 17,819/33,301 (53.5%) for blacks, 4,722/9,508 (49.7%) for Asian/Pacific Islanders, and 7,919/15,782 (50.2%) for Hispanics (p<0.001). Mean tumor size differed among the racial groups: 2.07cm in whites, 2.54cm in blacks, 2.23cm in Asians, and 2.48cm in Hispanics (p<0.001). When stratified by tumor size, BCS was most common in blacks and least common in Asians for all tumors >2cm (p<0.001). On multivariable analysis adjusted for age, tumor size, nodal status, grade, molecular type, geographic area, urban/rural residence, insurance status, and census-derived median income and education for the patient's zip code, the odds ratio for BCS for blacks compared to whites was 1.23 (95% confidence interval [CI] 1.20-1.27, p<0.001), for Asians was 0.84 (95% CI 0.80-0.88, p<0.001), and for Hispanics was 1.00 (95% CI 0.96-1.05, p=0.885). When adjusted for patient demographics, tumor-related variables, and geographic area, BCS rates are higher in blacks and lower in Asians compared to whites.

The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer.

Background:Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB.Objective:To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care.Data Sources/Study Design:Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB.Results:Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12–2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28–2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95–1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82–1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics.Conclusions:Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.

Abstract P4-02-15: Preoperative MRI of the breast and ipsilateral breast tumor recurrence: Long-term follow up

Abstract Introduction: Local recurrence after breast conserving surgery for invasive breast cancer is uncommon, reported in 5 to 10% of cases at 10 years after surgery. Prior studies with short term follow-up have shown that preoperative breast MRI does not reduce re-excision rates for positive margins or reduce local recurrence after lumpectomy and radiation therapy. This study aims to determine 1) if preoperative breast MRI is associated with reduced ipsilateral breast tumor recurrence (IBTR) rates in the longer term and 2) the IBTR rates of a high risk (triple negative (TN) and Her-2 positive) subgroup in those receiving or not receiving preoperative MRI. Methods: Between 1999 and 2005, a cohort of patients with invasive breast cancer undergoing breast conservative surgery and radiation therapy were identified from a prospectively collected database and followed. The primary endpoint was IBTR rate. Secondary outcomes included the determination of factors associated with the use of preoperative breast MRI and prognostic factors related to IBTR. IBTR rate was calculated by Kaplan-Meier method. Univariate analysis was calculated using log-rank test and chi-squared test. Results: The cohort consisted of 470 cases with invasive breast cancer undergoing lumpectomies with negative resection margins. All patients received adjuvant radiation therapy. 127 (27%) patients underwent preoperative breast MRI and 343 (73%) did not. Median follow-up was 97 months. The overall 10-year IBTR rate was 3.6%. Overall, there was no significant difference in IBTR rate at 10 years between those receiving preoperative MRI and those without (IBTR: 1.6% and 4.2%, respectively (p = 0.37). There were no differences in IBTR rate between MRI and no-MRI after adjusting for age, year of surgery, tumor size, and adjuvant treatments on univariate analysis. For patients who recurred, median time to recurrence was 26 months for MRI group vs. 25 months for no-MRI group. Factors associated with the receipt of preoperative MRI were age &amp;lt; 50 years, lesion &amp;gt; 2 cm and receipt of adjuvant chemotherapy. We also found that the TN and Her-2 positive combined subgroup had a higher IBTR rate than all others (9.8% vs. 3.1%, p= 0.03). In those that received preoperative MRI, there was no difference in IBTR between the high risk group (n= 33) and the remaining patients (3.3% vs 1.2%, p= 0.5), but in the group without an MRI, the IBTR rate of the high risk group (n= 75) was 11.8% compared to the remainder (vs. 4.0%, p= 0.0529). For the TN and Her-2 positive combined group, the difference in IBTR rate when this subgroup was subdivided if they had received preoperative MRI vs. no-MRI (3.3% vs. 11.8%, p= 0.3) was not significant. Conclusion: With long term 10-year follow up, there is no overall significant difference in IBTR rate whether preoperative breast MRI is performed versus not. However, the high risk triple negative breast cancers and Her-2 positive populations combined have shown an increased IBTR rate, and this was more marked in those who did not receive preoperative MRI. Citation Format: Gervais M-K, Maki E, Schiller DE, McCready DR. Preoperative MRI of the breast and ipsilateral breast tumor recurrence: Long-term follow up. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-15.

The effect of neoadjuvant chemotherapy on short-term outcomes in breast surgery: A propensity score adjusted analysis of NSQIP data.

115 Background: Neoadjuvant chemotherapy (NAC) is increasingly used in the treatment of breast cancer. The primary objective of this study was to determine whether administration of NAC increased the proportion of overall 30-day post-operative complications among patients undergoing surgery for invasive breast cancer. Methods: An analysis of the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP) participant user files from 2005-2012 was performed. Patients undergoing surgery for invasive breast cancer were included; those with high-risk comorbidities or concurrent surgery were excluded. The primary outcome was a composite of overall 30-day post-operative complications. A propensity score was calculated and a propensity score adjusted multivariable logistic regression model was used to determine the independent effect of NAC on overall 30-day complications. Results: In the study period67,685 patients having surgery for invasive breast cancer were identified; of those, 3,624 (5.5%) received NAC. The rate of NAC use within this cohort increased from 5.5% to 10.2%. Patients who received NAC were: younger and had fewer medical comorbidities, but, were more likely to receive neoadjuvant radiation and undergo bilateral surgery. On unadjusted analysis, patients receiving NAC had significantly more post-operative complications than those not receiving NAC (4.9% vs. 3.7%, p = 0.0003) mainly due to infection and bleeding. However, after adjusting for confounders by propensity score adjusted multivariable regression, there was no longer a significant difference in overall 30-day post-operative complications between those receiving NAC versus not (odds ratio 1.16 [95%CI: 0.98, 1.36]). Conclusions: This is the largest study to examine the effect of NAC on post-operative complications in patients undergoing surgery for invasive breast cancer. The receipt of NAC does not impart a significantly increased risk of post-operative complications in this patient population.

Neoadjuvant Chemotherapy for Breast Cancer, Is Practice Changing? A Population-Based Review of Current Surgical Trends

Neoadjuvant chemotherapy in breast cancer is used to downstage locally advanced and inoperable tumors. Expanded benefits of neoadjuvant chemotherapy include downstaging of tumors to allow breast-conserving surgery (BCS) and assessment of in vivo tumor response. We sought to identify patterns and predictors of neoadjuvant chemotherapy use to determine if this has translated into population-level clinical practice. All patients undergoing surgery for invasive breast cancer between January 2012 and June 2014 were identified from our provincial synoptic operating room database. Data regarding patient demographics, hospital, operating surgeon, preoperative tumor characteristics, neoadjuvant treatment, and type of surgery performed were collected. Descriptive statistics and multivariable analysis were used to identify predictors of neoadjuvant chemotherapy. A total of 4186 patients were identified, 363 (8.53%) of whom underwent neoadjuvant chemotherapy. A significant increase was seen in the use of neoadjuvant chemotherapy over time. In multivariable analysis, neoadjuvant chemotherapy was associated with prechemotherapy tumor size, multicentricity, lymph node positivity, and decreasing patient age. In addition, there was significant variability in neoadjuvant chemotherapy use between operating surgeons. Of those patients who underwent neoadjuvant chemotherapy, 68.9% were not pretreatment candidates for BCS. At the time of definitive surgery, 72.1% had mastectomy, with 18.7% opting for contralateral prophylactic mastectomy. As reported, this was due to the tumor being advanced/too large (50.4%), patient preference (12.6%), multicentricity (8.8%) and margins, genetics, and previous radiotherapy (4%). A significant increase in the use of neoadjuvant chemotherapy over time was identified, and treatment with mastectomy as definitive surgical management remained high. There was significant variability in neoadjuvant chemotherapy use by the operating surgeons, in addition to factors generally associated with more locally advanced/aggressive tumors.

Abstract P1-16-03: Residual disease after breast conservation surgery: To excise or not to excise?

Abstract Background: The definition of adequate margins after breast conservation surgery for invasive breast cancer has been a highly debated topic. A recent consensus statement by the SSO/ASTRO recommends re-excision only for positive margins, defined as tumor at ink. In light of this consensus statement, we studied the characteristics of patients undergoing breast conservation surgery with subsequent re-excision at our institution in order to examine factors predictive for residual disease (RD+) in the re-excision specimen, as well as a second re-excision. Methods: In this IRB approved retrospective chart review of our breast cancer cases from 1998-2013, we reviewed 828 patients who underwent breast conservation surgery with re-excision for invasive breast carcinoma. A close margin was defined as less than 2mm from the inked margins, and a positive margin was defined as tumor at ink. We analyzed various clinicopathologic features. RD+ was missing in 7 patients (0.8%), who were excluded from that analysis. Pearson chi-square was used to test significance in univariate analysis. Binary logistic regression was applied in multivariate analysis of factors significant at p&amp;lt;0.05. Results: Overall, 230 patients (28%) had RD+, and 103 patients required a second re-excision (12.4%) due to persistently positive or close margins (44% of RD+). Factors not significant for RD+ were: diagnosis era (before June 2007 vs. after), menstrual status, age &amp;lt; 40, race, excision volume, tumor size, nodal status, grade, histology, lymphovascular invasion, and hormone receptor status. For patients with only close margins, there was no difference in RD+ by margin width, as defined by &amp;lt;0.5mm, 0.5 to &amp;lt;1mm, 1mm to &amp;lt;2mm. Factors significant for RD+ were: disease that was mammographically occult or calcifications only (35%) vs. mass or architectural distortion (25%), p=0.003; positive margin vs. close margin (33% vs. 24%, p=0.004); margin positive or close for DCIS (41%) vs. both DCIS/invasive (30%) vs. invasive alone (17%), p&amp;lt;0.001; presence of DCIS (30% vs. 16%, p=0.001); extensive intraductal component (EIC) (42% vs. 24%, p&amp;lt;0.001); the number of positive or close margins (1: 16%, 2: 26%, 3+: 48%, p&amp;lt;0.001). In multivariate analysis, the number of positive or close margins was significant, (p&amp;lt;0.001), as was a margin positive or close for DCIS (p&amp;lt;0.001). Factors significant in univariate analysis for a second re-excision were similar as those for RD+. In multivariate analysis, independent factors for second re-excision were: EIC (p=0.007), number of positive or close margins (p&amp;lt;0.001), and a margin positive or close for DCIS (p=0.001). Conclusions: Residual disease at re-excision for positive or close margins was present in approximately one-fourth of patients. The probability of residual disease was unrelated to margin positivity or margin width within 2mm. Consideration of re-excision should take into account the burden of intraductal disease in the specimen, its presence at or close to the margin, and the number of positive or close margins. Citation Format: Catherine R Campo, Erika Reategui, Sarah P Cate, John Rescigno, Priyanka Mittar, Alyssa Gillego, Susan K Boolbol. Residual disease after breast conservation surgery: To excise or not to excise? [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-03.

A Patient-Centered Approach to Wait Times in the Surgical Management of Breast Cancer in the Province of Ontario.

Wait time for breast cancer is an important contributor to cancer outcomes and patient satisfaction. This study sought to define a patient-centered wait time by measuring the time from the first abnormal imaging to definitive surgery. The authors hypothesized that multiple preoperative investigations significantly increase the patient-centered wait time. A retrospective analysis of prospectively maintained databases at the Institute for Clinical and Evaluative Sciences in Ontario, Canada was performed. Women undergoing primary surgery for invasive breast cancer from 2003 to 2011 were evaluated. The median wait time between the first abnormal imaging and definitive surgery was calculated. Uni- and multivariable analyses were performed to identify characteristics of the patients, treating institution, and diagnostic pathway that contribute significantly to the patient-centered wait time. Our final cohort consisted of 42,179 patients: 31,837 (75%) who had breast conserving surgery and 10,342 (25%) who underwent mastectomy. The median wait time from the first abnormal imaging to definitive surgery was 52days (intraquartile range 35-76days). In adjusted analysis, older patient age, later year of surgery, additional preoperative imaging, and biopsies beyond those required for diagnosis significantly and independently extended the surgical wait time. Preoperative consultations and institutional factors such as volume of breast surgery performed and geographic location also independently had an impact on surgical wait time. This study defined a novel patient-centered measure of surgical wait time that more fully embraces the wait experienced by the patient. Many common preoperative interventions had a significant impact on overall wait time experienced by the patient. Evidence-based quality initiatives to coordinate appropriate investigations are needed to reduce wait times.

PB.38. Extent of agreement between radiological and pathological size and factors affecting completeness of excision in breast-conserving surgery for invasive breast cancer

Completeness of excision is the most important factor influencing local recurrence for invasive breast cancer. The aim of this study was to determine whether or not radiological underestimation of tumour size increased the risk of incomplete excision in patients undergoing breast-conserving surgery (BCS).

191. Causes of variation in immediate breast reconstruction after ablative surgery for invasive breast cancer

Background: In recent years there has been an increased interest in performing immediate breast reconstruction after ablative surgery for invasive breast cancer. However, in the Netherlands, considerable variation exists in the performance of immediate breast reconstruction between hospitals. Possible explanations for this variation could be related to several patient, surgeon, or hospital factors, but the exact causes are not known.

Impact of hospital volume on breast cancer outcome: a population-based study in the Netherlands.

For low-volume tumours, high surgical hospital volume is associated with better survival. For high-volume tumours like breast cancer, this association is unclear. The aim of this study is to determine to what extent the yearly surgical hospital breast cancer volume is associated with overall survival. All patients, diagnosed with primary invasive non-metastatic breast cancer in the period 2001-2005, were selected from the Netherlands Cancer Registry. Hospitals were grouped by their annual volume of surgery for invasive breast cancer. Cox proportional hazard models were used including patient and tumour characteristics as covariates. Follow-up was completed until the 1st of February 2013. Primary endpoint was 10-year overall survival rate. In total, 58,982 patients with invasive non-metastatic breast cancer were diagnosed during the period 2001-2005. Hospitals were grouped by their (mean) annual surgical volume: <75 (n=19), 75-99 (n=30), 100-149 (n=29), 150-199 (n=9) and ≥200 (n=14). The 10-year observed survival rates were 77, 81, 80, 82 and 82%, respectively. After case-mix adjustment, patients in low-volume hospitals had a HR of 1.09 (<75 vs. ≥200; 95% CI 1.03-1.15). Survival was significantly higher for lobular carcinoma and for diagnosis in the most recent year (2005). Being a male, having a higher age at diagnosis, a higher tumour grade, a larger tumour size, a higher number of positive lymph nodes, an earlier year of diagnosis and a lower SES resulted in a reduced survival and influenced death, all to a larger extent than surgical volume did. In the Netherlands, surgical hospital volume influences 10-year overall survival only marginally and far less than patient and tumour characteristics. No difference in survival was revealed for invasive non-metastatic breast cancer patients in hospitals with 75-99 operations per year compared with hospitals with over 200 operations per year.