Surgical Overtreatment Research Articles

Artificial Intelligence in Pancreatic Intraductal Papillary Mucinous Neoplasm Imaging: A Systematic Review.

Based on the Fukuoka and Kyoto international consensus guidelines, the current clinical management of intraductal papillary mucinous neoplasm (IPMN) largely depends on imaging features. While these criteria are highly sensitive in detecting high-risk IPMN, they lack specificity, resulting in surgical overtreatment. Artificial Intelligence (AI)-based medical image analysis has the potential to augment the clinical management of IPMNs by improving diagnostic accuracy. Based on a systematic review of the academic literature on AI in IPMN imaging, 1041 publications were identified of which 25 published studies were included in the analysis. The studies were stratified based on prediction target, underlying data type and imaging modality, patient cohort size, and stage of clinical translation and were subsequently analyzed to identify trends and gaps in the field. Research on AI in IPMN imaging has been increasing in recent years. The majority of studies utilized CT imaging to train computational models. Most studies presented computational models developed on single-center datasets (n=11,44%) and included less than 250 patients (n=18,72%). Methodologically, convolutional neural network (CNN)-based algorithms were most commonly used. Thematically, most studies reported models augmenting differential diagnosis (n=9,36%) or risk stratification (n=10,40%) rather than IPMN detection (n=5,20%) or IPMN segmentation (n=2,8%). This systematic review provides a comprehensive overview of the research landscape of AI in IPMN imaging. Computational models have potential to enhance the accurate and precise stratification of patients with IPMN. Multicenter collaboration and datasets comprising various modalities are necessary to fully utilize this potential, alongside concerted efforts towards clinical translation. Artificial Intelligence holds promise in the field of IPMN by augmenting IPMN detection, differentiation of different types of pancreatic cysts, stratifying malignant progression risk, and automating the analysis of IPMN imaging through computational cyst segmentation.The majority of studies related to AI-based analysis of IPMN imaging use single-center patient cohorts of less than 250 patients to develop and validate computational models and consider imaging as the only data modality.Reporting transparency of existing studies on AI in IPMN imaging is limited and there remains a scarcity of comprehensive, multimodal approaches as well as clinical translation.

Axillary Overtreatment in Patients with Breast Cancer After Neoadjuvant Chemotherapy in the Current Era of Targeted Axillary Dissection.

In the current era of targeted axillary dissection (TAD), there are still cases where axillary lymph node dissection (ALND) is indicated, but histopathological examination confirms the regression of nodal metastases (ypN0). In this situation, ALND may represent undesirable overtreatment. A retrospective study at the Comprehensive Cancer Centre was conducted based on a prospectively maintained database. Patients who underwent surgery after neoadjuvant chemotherapy (NAC) between 2020 and 2023 were selected, specifically those for whom ALND was directly indicated after NAC. Subsequently, clinical-pathological characteristics were compared between cases with ypN0 and those with persistent metastases (ypN+). The reasons for indicating ALND in ypN0 cases were extracted from the medical records. ALND was indicated in 118 cases across 117 patients, of which ypN0 was observed in 44 cases (37%). There were significantly more ypN0 cases for inflammatory carcinomas (68%), the non-luminal HER2-positive phenotype (76%), and carcinomas with histopathological regression of the primary tumor (76%) or the persistence of only the non-invasive component of ypTis (67%). Typical reasons for ALND in ypN0 cases included inflammatory carcinoma (n = 13, 29.5%), locally advanced carcinoma (n = 5, 11.4%), occult carcinoma (n = 2, 4.5%), or persistent lymphadenopathy on ultrasound examination after NAC, especially in the tumor phenotypes HER2-positive and triple-negative breast cancer (TNBC) (n = 8, 18.2%). Through real-world evidence data analysis, subgroups of breast cancer patients treated with NAC were identified who may experience surgical overtreatment in the axilla. These include patients with inflammatory carcinoma, locally advanced carcinoma, occult carcinoma, or patients with persistent lymphadenopathy on US examination after NAC, particularly in the tumor phenotypes HER2-positive and TNBC.

Risk of Surgical Overtreatment in cN1 Breast Cancer Patients who Become ypN0 After Neoadjuvant Chemotherapy: SLNB Versus TAD.

Two surgical approaches have emerged for axillary staging in cN1 breast cancer patients after neoadjuvant chemotherapy (NAC): sentinel lymph node biopsy (SLNB) and targeted axillary dissection (TAD). Direct comparisons of technical and oncological outcomes with SLNB versus TAD are lacking. We routinely performed SLNB from 2017 to 2018 for cN1 breast cancer patients who converted to cN0 after NAC, then adopted TAD from 2019 to 2022. To minimize the false-negative rate (FNR), we required retrieval of ≥3 sentinel lymph nodes (SLN) (2017-2018) or retrieval of the clipped node (CN) and ≥2 SLN (2019-2022). In ypN0 cases meeting these criteria, axillary lymph node dissection (ALND) was omitted. We compared the rate of per-protocol required ALND due to technical failure of SLNB versus TAD and reported axillary recurrence rates. Among 191 cN1 ypN0 patients, 77 underwent SLNB and 114 underwent TAD. The overall rate of required ALND due to technical failure was 14.7% and did not differ between SLNB versus TAD (16.9% vs. 13.2%, p = 0.38). The most common technical failure with SLNB was retrieving <3 SLN (10.4%); for TAD, it was not retrieving the CN (7.1%). Median follow-up was 3.9 years for SLNB patients and 1.7 years for TAD patients; there were 1 (1.3%) and 0 (0.0%) axillary recurrences, respectively. Sentinel lymph node biopsy and TAD for cN1 patients after NAC showed equivalent technical failure rates and low axillary recurrence rates. When applying strict criteria to minimize FNR of axillary staging surgery, approximately 15% of ypN0 patients may be overtreated with ALND.

Critical appraisal of the adequacy of surgical indications for non-functioning pancreatic neuroendocrine tumours.

The lack of preoperative prognostic factors to accurately predict tumour aggressiveness in non-functioning pancreatic neuroendocrine tumours may result in inappropriate management decisions. This study aimed to critically evaluate the adequacy of surgical treatment in patients with resectable non-functioning pancreatic neuroendocrine tumours and investigate preoperative features of surgical appropriateness. A retrospective study was conducted on patients who underwent curative surgery for non-functioning pancreatic neuroendocrine tumours at San Raffaele Hospital (2002-2022). The appropriateness of surgical treatment was categorized as appropriate, potential overtreatment and potential undertreatment based on histologic features of aggressiveness and disease relapse within 1 year from surgery (early relapse). A total of 384 patients were included. Among them, 230 (60%) received appropriate surgical treatment, whereas the remaining 154 (40%) underwent potentially inadequate treatment: 129 (34%) experienced potential overtreatment and 25 (6%) received potential undertreatment. The appropriateness of surgical treatment was significantly associated with radiological tumour size (P < 0.001), tumour site (P = 0.012), surgical technique (P < 0.001) and year of surgical resection (P < 0.001). Surgery performed before 2015 (OR 2.580, 95% c.i. 1.570 to 4.242; P < 0.001), radiological tumour diameter < 25.5 mm (OR 6.566, 95% c.i. 4.010 to 10.751; P < 0.001) and pancreatic body/tail localization (OR 1.908, 95% c.i. 1.119 to 3.253; P = 0.018) were identified as independent predictors of potential overtreatment. Radiological tumour size was the only independent determinant of potential undertreatment (OR 0.291, 95% c.i. 0.107 to 0.791; P = 0.016). Patients subjected to potential undertreatment exhibited significantly poorer disease-free survival (P < 0.001), overall survival (P < 0.001) and disease-specific survival (P < 0.001). Potential overtreatment occurs in nearly one-third of patients undergoing surgery for non-functioning pancreatic neuroendocrine tumours. Tumour diameter emerges as the sole variable capable of predicting the risk of both potential surgical overtreatment and undertreatment.

Abstract PO5-03-02: Ductal carcinoma in situ: An excess regard of the axilla?

Abstract Abstract: Ductal Carcinoma in Situ (DCIS) is a malignant proliferation of the epithelial inside the breast duct, which does not invade the myoepithelial layer and, therefore, does not have the capacity to generate metastases. [1]. However, an upstaging after surgery is possible, since there may be a concomitant invasive lesion that was not diagnosed in the pathological examination from biopsy, being discovered only after the surgical procedure [1]. In the pre-screening mammography era, DCIS was diagnosed. more commonly in symptomatic women presenting with a palpable nodule, papillary flow, or through an incidental finding on a breast biopsy [2], accounting for 1-2% of cancer cases. [3]. After the advent of mammographic screening, the incidence has considerably increased among asymptomatic women with mammographic changes such as calcifications. [4]. Nowadays the diagnosis of DCIS corresponds to 20-25% of biopsies secondary to screening mammographic changes. [1]. As we do know that the chance of axillary metastasis is potentially null, old series where axillary dissection (AD) was performed ipsilareral to the index tumor, axillary involvement was observed in less than 1% of cases [9]. Objectives: Our objective in this study was to describe in a single breast cancer reference center the surgical treatment of patients diagnosed with DCIS (mastectomy or breast conservative surgery – BCS). Methods: A retrospective analysis was made using the Pérola Byington Hospital’s database, from January 2011 to December 2019. During this period, 11,373 cases of breast cancer were treated int the institution and 812 (7.4%) were DCIS. Data was available and we could analyze 494 patients who underwent vacuum-guided biopsy guided by mammography or ultrasound and were diagnosed with DCIS and underwent surgical treatment at the Hospital. We grouped the patients into 3 age groups: under 40, 40-49, and 50 and over. In all groups, we had patients who underwent SNB using the patent blue technique or AD and were evaluated using the H&amp;E method. It is not part of the Institutional protocol to perform IHC in axillary lymph nodes. We had also evaluated the type of surgery (BCS or mastectomy) in each age group. Results: DCIS was diagnosed through mammographic alterations in 62% of all cases and nuclear grade 2 was the most common, with 47%, followed by grade 3 and 1, 46% and 4%, respectively. In 2% of cases the data was missing. Comedoconecrosis was present in 78% of our specimens. BCS was the most frequently surgery performed (73% of cases), with the axillary approach being performed in 35% of these patients (32% for SNB and 3% for AD). While 27% of patients underwent radical surgery and in this group 92% were submitted to axillary approach (70% SNB and 22% AD). In the group of patients younger than 40 years, 74% of patients (17 out of 23 in total) underwent an axillary approach regardless of the type of surgery. When evaluating the predetermined age groups, we saw that most of our patients were 50 years or more (69%), followed by patients between 40-49 years (26%) and 5% in patients under 40 years. In 3% of cases (16 in 494) we reclassified the lesion as invasive carcinoma. None of them had a lymph node involved by malignant cells after surgery and that’s include the cases reclassified as invasive carcinoma. Conclusion: The results obtained in this analysis showing no axillary involvement will make us rethink the indications for the concomitant surgical approach of the breast and the axilla in cases with a diagnosis of DCIS as a way to reduce the axillary surgical overtreatment. It was not our goal to compare the costs and complications of each method of diagnosis and the prognostic factors after the treatment of DCIS. Citation Format: Andressa Amorim, Andre Mattar, Marcellus Ramos, Reginaldo Coelho Lopes, Luciana Damous, Luiz Henrique Gebrim. Ductal carcinoma in situ: An excess regard of the axilla? [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-03-02.

Should patients with hormone receptor-positive, HER2-negative breast cancer and one or two positive sentinel nodes undergo axillary dissection to determine candidacy foradjuvant abemaciclib?

The monarchE trial demonstrated improved outcomes with the use of adjuvant abemaciclib in patients with high-risk hormone receptor-positive, HER2-negative (HR+/HER2-)breast cancer defined as ≥4 positive lymph nodes (+LNs) or one to three +LNs with one or more additional high-risk features (HRFs). The proportion of patients with one or two positive sentinel lymph nodes (+SLNs) without HRFs who had ≥4 +LNs at the time of completion axillary lymph node dissection (cALND), and who therefore qualified for receipt of abemaciclib, was investigated. Females with pathologically node-positivenonmetastatic HR+/HER2- breast cancer stratified by the number of +SLNs and +LNs and the presence of one or more HRFs were identified from the National Cancer Database (2018-2019). The proportion of patients meeting the criteria for abemaciclib both before and after ALND was assessed. Of the 22,048 patients identified, 1578 patients underwent upfront surgery, had one or two +SLNs without HRFs, and went on to cALND. Only 213 (13%) of these patients had ≥4 +LNs; thus, cALND performed solely to determine abemaciclib candidacy would have constituted surgical overtreatment in 1365 patients (87%). When stratified by the number of +SLNs, only 10% of those with one +SLN and 24% of those with two +SLNs had ≥4 +LNs after cALND, which meets the criteria for abemaciclib. Patients with one +SLN without HRFs are unlikely to have ≥4 +LNs and should not be subjected to the morbidity of ALND in order to inform candidacy for abemaciclib. An individualized multidisciplinary discussion should be undertaken about the risk:benefit ratio of ALND and abemaciclib for those with two +SLNs.

A Practical Strategy to Reduce Surgical Overtreatment of Intraductal Papillary Mucinous Neoplasms of the Pancreas.

A Practical Strategy to Reduce Surgical Overtreatment of Intraductal Papillary Mucinous Neoplasms of the Pancreas.

Axillary ultrasound for predicting response to neoadjuvant treatment in breast cancer patients—a single institution experience

BackgroundIn node-positive breast cancer patients at diagnosis (cN +) that render node-negative after neoadjuvant systemic treatment (NAST), axillary lymph node dissection (ALND) can be avoided in selected cases. Axillary ultrasound (AUS) is most often used for re-staging after NAST. We aimed to determine sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of AUS after NAST for predicting nodal response at the Institute of Oncology, Ljubljana.MethodsBiopsy-confirmed cN + patients consecutively diagnosed at our institution between 2008 and 2021, who received NAST, followed by surgery were identified retrospectively. Only patients that underwent AUS after NAST were included. AUS results were compared to definite nodal histopathology results. We calculated sensitivity, specificity, PPV and NPV of AUS. We also calculated the proportion of patients with false-positive AUS that results in surgical overtreatment (unnecessary ALND).ResultsWe identified 437 cN + patients. In 244 (55.8%) AUS after NAST was performed. Among those, 42/244 (17.2%) were triple negative (TN), 78/244 (32.0%) Her-2 positive (Her-2 +), and 124/244 (50,8%) luminal Her-2 negative cancers. AUS was negative in 179/244 (73.4%), suspicious/positive in 65/244 (26.6%) (11/42 (26.2%) TN, 19/78 (24.4%) Her-2 + , and 35/124 (28.2%) luminal Her-2 negative cancers). On definite histopathology, nodal complete response (pCR) was observed in 89/244 (36.5%) (19/42 (45.2%) TN, 55/78 (70.5%) Her-2 + , and 15/124 (12.1%) luminal Her-2 negative cancers). Among patients with suspicious/positive AUS, pCR was observed in 20/65 (30.8%) (6/11 (54.5%) TN, 13/19 (68.4%) Her-2 + and 1/35 (2.9%) luminal Her-2 negative cancers). Sensitivity was 29.0%, specificity 77,5%, PPV 69.2%, NPV 38.5%. Specificity and PPV in TN was 68.4% and 45.4%, in Her-2 + 76.4% and 31.6%, in luminal Her-2 negative 93,3% and 97,1%, respectively.ConclusionIn approximately half of the patients, AUS falsely predicts nodal response after NAST and may lead to overtreatment in 30% of the cases (ALND). However, AUS has to be interpreted in context with tumor subtype. In luminal Her-2 negative cancers, it has a high PPV and is therefore useful.

Fertility preserving management of ovarian torsion

To analyze characteristics of acute and chronic ovarian torsion, review treatment recommendations, and present possible surgical techniques for fertility preservation in young women. Literature review and demonstration of perioperative management of ovarian torsion using radiologic images and intraoperative video footage. Ovarian torsion is mostly mentioned in context of gynecologic emergencies, where acute ovarian torsion with arterial obstruction leads to ovarian ischemia and necrosis. However, ovarian torsion can also occur as a partial or intermittent torsion with venous and lymphatic obstruction, followed by ovarian swelling. In both cases, surgical management of ovarian torsion commonly includes oophorectomy, although leading guidelines recommend preservation of the ovary. We here aimed to raise awareness for the clinical features of ovarian torsion and demonstrate adequate perioperative management, thereby avoiding surgical overtreatment in young women. Medical University of Vienna, Department of Obstetrics and Gynecology. We present a case of acute ovarian torsion with a consequently ischemic ovary as well as a case of chronic ovarian torsion with related massive ovarian edema. The patients included in this video gave consent for publication of the video and posting of the video online, including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.), and other applicable sites. Laparoscopic management with detorsion of the torquated ovaries, cystectomy on an ischemic ovary and oophoropexy to the pelvic side wall and utero-ovarian ligament to prevent recurrence. Postoperative relief of pain and normalization of ovarian size and morphology on ultrasound imaging. The current cases show successful conservative surgical management of ovarian torsion, hence preserving hormonal function and fertility in young women. Although it is recommended to preserve fertility in young women affected by ovarian torsion, surgical overtreatment by means of oophorectomy is still common in clinical routine. Increasing awareness for the clinical characteristics of acute and chronic ovarian torsion, as well as for the importance of preservation of the ovary, is crucial. We therefore believe that ovarian torsion and its surgical management deserve increased attention in the future.

Descripción de un caso de adenomatosis erosiva del pezón: tratamiento quirúrgico

Erosive adenomatosis is a rare benign neoplasm that affects the nipple. Characterized by erosion, telorrhoea, telorrhagia, nodularity, pruritus and erythema, causing a progressive destructive process of the nipple, which can be confused with Paget's disease; which is why knowledge of this pathology is essential to avoid surgical overtreatment. We present the case of a 35-year-old patient diagnosed and treated with surgery, as well as a review of the literature on this entity.

Real-Life Management of Pancreatic Cysts: Simplified Review of Current Guidelines.

Pancreatic cysts are becoming a popular diagnostic tool due to the increased availability of high-quality cross-sectional imaging. Pancreatic cystic lesions constitute closed, liquid-containing cavities, which are either neoplastic or non-neoplastic. While serous lesions often follow a benign course, mucinous lesions can hide carcinoma and, therefore, require different management. Moreover, all cysts should be considered mucinous until proven otherwise, thus limiting the errors in managing these entities. Due to the need for high contrast soft tissue imaging, magnetic resonance imaging represents an elective, non-invasive diagnostic tool. Endoscopic ultrasound (EUS) has started gaining more prominence with regard to the proper diagnosis and management of pancreatic cysts, offering quality information with minimal risks. Enabling both the acquisition of endoscopic images of the papilla and the endosonographic high-quality evaluation of septae, mural nodules along with the vascular patterns of the lesion contribute to a definitive diagnosis. Moreover, the possibility of obtaining cytological or histological samples could become mandatory in the foreseeable future, allowing for more precise molecular testing. Future research should focus on detecting methods to quickly diagnose high-grade dysplasia or early cancer for patients with pancreatic cysts, thus allowing time for appropriate treatment and avoiding surgical overtreatment or over surveillance in selected cases.

What do we know about the epidemiology and the management of human echinococcosis in Albania?

Echinococcosis is a life-threatening neglected zoonotic disease. Cystic echinococcosis (CE) due to Echinococcus (E.) granulosus usually involves livestock and dogs; alveolar echinococcosis (AE) due to E. multilocularis involves rodents and canines such as foxes and dogs. Human hosts are infected accidentally via hand to mouth and/or foodborne/waterborne pathways. Albania is deemed to be endemic for cystic echinococcosis (CE), but there is a scarcity of data to confirm this. A systematic literature search was performed in PubMed, Google Scholar, and in other medical sources. Because of the scarcity of existing information, data confirming CE cases were reviewed from the medical hospital records of Albania’s largest Hospital, the Mother Teresa University Hospital (UHCMT) Tirana, and from a large private laboratory in Tirana (Pegasus laboratory). A total of eight eligible publications on 540 CE patients were found. Three hundred forty seven additional cases hospitalized in UHCMT from 2011 to 2020 were confirmed, as well as 36 laboratory cases and 10 Albanian cases notified in Germany. Taking all cases into account and considering 162 overlapping cases, 771 cases were documented from 2011 to 2020. The only case reported as AE was most likely a multi-organic CE. Surgery was the most frequent therapy approach used (84.7%). Autochthonous human CE seems to be widespread, and transmission is ongoing in Albania. CE patients in Albania undergo surgery more frequently compared with CE cases in other European countries. In order to establish a realistic estimate of prevalence and incidence of CE in Albania, mandatory notification should be reinforced. Stage-specific therapy can be used in CE to reduce therapy cost and diminish mortality by avoiding surgical overtreatment.

Association of minimizing the false negative rate of axillary staging surgery in patients with cN1 breast cancer after neoadjuvant chemotherapy with surgical overtreatment.

587 Background: Efforts to minimize the false negative rate (FNR) of axillary staging in cN1 breast cancer patients (pts) treated with neoadjuvant chemotherapy (NAC) have received much attention since the publication of ACOSOG Z1071. We first adopted sentinel node biopsy (SNB) with a requirement of retrieving ≥3 nodes, and later transitioned to targeted axillary dissection (TAD) with a requirement of retrieving the biopsy-proven clipped node (CN) and ≥3 nodes overall. Group consensus was to perform axillary lymph node dissection (ALND) if these technical requirements were not met. This study evaluates likelihood of surgical overtreatment with ALND due to technical failures of SNB or TAD in cN1 pts who converted to ypN0 status, and reports oncologic outcomes with each approach. Methods: Among 598 cN1 breast cancer pts treated with NAC from 2017-2022 in our prospective institutional database, we included 191 (31.9%) with attempted SNB or TAD and ypN0 status. We used descriptive statistics and chi-squared tests to compare technical complications of SNB vs. TAD resulting in requirement for ALND per group consensus despite ypN0 status. Kaplan Meier methods were used to determine oncologic outcomes in those treated with SNB or TAD alone. Results: Planned axillary surgery was SNB in 77 (40.3%) pts and TAD in 114 (59.7%). The CN was not visualized for seed localization in 14 pts (12.2% of planned TAD) and the seed was not found to be within the CN intra-operatively in 20 pts (20.0% of those with seed placed). Technical failures resulting in requirement of ALND per group consensus criteria occurred in 14 (18.2%) pts with planned SNB and 17 (14.9%) with planned TAD. Among planned TAD pts, the rate of not retrieving the CN did not change over time (p=0.52). Median follow-up in those treated with SNB alone (n=79) was 3.5 years with 1 (1.3%) axillary recurrence as well as 2 local and 2 distant recurrences and 1 non-breast cancer death. 3-yr recurrence-free survival was 90.4% (95%CI: 79.5-95.7%). Median follow-up in those with TAD alone (n=92) was 1.8 years with no recurrences or deaths. Conclusions: This study contributes to a growing body of literature supporting the oncologic safety of omitting ALND in cN1 ypN0 pts treated with NAC, irrespective of the axillary staging approach. Technical limitations in identifying ≥3 nodes or localizing and retrieving CNs resulted in overtreatment with ALND in a significant proportion (≥15%) of ypN0 pts, without significant differences between SNB vs. TAD approaches. These data support consideration of re-evaluating NCCN guidelines recommending retrieval of ≥3 nodes and localization of the CN to minimize risk of overtreatment. [Table: see text]

Towards the improvement of breast cancer management based on EUSOMA quality indicators: Insights from a 15-year institutional experience.

e13662 Background: Breast cancer (BC) is the most common female malignancy and the leading cause of cancer-related deaths among women worldwide. Quality indicators (QIs) are evidence-based measures in healthcare used to track and improve patient care. In 2010, the European Society of Breast Cancer Specialists (EUSOMA) identified several quality indicators that could be adopted by breast cancer dedicated institutions. These QIs allow standardized clinical performance and quality assurance for BC care. We assessed the compliance of EUSOMA QIs published in 2017 by the Hospital de los Valles (HDLV), an Ecuadorian private institution, as a tool to assess BC management. This is the first project in Ecuador and South America that evaluates breast cancer quality indicators. The importance of this project is to create a foundation to identify areas for the improvement of breast cancer care in Ecuador. Methods: Women between 20 and 80 years of age with a histopathological diagnosis of BC and surgically treated at HDLV between 2007 and 2022 were included and analyzed in compliance with the updated EUSOMA QIs (2017). Exclusion criteria: male patients, breast cancer cases diagnosed by core biopsy only and without surgical excision, previous chemotherapy exposure. The number of cases meeting each criteria for EUSOMA QIs is expressed as percentages. Results: 137 women with breast cancer were included for analysis. Based on available information and resources, we were able to assess 14 out of the 34 QIs proposed by EUSOMA. Six indicators reached the minimum standard suggested by EUSOMA: 3 out of 7 QIs for diagnosis, 2 out of 3 for surgical and locoregional treatment, and 1 out of 4 for surgical and quality of life. Standards in triple diagnosis, waiting time, and surgical approaches were accomplished, while standards for surgical over-treatment and simultaneous reconstructive surgery did not meet standards. Conclusions: The lack of data about treatment, follow-up, and low access to standardized procedures limited the number of QIs assessed. This study marks a milestone towards continuous BC care improvement and indicates the need for local QIs and their regional implementation.

Diagnostic Value of the Texture Analysis Parameters of Retroperitoneal Residual Masses on Computed Tomographic Scan after Chemotherapy in Non-Seminomatous Germ Cell Tumors.

After chemotherapy, patients with non-seminomatous germ cell tumors (NSGCTs) with residual masses >1 cm on computed tomography (CT) undergo surgery. However, in approximately 50% of cases, these masses only consist of necrosis/fibrosis. We aimed to develop a radiomics score to predict the malignant character of residual masses to avoid surgical overtreatment. Patients with NSGCTs who underwent surgery for residual masses between September 2007 and July 2020 were retrospectively identified from a unicenter database. Residual masses were delineated on post-chemotherapy contrast-enhanced CT scans. Tumor textures were obtained using the free software LifeX. We constructed a radiomics score using a penalized logistic regression model in a training dataset, and evaluated its performance on a test dataset. We included 76 patients, with 149 residual masses; 97 masses were malignant (65%). In the training dataset (n = 99 residual masses), the best model (ELASTIC-NET) led to a radiomics score based on eight texture features. In the test dataset, the area under the curve (AUC), sensibility, and specificity of this model were respectively estimated at 0.82 (95%CI, 0.69-0.95), 90.6% (75.0-98.0), and 61.1% (35.7-82.7). Our radiomics score may help in the prediction of the malignant nature of residual post-chemotherapy masses in NSGCTs before surgery, and thus limit overtreatment. However, these results are insufficient to simply select patients for surgery.

Does a brief surgeon training in negotiation theory principles decrease rates of contralateral prophylactic mastectomy?

Despite the lack of any oncologic benefit, contralateral prophylactic mastectomy (CPM) use among women with unilateral breast cancer is increasing. This patient-driven trend is influenced by fear of recurrence and desire for peace of mind. Traditional educational strategies have been ineffective in reducing CPM rates. Here we employ training in negotiation theory strategies for counseling and determine the effect on CPM rates. In consecutive patients with unilateral breast cancer treated with mastectomy from 05/2017 to 12/2019, we examined CPM rates before and after a brief surgeon training in negotiation skills. This comprised a systematic framework for patient counseling utilizing early setting of the default option, leveraging social proof, and framing. Among 2144 patients, 925 (43%) were treated pre-training and 744 (35%) post-training. Those treated in the 6-month transition period were excluded (n = 475, 22%). Median patient age was 50years; most patients had T1-T2 (72%), N0 (73%), and estrogen receptor-positive (80%) tumors of ductal histology (72%). The CPM rate was 47% pre-training versus 48% post-training, with an adjusted difference of -3.7% (95% CI -9.4 to 2.1, p = 0.2). In a standardized self-assessment survey, all 15 surgeons reported a high baseline use of negotiation skills and no significant change in conversational difficulty with the structured approach. Brief surgeon training did not affect self-reported use of negotiation skills or reduce CPM rates. The choice of CPM is a highly individual decision influenced by patient values and decision styles. Further research to identify effective strategies to minimize surgical overtreatment with CPM is needed.

Abstract P4-07-41: Is axillary evaluation still necessary in DCIS?

Abstract Background Ductal carcinoma-in-situ (DCIS) is a growing health problem in the world. Before the advent of screening mammography, the incidence of DCIS was low, and patients presented with DCIS that had become clinically symptomatic. Upon this evidence, a strategy of aggressive surgical therapy like the approach with invasive cancer was adopted. The status of the regional lymph nodes is the most important prognostic factor and predictor of survival in breast cancer, but as DCIS is a malignant proliferation of the epithelial inside the breast duct and, therefore, does not have the capacity to generate metastasis. However, an upstaging after surgery is possible. The need for sentinel node biopsy (SNB) in patients with a preoperative biopsy diagnosis of DCIS is still controversial but is done in selected cases. Objectives Our main objective in this study was to evaluate the surgical approach in the axilla (SNB or axillary dissection – AD) of patients diagnosed with DCIS in a single institution and describe the surgical treatment (mastectomy or breast conservative surgery – BCS). In addition, we aimed to find the reasons that led our surgeons to choose one or the other treatment. Methods A retrospective analysis was made using the Pérola Byington Hospital’s database, from January 2011 to December 2019. During this period, 11,373 cases of breast cancer were treated int the institution and 812 (7.4%) were DCIS. Data was available and we could analyze 494 patients who underwent core biopsy or vacuum-guided biopsy guided by mammography or ultrasound and were diagnosed with DCIS and underwent surgical treatment at the Hospital. We grouped the patients into 3 age groups: under 40, 40-49, and 50 and over. In all groups, we had patients who underwent SNB using the patent blue technique or axillary dissection (AD) and were evaluated using the H&amp;E method. We had also evaluated the type of surgery (BCS or mastectomy) in each age group. Results DCIS was diagnosed through mammographic alterations in 62% of all cases and nuclear grade 2 was the most common, with 47%, followed by grade 3 and 1, 46% and 4%, respectively. In 2% of cases the data was missing. Comedonecrosis was present in 78% of our specimens. The type of surgery (radical or BCS) was evaluated and BCS was made in 360 patients (72,87% of the cases), with the axillary approach being performed in 125 patients of these patients (50,20% of cases that went to axillary approach including 9 patients that were submitted to AD). In 27,1% the surgical approach was a radical surgery (total mastectomy or skin sparing mastectomy) and in this group 92,5% were submitted to axillary approach. There was a strong correlation in the type of surgery and axillary approach (p-value 0,000) In the group of patients younger than 40 years, 74% of patients (17 out of 23 in total) underwent an axillary approach regardless of the type of surgery (p-value 0.036) When evaluating the predetermined age groups, we saw that most of our patients were 50 years or more (69%), followed by patients between 40-49 years (26%) and 5% in patients under 40 years. In only 3% of cases (16 in 494) we reclassified the lesion as invasive carcinoma after the surgery. None of them had a lymph node involved by malignant cells after surgery and that’s include the cases reclassified as invasive carcinoma. Conclusion The results obtained in this analysis showing no axillary involvement will make us rethink the indications for the concomitant surgical approach of the breast and the axilla in cases with a diagnosis of DCIS to reduce the axillary surgical overtreatment. It was not our goal to compare the costs, mobility, and complications of the surgical treatment as the survival in these patients that can be addressed in another studies. Citation Format: Marcellus Ramos, Andre Mattar, Andressa Amorim, Felipe Cavagna, Mariana Passos, Raquel Fernandes, Jorge Shida, Luiz Henrique Gebrim. Is axillary evaluation still necessary in DCIS? [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-41.

Limitations and prospects in the management of IPMN: a retrospective, single-center observational study

BackgroundWith increasing use and enhanced accuracy of cross-sectional imaging, the diagnosis of intraductal papillary mucinous neoplasms (IPMNs) of the pancreas has increased over the last few decades. The extent to which malignant transformation occurs remains unclear, making the management of IPMNs controversial. The aim of this study was to evaluate the progression rate and outcome of follow-up in patients with IPMNs.MethodsA database of all patients diagnosed with IPMN at the Cantonal Hospital HFR Fribourg, Switzerland, between January 2006 and December 2019 with a follow-up of at least 6 months was analyzed retrospectively. Descriptive statistics were performed on patient demographics, IPMN characteristics, and follow-up data.ResultsA total of 56 patients were included in this study. Ten patients underwent primary surgery, 46 were enrolled in a surveillance program.21.7% (n = 5) of patients under surveillance presented with worrisome features of IPMN; progression rates were significantly higher in these patients (p = 0.043). Most progression occurred in the early follow-up period. Five patients underwent surgery due to progression, of which 2 presented high-grade dysplasia and 2 malignancy on postoperative histology.ConclusionsThe limited predictive value of current guidelines may lead to surgical overtreatment, and the decision to proceed with surgical resection should be made with caution. Further prospective analyses and the development of novel biomarkers are needed to better understand the natural history of IPMN and improve diagnostic precision.

Long-term oncological outcomes of endoscopic full-thickness resection after previous incomplete resection of low-risk T1 CRC (LOCAL-study): study protocol of a national prospective cohort study

BackgroundT1 colorectal cancer (CRC) without histological high-risk factors for lymph node metastasis (LNM) can potentially be cured by endoscopic resection, which is associated with significantly lower morbidity, mortality and costs compared to radical surgery. An important prerequisite for endoscopic resection as definite treatment is the histological confirmation of tumour-free resection margins. Incomplete resection with involved (R1) or indeterminate (Rx) margins is considered a strong risk factor for residual disease and local recurrence. Therefore, international guidelines recommend additional surgery in case of R1/Rx resection, even in absence of high-risk factors for LNM. Endoscopic full-thickness resection (eFTR) is a relatively new technique that allows transmural resection of colorectal lesions. Local scar excision after prior R1/Rx resection of low-risk T1 CRC could offer an attractive minimal invasive strategy to achieve confirmation about radicality of the previous resection or a second attempt for radical resection of residual luminal cancer. However, oncologic safety has not been established and long-term data are lacking. Besides, surveillance varies widely and requires standardization.Methods/designIn this nationwide, multicenter, prospective cohort study we aim to assess feasibility and oncological safety of completion eFTR following incomplete resection of low-risk T1 CRC. The primary endpoint is to assess the 2 and 5 year luminal local tumor recurrence rate. Secondary study endpoints are to assess feasibility, percentage of curative eFTR-resections, presence of scar tissue and/or complete scar excision at histopathology, safety of eFTR compared to surgery, 2 and 5 year nodal and/or distant tumor recurrence rate and 5-year disease-specific and overall-survival rate.DiscussionSince the implementation of CRC screening programs, the diagnostic rate of T1 CRC is steadily increasing. A significant proportion is not recognized as cancer before endoscopic resection and is therefore resected through conventional techniques primarily reserved for benign polyps. As such, precise histological assessment is often hampered due to cauterization and fragmentation and frequently leads to treatment dilemmas. This first prospective trial will potentially demonstrate the effectiveness and oncological safety of completion eFTR for patients who have undergone a previous incomplete T1 CRC resection. Hereby, substantial surgical overtreatment may be avoided, leading to treatment optimization and organ preservation.Trial registration Nederlands Trial Register, NL 7879, 16 July 2019 (https://trialregister.nl/trial/7879).

Idiopathic retroperitoneal fibrosis with endometrial cancer: a case report and literature review

BackgroundRetroperitoneal fibrosis is a rare disease characterized by chronic nonspecific inflammation, which leads to clinical compression manifestations of retroperitoneal organs especially ureter. Approximately 70 percent of retroperitoneal fibrosis cases are idiopathic which has no clear etiology. This study reported a rare case of a 48-year-old woman presented with idiopathic retroperitoneal fibrosis and endometrial cancer.Case presentationA 48-year-old woman presented with irregular vaginal bleeding without abdominal pain, bloating or discomfort. The patient was diagnosed iRPF after splenectomy 13 years ago. Then she took prednisone for 2 years and took tamoxifen for about 11 years. She stopped taking the medication from October 2019 to May 2020 and then started taking tamoxifen again until November 2020. Two weeks after she stopped taking tamoxifen, she presented with irregular vaginal bleeding. Gynecological ultrasound revealed a thick endometrium with uneven echo enhancement and blood flow signals. Then diagnostic curettage was performed with pathological examination showed endometroid carcinoma. Later, the patient was admitted to Peking University Third Hospital for surgery. Preoperative imaging examinations, including CT, MRI, and PET/CT, all showed pelvic enlarged lymph nodes and they were highly suspected to have lymph node metastasis. The patient underwent laparoscopic surgical staging and enlarged lymph nodes in the pelvic and aortic regions were removed. Finally, the pathology confirmed that endometrioid adenocarcinoma and fibrosis, but there was no tumor infiltration in these enlarged lymph nodes. The patient is now in good condition.ConclusionThis case report stressed the difficulty to distinguish between lymph node metastasis and inflammatory hyperplasia by common imaging methods. Due to increased surgical difficulty among retroperitoneal patients, lymphadenectomy should be carefully evaluated to avoid additional surgical complications and over-treatment.