Surgical Management Of Breast Cancer Research Articles

Does the use of acellular dermal matrices (ADM) in women undergoing pre-pectoral implant-based breast reconstruction increase operative success versus non-use of ADM in the same setting? A systematic review protocol

BackgroundBreast cancer is the most common malignancy among women in the UK. Following mastectomy, reconstruction is now integral to the surgical management of breast cancer, of which implant-based reconstruction (IBBR) is the most common type. IBBR initially evolved from pre-pectoral to post-pectoral due to complications, but with developments in oncoplastic techniques and new implant technology, interest in pre-pectoral IBBR has increased.Many surgeons use acellular dermal matrices (ADM); however, there is little evidence in literature as to whether this improves surgical outcomes in terms of complications, failure and patient satisfaction. This review aims to assess the available evidence as to whether there is a difference in surgical outcomes for breast reconstructions using ADM versus non-use of ADM.MethodsA database search will be performed using Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Clinicaltrials.org. The search timeframe will be 10 years.Studies will be screened using inclusion and exclusion criteria and data extracted into a standardised spreadsheet. Risk of bias will be assessed. Screening, extraction and risk-of-bias assessments will be performed independently by two reviewers and discrepancies discussed and rectified. Data analysis and meta-analysis will be performed using Microsoft Excel and R software. Forest plots will be used for two-arm studies to calculate heterogeneity and p-value for overall effect.DiscussionWith the renaissance of pre-pectoral IBBR, it is important that surgeons have adequate evidence available to assist operative decision-making. Assessing evidence in literature is important to help surgeons determine whether using ADM for IBBR is beneficial compared to non-use of ADM. This has potential impacts for patient complications, satisfaction and cost to healthcare trusts.Systematic review registrationPROSPERO 2023 CRD42023389072.

Impact of comorbidity on surgical management of breast cancer in elderly patients.

e12596 Background: More than half of breast cancers are diagnosed above the age of 60 years, a quarter of which diagnosed with invasive breast cancer among those over 75 years of age. Treatment of breast cancer (BC) at this age remains a complex problem. Elderly patients often have various comorbidities that impose increased risks of complications with antitumor treatment. This leads to both excessive and insufficient treatment of BC. In patients over 75 years of age, an individual approach to treatment is recommended, taking into account their general health and life expectancy, the risk of death from breast cancer compared to other causes, as well as the advantages and disadvantages of treatment methods. Objective: To evaluate the influence of comorbidity on the risks of complications (early and delay) after surgical treatment in elderly and senile patients (pts). Methods: A retrospective analysis of the results of breast cancer treatment in 292 pts over 75 years of age, who underwent surgical treatment at the first stage in SBIH Moscow Clinical Scientific and Practical Center named after A.S. Loginov of DHM from 2016 to 2019. The initial stages of breast cancer (I and IIA) were diagnosed in 257 (88.0%) pts, 35 pts (12.0%) has IIB and IIIA clinical stages. Radical mastectomy was performed in 171 (58.6%) cases, breast-conserving surgery was performed in the remaining 121 (41.4%). Forty-six (15.8%) patients had diabetes mellitus, 121 (41.4%) had cardiovascular disease, 36 (12.3%) had heart rhythm disorders, 38 (13.0%) had chronic cerebral ischemia, and the risk of grade 3 and 4 cardiovascular complications was found in 251 (86.0%) cases. Results: In the early postoperative period severe complications occurred in 1 (1.7%) patient (acute coronary syndrome) leading to death. No local recurrences were detected. The overall 3-year survival rate was 86.3% and the recurrence-free survival rate was 89.7%. In 10 (3.4%) cases, death was due to progression of RRMS, 30 (10.3%) patients died from other causes (acute cardiovascular failure, stroke, COVID-19). Conclusions: Comorbid conditions in elderly patients after surgery did not affect the development of complications in the early postoperative period. Preliminary preoperative preparation of elderly patients (correction and selection of drug therapy for concomitant chronic diseases) reduces the risk of early postoperative complications.

Third national surgical consensus conference of the Italian Association of Breast Surgeons (ANISC) on management after neoadjuvant chemotherapy: The difficulty in reaching a consensus

IntroductionNeoadjuvant chemotherapy (NAC) has a profound impact on surgical management of breast cancer. For this reason, the Italian Association of Breast Surgeons (ANISC) promoted the third national Consensus Conference on this subject, open to multidisciplinary specialists. Materials and methodsThe Consensus Conference was held on-line in November 2022, and after an introductory session with five core-team experts, participants were asked to vote on eleven controversial issues, while results were collected in real-time with a polling system. ResultsA total of 164 dedicated specialists from 74 Breast Centers participated. Consensus was reached for only three of the eleven issues, including: 1) the indication to assess the response with Magnetic Resonance Imaging (79 %); 2) the need to re-assess the biological factors of the residual tumor if present (96 %); 3) the possibility of omitting a formal axillary node dissection for cN1 patients if a pathologic Complete Response (pCR) was confirmed with analysis of one or more sentinel lymph nodes (82 %). The majority voted in favor of mapping both the breast and nodal lesions pre-NAC (59 %), and against the omission of sentinel lymph node biopsy in cN0 patients in the case of pathologic or clinical Complete Response (69 %). In cases of cT3/cN1+ tumors with pCR, only 8 % of participants considered appropriate the omission of Post-Mastectomy Radiation Therapy. ConclusionThere is still a wide variability in surgical approaches after NAC in the “real world”. As NAC is increasingly used, multidisciplinary teams should be attuned to conforming their procedures to the rapid advances in this field.

Shoulder dysfunction after partial mastectomy and mini-latissimus dorsi or thoracodorsal artery perforator flaps for breast cancer according to the type of axillary surgeries

Background Breast cancer is the most common cancer type among women and can lead to death. Over the past few decades, there has been a significant change in the surgical management of breast cancer. The aim of this study is to assess how shoulder function was affected by reconstruction using latissimus dorsi mini flap (LDMF) and thoracodorsal artery perforator (TDAP) flaps following partial mastectomy according to surgeries to axilla. Patients and methods This was a prospective randomized study carried out on 40 consecutive female patients, complaining of early stages of breast cancer (stages I, II), undergo partial breast resection and with small tumor to breast volume ratio. All patients were randomized into two equal groups. Group I: early breast cancer (stages I, II) who underwent mastectomy defect by either TDAP flap. Group II: early breast cancer (stages I, II) who underwent mastectomy LDMF. Axillary surgeries were done to each group either sentinel lymph node biopsy dissection (SLND) or axillary lymph node dissection (ALND). Results Shoulder mobility affection 6 months postoperative was significantly higher in LDMF group than TDAP flap group (P=0.045). Regarding relation between types of lymph node surgeries and shoulder mobility affection 3–6 months postoperative, shoulder mobility affection was significantly different among the four groups as affected although ALND and LDMF group was higher. Relation between types of lymph node surgeries and effect on shoulder mobility 6 months, shoulder mobility was normal in 16 (72.73%) patients in sentinel lymph node biopsy (SLNB) and in seven (38.89%) patients in ALND and effected in six (27.27%) patients in SLNB and in 11 (61.11%) patients in ALND. Regarding shoulder mobility, affection was significantly higher in ALND than SLNB (P=0.031). Conclusions The LDMF approach with ALND is with higher shoulder mobility affection in postoperative follow-up after partial mastectomy than LDMF with SLND, TDAP flap with ALND, and TDAP flap with SLND. According to the different types of axillary surgery, ALND had higher shoulder mobility affection.

Latissimus dorsi mini flap versus thoracodorsal artery perforator flap in reconstruction of partial mastectomy defects in early breast cancer: a prospective comparative study

Background Breast cancer is the most common cancer type among women and can lead to death. The surgical management of breast cancer has witnessed a considerable evolution in the past few decades. The aim was to compare the thoracodorsal artery perforator (TDAP) flap with the latissimus dorsi (LD) mini flap in the reconstruction of outer quadrants partial mastectomy defects in early breast cancer patients regarding feasibility, cosmesis, postoperative complications, and early musculoskeletal functional outcome. Patients and methods A prospective randomized study was carried out on 40 consecutive female patients complaining of early breast cancer (stages I, II), undergoing partial breast resection (lumpectomy or quadrantectomy with axillary lymph node dissection), and with a small tumor to breast volume ratio. All patients were randomized into two equal groups in a parallel manner by computer-generated numbers, and their allocation code was kept in a closed opaque envelope: group I: early breast cancer (stages I, II) who underwent mastectomy defect by either TDAP flap. Group II: early breast cancer (stage I, II) who underwent mastectomy the LD mini flap. Results Operation time, drain removal, and hospital stay were significantly lower in LD mini-flap group than TDAP flap group (P=0.032, P<0.05, respectively). Complications and reoperation were insignificantly different between the two groups. Shoulder mobility 6 months and breast scar satisfaction was significantly higher in LD mini-flap group than TDAP flap group (P=0.045 and 0.009, respectively). Breast scar satisfaction and total score of satisfaction were significantly higher in LD mini-flap group than TDAP flap group (P<0.05). Time of adjuvant therapy (first cycle) was insignificantly different between both groups. Conclusions In early breast cancer patients, the LD mini flap is a superior technique to TDAP as it had lower operation time, short hospital stays, drain removal, breast scar satisfaction, and total score of patient satisfaction but with high shoulder mobility affection.

Comparative Study Between The Conventional Modified Radical Mastectomy And Modified Radical Mastectomy With Quilting Technique To Axillary Skin Flap In Reduction Of Postoperative Seroma In Surgical Management Of Breast Cancer

Comparative Study Between The Conventional Modified Radical Mastectomy And Modified Radical Mastectomy With Quilting Technique To Axillary Skin Flap In Reduction Of Postoperative Seroma In Surgical Management Of Breast Cancer

Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer.

Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.

A large hemangioma of the breast influencing the management of breast cancer

Introduction: Hemangiomas are a rare welldemarcated proliferation of mature blood vessels lined by a single layer of endothelial cells occurring in up to 1.3% of mastectomy specimens. Accurate diagnosis often requires the incorporation of clinical, radiological, and histological features. Case Report: A 61-year-old female presented with a self-detected right breast lesion. Initial work-up revealed a right breast lesion at 12 o’clock with core biopsy confirming intermediate grade ductal carcinoma in situ. The management was complicated by the presence of a large right chest wall congenital cavernous hemangioma. Wide local excision of the breast lesion was performed with no sentinel lymph node biopsy done due to extensive vascular malformation. Further excision of margins was required to achieve surgical clearance. Conclusion: Despite its rarity, clinicians should be aware of the potential occurrence of a hemangioma on the breast and potential implications for the surgical management of breast cancer.

Simultaneous Symmetry Procedure in Patients Undergoing Oncoplastic Breast-Conserving Surgery: An Evaluation of Patient Desire and Revision Rates.

In the era of oncoplastic breast conserving-surgery (OBCS), cosmetic outcomes and the desire for symmetry have become essential elements of the surgical management of breast cancer (BC). The timing of contralateral symmetry procedures remains a controversial topic. Simultaneous symmetry procedures (SSP) in OBCS have not been routinely offered due to the perceived risk of delayed asymmetry, potentially increasing the need for delayed cosmetic revision. This study evaluates the rate of revision after SSP in patients undergoing OBCS. We reviewed our institutional prospectively maintained database identifying all BC patients treated surgically since our introduction of oncoplastic surgery in 2018. We routinely offer SSP when appropriate. Descriptive statistics evaluated oncoplastic surgical techniques, SSP offerings and procedures, perioperative complications, and revision rates after treatment completion. Between 2018 and 2022, 485 breast cancer patients underwent partial mastectomy, and 396 (82%) underwent OBCS. Of the 313 patients offered SSP, 272 (87%) accepted. The margin reexcision rate of this cohort was 20%. Of the 272 patients with SSP, 152 (56%) underwent intraoperative radiation therapy (IORT), and 105 (39%) had adjuvant external beam radiation therapy. Three patients (1%) experienced complications involving the symmetry side. No patients with complications experienced a delay in adjuvant therapies or requested cosmetic revisions. Three patients (1%) desired surgical revisions due to asymmetry. Symmetry procedures at the time of OBCS are widely accepted by patients and rarely require delayed cosmetic revision. Simultaneous symmetry procedures should be routinely discussed with patients during the surgical planning of OBCS.

Outcomes of Different Quality of Life Assessment Modalities After Breast Cancer Therapy

Improvement in clinical understanding of the priorities of patients with breast cancer (BC) regarding postoperative aesthetic outcomes (AOs) is needed. To assess expert panel and computerized evaluation modalities against patient-reported outcome measures (PROMs), the gold standard of AO assessment, in patients after surgical management of BC. Embase, MEDLINE, PsycINFO, PubMed, the Cochrane Central Register of Controlled Trials, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov were interrogated from inception through August 5, 2022. Search terms included breast conserving AND aesthetic outcome AND breast cancer. Ten observational studies were eligible for inclusion, with the earliest date of database collection on December 15, 2022. Studies with at least 1 pairwise comparison (PROM vs expert panel or PROM vs computerized evaluation with Breast Cancer Conservation Treatment cosmetic results [BCCT.core] software) were considered eligible if they included patients who received BC treatment with curative intent. Studies reporting solely on risk reduction or benign surgical procedures were excluded to ensure transitivity. Two independent reviewers extracted study data with an independent cross-check from a third reviewer. The quality of included observational studies was assessed using the Newcastle-Ottawa Scale, and the level of evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. Confidence in network meta-analysis results was analyzed with the Confidence in Network Meta-analysis semiautomated tool. Effect size was reported using random-effects odds ratios (ORs) and cumulative ratios of ORs with 95% credibility intervals (CrIs). The primary outcome of this network meta-analysis was modality (expert panel or computer software) discordance from PROMs. Four-point Likert responses across PROMs, expert panel assessment, and BCCT.core evaluation of AOs were assessed. A total of 10 observational studies including 3083 patients (median [IQR] age, 59 [50-60] years; median [range] follow-up, 39.0 [22.5-80.5] months) with reported AOs were assessed and homogenized in 4 distinct Likert response groups (excellent, very good, satisfactory, and bad). Overall network incoherence was low (χ22 = 0.35; P = .83). Overall, panel and software modalities graded AO outcomes worse than PROMs. Specifically, for excellent vs all other responses, the panel to PROM ratio of ORs was 0.30 (95% CrI, 0.17-0.53; I2 = 86%) and the BCCT.core to PROM ratio of ORs was 0.28 (95% CrI, 0.13-0.59; I2 = 95%), while the BCCT.core to panel ratio of ORs was 0.93 (95% CrI, 0.46-1.88; I2 = 88%). In this study, patients scored AOs higher than both expert panels and computer software. Standardization and supplementation of expert panel and software AO tools with racially, ethnically, and culturally inclusive PROMs is needed to improve clinical evaluation of the journey of patients with BC and to prioritize components of therapeutic outcomes.

COVID-19 and Breast Cancer: Analysis of Surgical Management of a Large Referral Center during the 2020–2021 Pandemic Period

Coronavirus disease-19 (COVID-19) has spread worldwide since December 2019 and was officially declared a pandemic in March 2020. Due to the rapid transmission and the high fatality rate, drastic emergency restrictions were issued, with a negative impact on routine clinical activities. In particular, in Italy, many authors have reported a reduction in the number of breast cancer diagnoses and critical problems in the management of patients who accessed the breast units during the dramatic first months of the pandemic. Our study aims to analyze the global impact of COVID-19 in the two years of the pandemic (2020-2021) on the surgical management of breast cancer by comparing them with the previous two years. In our retrospective study, we analyzed all cases of breast cancer diagnosed and surgically treated at the breast unit of "Città della Salute e della Scienza" in Turin, Italy, making a comparison between the 2018-2019 pre-pandemic period and the 2020-2021 pandemic period. We included in our analysis 1331 breast cancer cases surgically treated from January 2018 to December 2021. A total of 726 patients were treated in the pre-pandemic years and 605 in the pandemic period (-121 cases, 9%). No significant differences were observed regarding diagnosis (screening vs. no screening) and timing between radiological diagnosis and surgery for both in situ and invasive tumors. There were no variations in the breast surgical approach (mastectomy vs. conservative surgery), while a reduction in axillary dissection compared to the sentinel lymph node in the pandemic period was observed (p-value < 0.001). Regarding the biological characteristics of breast cancers, we observed a greater number of grades 2-3 (p-value = 0.007), pT stage 3-4 breast cancer surgically treated without previous neoadjuvant chemotherapy (p-value = 0.03), and a reduction in luminal B tumors (p-value = 0.007). Overall, we report a limited reduction in surgical activity for breast cancer treatment considering the entire pandemic period (2020-2021). These results suggest a prompt resumption of surgical activity similar to the pre-pandemic period.

D101. High Deductible Health Plans Delay Surgical Management of Breast Cancer

PURPOSE: High deductible health plans (HDHPs) have been shown to delay timing of screening for breast cancer, though the relationship with timing of breast cancer surgery is unknown. The objective of this study was to characterize the association between HDHPs and the timing of surgery following routine mammogram. METHODS: Data from the IBM® MarketScan® Commercial Claims Database from 2007-2016 were queried to identify women who underwent screening mammogram with or without a subsequent breast cancer operation. The quarter of breast cancer screening and surgery were modeled with ordinal logistic regression. Time from screening to surgery (time to surgery, TTS) was evaluated using a Cox proportional hazard function. RESULTS: Among 223,964 patients who had mammograms, 0.7% underwent breast cancer surgery within the following year. For patients in HDHPs compared to low deductible health plans (LDHPs), the odds of screening (odds ratio [OR] 1.146, p<0.001) and surgery (OR 1.120, p<0.001) increased each quarter. HDHP enrollment was not associated with a difference in TTS. Screening in Q3 was associated with shorter TTS compared to screening in Q1 (hazard ratio [HR] 1.070, p<0.001). CONCLUSION: HDHPs were associated with delays in breast cancer screening and surgery, but not with delays in TTS after diagnosis. Interventions to improve breast cancer care, including breast reconstruction, in the HDHP population should concentrate on reducing barriers to timely screening.

Cytological Diagnostic and Prognostic Methods using Immunocytochemistry (Estrogen Receptor) for Surgical Management of Breast Cancer

The purpose of this study was to assess the utility of fine needle aspiration cytology (FNAC), immunocytochemistry(ICC) using estrogen receptor(ER) in diagnosing breast lesions. This was done by comparing it to histopathology with immunohistochemistry(IHC), which serves as the gold standard for diagnosing these lesions. To compare these modalities of investigation,50 samples were collected using FNAC and were compared to the same samples obtained by histopathology. For FNAC the results were as follows, Sensitivity=100%, Specificity=100%,Diagnostic Accuracy=100% Positive Predictive Value(PPV)=100% and Negative Predictive Value(NPV)=100% . For ICC using ER the results were as follows, Sensitivity=100%,Accuracy=100%,Positive Predictive Value=100%,Negative Predictive Value=100%. This indicates that FNAC and ICC using ER can be used as a reliable alternative to gold-standard diagnostic tests when the latter cannot be done due to a lack of resources or in circumstances where there is a need to perform a painless, minimally invasive procedure such as in inoperable breast carcinoma. This study also involved using text data analysis on FNAC reports. On analysis, it was found that the useful words were 11.35% of the data set, implying that the process of normalization, will result in the formation of condensed data, which can then be utilized for assisting clinical chart reviews and clinical decision support systems.

Current Considerations in Surgical Treatment for Adolescents and Young Women with Breast Cancer.

Adolescents and young women (AYA) with breast cancer represent a unique patient population, compared to the general population with breast cancer. We performed a literature review to evaluate the factors that influenced the surgical outcomes in this patient population. Fifty-two studies were identified, which evaluated breast surgery type, axillary surgery, contralateral prophylactic mastectomy (CPM), surgical timing, psychological factors, disparities, and imaging use. AYA patients had equivalent oncologic outcomes with breast conserving surgery (BCS) or mastectomy. CPM did not improve survival. There are limited data on axillary management in the AYA population, and while more data would be beneficial, this is currently extrapolated from the general breast cancer population. A shorter time to initiate treatment correlated to better outcomes, and disparities need to be overcome for optimal outcomes. AYA patients appreciated involvement in clinical decisions, and shared decision making should be considered whenever possible. Providers must keep these factors in mind when counseling AYA patients, regarding the surgical management of breast cancer.

Preserving Nipple Sensitivity after Breast Cancer Surgery: A Systematic Review and Meta-Analysis.

As breast-conserving procedures become increasingly safe and viable options for surgical management of breast cancer, efforts have focused on assessing and optimizing patient-reported outcome measures (PROMs), such as nipple sensation. This study aims to evaluate the current understanding of nipple-areolar complex (NAC) sensation outcomes in breast cancer patients undergoing breast cancer surgeries, namely, nipple-sparing mastectomies (NSM), skin-sparing mastectomies (SSM), and lumpectomies. Articles including terms related to "nipple," "mastectomy," "sensation," and "patient-reported outcome" were queried from three databases according to PRISMA guidelines. Study characteristics, patient demographics, and surgical details were recorded. Outcomes of interest included objective nipple sensitivity testing and PROMs. Of 888 manuscripts identified, 28 articles met the inclusion criteria. Twelve studies (n = 578 patients) used objective measures to evaluate sensitivity, such as monofilament testing. Sixteen studies (n = 1785 patients) assessed PROMs through validated or investigator-generated surveys. Three of the included studies reported NAC sensitivity in patients who received NSM with neurotization (n = 203 patients) through a variety of techniques that used various grafts to coapt a lateral intercostal nerve to the NAC nerve stumps. Results of investigator surveys showed that of 1565 patients without neurotization, nipple sensation was maintained in 29.0% (n = 453) of patients. Of 138 NSM patients without NAC neurotization, SWM testing showed an average loss of protective sensation in the nipple (average SWM score: 4.7) compared to normal or diminished sensation to light touch in nonoperated controls (average SWM score: 2.9, n = 195). Of patients who underwent NSM with neurotization, one study (n = 78) reported maintenance of NAC sensation in 100% of patients, while another study (n = 7) reported average diminished protective sensation in the nipple (average SWM score: 3.9). Our study has shown that objective and patient-reported results of nipple sensitivity support nipple-sparing techniques as a viable option for preserving NAC sensation, although patients can expect a decrease in sensation overall. Neurotization of the NAC during NSM shows promising results of improved postoperative nipple sensitivity, though additional studies are warranted to confirm this finding. Variations between study methodologies highlight the lack of standardization in sensory testing techniques when evaluating NAC sensation.

Surgical management of breast cancer in Victoria: A state-wide audit.

The Victorian Tumour Summits are an initiative of the Victorian Integrated Cancer Services to engage clinicians and consumers in identifying unwarranted variations in cancer care across the state. From the analysis presented at the Victorian Breast Tumour Summit in 2021, this study provides a state-wide overview of epidemiology and surgical care of breast cancer in Victoria to outline any variations in care across the state, and limitations in data reporting, which impacts the understanding of breast cancer burden and service planning. A retrospective analysis of Victorian breast cancer patients diagnosed between 2016 and 2018 was performed using a linked data set provided by the Department of Health. The linked data sources include Victorian Cancer Registry, Victorian Admitted Episodes Dataset and Victorian Radiotherapy Minimum Data Set, from which patient demographic details, tumor characteristics and treatment records were extracted. Pearson's chi-squared test was used to determine the statistical significance of relationships between various categorical parameters. Variables including demographics, types of surgery (breast-conserving vs. mastectomy), rates of neoadjuvant chemotherapy, and time to surgery were examined. One thousand nine hundred thirty-seven patients with ductal carcinoma in situ and 13,375 patients with invasive breast cancer (IBC) were included. Of 11,351 patients with stages I-III IBC (85%, N=13,375) 66% underwent breast-conserving surgery (BCS), and 31% underwent mastectomy. The ratio of mastectomy to BCS increased with increasing disease stage. Neoadjuvant chemotherapy was utilized in 11% of early IBC patients who were surgically treated. Eighty-three percent of patients undergoing upfront breast surgery were treated within 5 weeks of diagnosis, with a significant difference in the median time to surgery between public and private sectors. Breast reconstruction was performed in 37% of mastectomy patients, of whom 83% underwent immediate breast reconstruction, and 17% underwent delayed breast reconstruction. Victorian breast cancer data show a high quality of surgical care coordination. Significant gaps in our data warrant future improvements in the Victorian breast cancer notification system and access to pharmaceutical data for an enhanced understanding of the breast cancer treatment pathways and care delivery.

Conservative axillary surgery is emerging in the surgical management of breast cancer.

Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.

Revisiting surgical management of breast cancer in a geriatric population.

Breast cancer is a leading cause of death not only in the young population but also in the elderly. There are no consensus treatment guidelines for elderly breast cancer patients. We purposed to discuss surgical treatment options for breast cancer cases over 80 years concerning morbidity and mortality. This retrospective study includes 58 patients over 80 years of age at the time of surgery for breast cancer between 2006 and 2017. A sum of 58 cases (54 females and 4 males), over 80 years of age, with an average age of 84.5±4.07 (80-94) years were included in the study. The modified radical mastectomy was the most common surgical modality in 30 (51.7%) cases, and the axillary intervention was performed on 41 (70.7%). Axillary dissection and sentinel lymph node biopsy were performed for 30 (51.7%) and 11 (18.9%) cases, respectively. Minor and major complications were observed in 8 (13.8%) cases. The average follow-up period of the patients was 37.5 (1-120) months. During the follow-up period, breast cancer-related mortality was observed in 9 (15.52%) cases. No statistical differences were detected in mortality with/without axillary intervention and chosen surgical modality. Comorbidity, the American Society of Anesthesiologists score, and life expectancy should be considered in the management and surgical planning of patients over 80 years of age with breast cancer. Minimally invasive approaches should be preferred for the elderly whenever feasible and applicable in the light of oncologic surgery principles in order to reduce complications and mortality rates.

11. Reversal of Trends in U.S. Breast Surgery Rates: An Analysis From 2005-2017 Using Three Nationwide Datasets

Purpose: Despite equivalent oncologic survivorship, U.S. lumpectomy rates previously declined in favor of more aggressive surgical options such as mastectomy, often performed in conjunction with a contralateral prophylactic mastectomy (CPM) with or without reconstruction. Using three national datasets, this study evaluates longitudinal trends in lumpectomy/mastectomy, CPM, and breast reconstruction rates, determining characteristics most associated with current surgical practice. Methods: Trends in lumpectomy, mastectomy, and reconstruction rates were evaluated using the NSQIP, SEER, and NCDB databases from 2005-2017, further examining mastectomy with a focus on CPM. Longitudinal trends were analyzed with Cochran-Armitage Trend tests and Poisson regression. Upon determining a notable reversal in lumpectomy rates in 2013, we compared NCDB lumpectomy patients before (2011) and after (2017) this change. Multivariate logistic regression using NCDB identified predictors of lumpectomy, CPM, and reconstruction. Results: We analyzed 3,467,645 female surgical breast cancer patients. Surgical trends were found to be similar in all three databases. Lumpectomy rates reached a nadir between 2010-2013, with a significant increase thereafter (NSQIP: +1%/year; SEER +1.6%/year; NCDB: +1.6%/year, all p<0.001). Concurrently there was corresponding decrease in mastectomy rates. Both CPM and reconstruction rates increased significantly from 2005-2013 (p<0.001), but have since stabilized. Age distribution of lumpectomy patients from 2011 to 2017 demonstrated an increase in patients 60-79 years of age with a concurrent increase in the proportion of patients with Medicare (p<0.001). On multivariate logistic regression analysis, the strongest predictors of lumpectomy were older age, black race, treatment at a community center, and clinical N0 disease. The strongest predictors of CPM were younger age, white race, and residence in a zip code with a higher median income. The strongest predictors of reconstruction were younger age, white race, private insurance, residence in a zip code with a higher median income, and undergoing CPM. Conclusion: This is the first study to document a reversal of trend in lumpectomy rates since 2013 with an associated decline in mastectomies and stabilization in CPM and reconstruction. While the databases differ in size and population, the trends are consistent among all three databases. Longitudinal data demonstrate a reversal of prior trends which favored more aggressive surgical management of breast cancer. The etiology of the recent reversal in trends is likely multifactorial; however, an increase in age of the breast cancer population is likely related to this change in the trends. This is also the first evidence of level breast reconstruction rates since passage of the WHCRA. Further research is required to understand factors driving these recent practice changes and associated impact on patient reported outcomes.

Sentinel lymph node biopsy: role in advance breast cancer

Prognosis in patients with breast cancer depends mainly on the extent of lymph node involvement, size of the tumor, and the histological grade of the tumor. Among these factors, axillary lymph node status is regarded as the single best marker of prognosis. Sentinel lymph node biopsy has become a standard staging tool in the surgical management of breast cancer. The positive impact of sentinel lymph node biopsy on postoperative negative outcomes in breast cancer patients, without compromising the oncological outcomes, is its major advantage. It has evolved over the last few decades and has proven its utility beyond early breast cancer. Its applicability and efficacy in patients with clinically positive axilla who have had a complete clinical response after neoadjuvant chemotherapy is being aggressively evaluated at present. However, the accuracy of sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with metastatic breast cancer is unclear. This review study discusses role of sentinel lymph node biopsy in role in advance breast cancer a useful tool in new clinical scenarios of metastatic breast cancer management.