Underwent Breast Conservation Surgery Research Articles

KHRONOS Project: Is time to surgery really important in the treatment of early breast cancer?

e12598 Background: Recent studies suggest that delaying surgery in early breast cancer (BC) longer than 8 weeks(w) has a worse overall survival compared to those who undergo surgery between 0-4 w. Because BC has developmental heterogeneity over time, the aim of our study is to demonstrate that time from diagnosis to primary surgery is not the most important factor and focus on the value of biology in BC development. Methods: Descriptive, observational and retrospective study in our centre with patients (pts) diagnosed with early stage BC from 2015-2022 without radiological lymph node involvement, whose first therapeutic strategy was surgery. We used chi-square test to analyse the association between categorical variables using SPSS statistical software. Results: 927 pts were included, of which 75.3% (696) maintained pre-surgical staging (N0), while 24.7% (228) changed from N0 to N+ after surgery, with 157 cases having exclusive sentinel lymph node involvement. 98 pts (11.1%) underwent axillary emptying. The histological characteristics were 789 cases (84.9%) ductal while 126 cases (13.6%) were lobular carcinoma. Tumor grades were distributed as follows: G1 (296 cases), G2 (419 cases), and G3 (205 cases). Hormone receptor expression was ER+ (51 cases), ++ (45), +++ (755), and PR + (77), ++ (134), +++ (537). HER2 expression in 516 cases were negative, HER2+ (195), ++ (151), +++ or FISH+ (56). Regarding surgery, 71.8% underwent breast conservative surgery while 28.2% underwent mastectomy. 583 pts were operated below 8w (62.9%), and in 344 (37.1%) time to surgery were > 8w. 583 pts were operated <8w (62.9%), 134 transitioned from N0 to N+ post-surgery, while 448 maintained negative nodal after surgery. In 344 (37.1%) time to surgery were > 8w, 94 pts went from radiologically N0 to nodal involvement after surgery; however, 248 maintained negative nodal status. Although there was a tendency for pts who underwent surgery beyond 8 w to have a greater change in nodal involvement, the differences were not statistically significant (p=0.129). When we performed a stratified analysis by subgroups, in terms of tumour grade, we observed that among pts with G3 tumours operated on >8w, 37.8% had gone from N0 to N+ vs. 23.8% of the group operated <8w, with statistically significant differences, p=0.034. No statistically significant differences were found stratifying by hormone receptors, HER2 or Ki67. Conclusions: In our study we do not find that delay from diagnosis to surgery in BC ≥ 8w worsens lymph node staging. However, we observe that changes in nodal staging occur (transitioning from N0 to N+ in early BC) in poorly differentiated tumors (G3). Therefore, due to BC developmental heterogeneity over time, we believe tumour biology is more important than time to surgery, this may be useful for prioritising pts with these characteristics on the surgical waiting list. Further studies including other biological factors are needed to confirm it.

Neoadjuvant pertuzumab, docetaxel, carboplatin, and trastuzumab (PTCH) regimen in patients with HER2 positive early, locally advanced, and oligometastatic breast cancer: Real-world Indian experience.

e12556 Background: Pertuzumab/docetaxel/carboplatin/trastuzumab (PTCH) regimen constitutes one of the standard neoadjuvant treatments in human epidermal growth factor receptor-2 (HER2) positive breast cancer. The real-world outcomes of its use from the Indian sub-continent are lacking. Methods: We retrospectively reviewed the medical records of 114 HER2-positive BC patients presenting with nonmetastatic or oligometastatic disease and treated with a uniform PTCH regimen in a neoadjuvant setting at the All India Institute of Medical Sciences, New Delhi, India, between Jan 2015 to May 2023. Total six cycles of PTCH [pertuzumab (840 mg loading followed by 420 mg), docetaxel (75 mg/m2), carboplatin (AUC 6), trastuzumab (8 mg/kg loading followed by 6 mg/kg) q21 days] were administered with primary GCSF prophylaxis. The primary outcome was invasive disease-free survival (iDFS). The secondary outcomes included pathological complete response (pCR) rates, overall survival (OS), and toxicity. Adjuvant trastuzumab is used for patients achieving pCR, while for patients not achieving pCR option of adjuvant trastuzumab emtansine (T-DM1) or trastuzumab was decided based on patient affordability. Results: One hundred and fourteen (114) patients were included with a median age of 47 years (range, 23-70). Overall, 52 (45.6%) patients had hormone-positive disease and 73 (64.01%) were premenopausal. Forty patients (35.08%) had stage II, 62 (54.38%) had stage III, and 12(10.5%) had oligometastatic disease. Sixty-one (53.5%) patients underwent breast conservation surgery and pCR was observed in 62 (54.38%) cases. With a median follow-up of 31 months, the 3-year iDFS was 81.5% and overall OS was not reached. Median iDFS was 33 months in patients with node-positive disease and was not reached in patients with node-negative disease. Three-year iDFS was 68.1% in patients who achieved pCR and 49.8% in those who did not achieve pCR (p=0.001). Grade 3/4 toxicity was seen in 26.7% of patients which caused dose modification and interruption in 13.9% of patients. The most common grade 3/4 toxicity was diarrhea in16 (14.03%) cases and thrombocytopenia in 11 (9.6)% cases . Febrile neutropenia was seen in 4 (3.5%) patients. Four patients (3.5%) had a reversible decrease in cardiac left ventricular ejection fraction. Conclusions: In a real-world context, PTCH is an effective and safe anthracycline-free regimen for use in curative (adjuvant and neoadjuvant) setting for HER2 positive breast cancer in Indian women Using neoadjuvant PTCH may improve pCR and obviate the need for adjuvant T-DM1 after surgery making it a cost-effective strategy in limited recourse setting. The survival outcomes were significantly better among those with node-negative disease and among those who achieved a pCR.

An overview of psychological analysis of patients with breast cancer undergoing total mastectomy and breast conservation surgery and its impact on objectified body consciousness at a tertiary care cancer centre.

e12537 Background: Breast cancer is the most common cancer among females, and surgery plays a central role in its treatment. Surgical treatments may have a negative psychological impact on women’s mental health regarding their body image. The purpose of this study was to compare the psychological health insights pertaining to objectified body consciousness scores before and after the surgery and also to observe whether these scores were comparable across the surgery types. Methods: This retrospective qualitative study included 706 breast carcinoma patients who underwent either Breast Conservation Surgery or Total Mastectomy at Manipal Cancer Centre, between the years 2020-2021. A validated questionnaire of Objectified Body Consciousness was used to obtain responses at diagnosis and at 6 months postsurgery and final scores were calculated for both instances. Two sample t- tests/analysis of variance and Chi-square tests were used to compare continuous and categorical variables respectively. Results: Out of total 706 breast cancer patients, 402 patients underwent Breast Conservation Surgery and 304 underwent Total Mastectomy procedure. A statistically significant change was seen in the mean Objectified Body Consciousness Score (14.22±15.44) for all patients when compared pre-operatively (72.72±11.38) and postoperatively (60.15±17.58). This change was higher in the Total Mastectomy group (29.38±11.53). Also, statistically significant rise in scores was seen with increasing age. There was a statistically significant difference between BCS and Total Mastectomy groups with respect to the distribution of age group, marital status, types of cancer, stage and grade of cancer, NACT administration and postoperative mean objectified body consciousness scores of patients (p-value <0.05). Conclusions: We could affirmatively conclude in our study that younger breast cancer patients and all patients who underwent a total mastectomy, had more psychological apprehension with the body image post-surgery, signifying these groups should be encouraged by healthcare professionals to reach out for counselling at the earliest. Knowing the pre-operative Objectified Body Consciousness scores and the type of surgery the patient is going to undergo, will help us to streamline categorical psycho-educational programs for each group and personalise our healthcare professionals to encourage women to reach out to social support groups and directed counselling at the earliest. This will help women adapt to their transformed life and be mentally prepared for the changes that are expected post-surgery.

A Prospective Study of the Efficacy of Endofascial Axillary Dissection to Reduce Axillary Seroma Formation

Abstract Introduction Seroma formation is a common complication following axillary dissection. The pathogenesis of seroma is poorly understood. Various chemical and mechanical methods have been tried to reduce seroma with varying results. In this study, we look at a novel method of axillary dissection to reduce seroma and its attendant morbidity. The objective of the study is to compare endofascial axillary lymphadenectomy with routine axillary lymphadenectomy regarding axillary drain output following breast conservation surgery. Methods We did a prospective interventional study of endofascial axillary dissection in patients undergoing breast conservation surgery. Comparison was done with historical controls who underwent breast conservation surgery with routine axillary lymphadenectomy before the study period. All patients were operated by the same surgeon. Results Breast conservation surgery with endofascial axillary dissection was performed in 36 patients and compared with 36 patients who underwent routine axillary dissection before the study period. The mean total axillary drain output in the endofascial and routine groups were 796.8 and 1,259.3 mL, respectively (p = 0.001). The average day of drain removal in the endofascial and routine groups were 10.8 and 14.9 days, respectively (p = 0.001). The nodal yield of the endofascial and routine groups were 15.3 and 16.4 nodes, respectively (p = 0.449). The duration of surgery of the endofascial and routine groups were 89.3 and 85.1 minutes, respectively (p = 0.366). Conclusion Endofascial axillary dissection significantly reduced the mean total axillary drain output and resulted in early drain removal compared with routine axillary dissection. There were no significant differences in the nodal yield, operative time, seroma aspirations, and wound complications between the endofascial and routine axillary dissection groups.

Abstract PO2-07-04: Applying the Alliance Trial Guidelines in Multi-focal Breast Disease Using an Artificial Intelligence Computational Platform: Economic Analysis and Cosmetic Sensitivity

Abstract Background: Traditionally, multi-focal breast cancer results in mastectomy. The Alliance Trial offers a paradigm shift in surgical options available for multi-focal breast cancer patients in the context of adjuvant chemotherapy. In the trial, patients with multi-focal disease (< 3 tumors) who underwent breast conservation surgery (BCS) were found to have similar outcomes to patients undergoing mastectomy. BCS for large volume tumors ( >30%) has been cited as having a high potential for cosmetic defect, and hence represents a typical upper limit for potential tissue removal in BCS. Here, we evaluated a patient cohort to better understand the economic impact of the Alliance trial and further categorize patients that would most benefit without suffering cosmetic impact. We employed a novel computational technology to quantify the ratio of tumor size to breast tissue volume. Methods: Using a publicly available, single site cohort (n=243, DUMC) of breast cancer patients that underwent mastectomy, we segmented the tumors using our TumorSight Viz software platform. This platform uses artificial intelligence to segment the tumor and surrounding tissues and allows for a volumetric and morphologic assessment in 3D space. We then applied relevant inclusion/exclusion criteria from the Alliance Trial to the cohort (Saha et al, 2018). In trial eligible patients, we used TumorSight Viz to create a convex hull (CH) around the multi-focal disease using dilations of 1 cm and 2 cm. The volume of the CH, corresponding to proposed surgical extirpation, and the overall breast volume (BV) were then computationally assessed in 3D. The ratio of CH to BV (CH:BV) was calculated and a cutoff of 30% (high potential for cosmetic deformity) was applied. A cost analysis was then carried out. We determined the aggregate per annum savings that could potentially be realized by transforming a subset of mastectomies to BCS by tabulating total costs of mastectomy+reconstruction vs. BCS+WBI (whole-breast irradiation), as well as adjusted for relative rates of adjuvant therapy (~80%) across the nationwide patient population. Results: We found that 19.3% of adjuvant mastectomy patients were eligible for BCS based on Alliance Trial criteria. Of those, 68% had tumor CH:BV < 30% when using a 1 cm dilation around the tumor. When using a 2 cm dilation, 56% had tumor CH:BV < 30%. Together, these results indicate that of all adjuvant mastectomy patients, an estimated 10.8-13.1% are eligible for BCS based on volumetric measures of cosmetically acceptable breast tissue removal. Our economic analysis of BCS vs. mastectomy revealed an estimated $28,500 cost savings for patients with private insurance, suggesting that both decreased costs and improved quality-of-life (QOL) can be mutually aligned. By assessing the nationwide number of patients receiving adjuvant therapy for breast cancer, alongside the percentage potentially eligible for BCS using the above cosmetic defect analysis, we estimate that BCS conversion from mastectomy offers to provide a net savings of $300-350 million annually. Conclusion: The Alliance Trial guidelines unveiled the potential option of BCS in ~20% of patients with multi-focal disease in our cohort, demonstrating considerable cost-savings. Computational tools can further differentiate individuals who may not be best candidates for BCS in this setting, ensuring high QOL and informed decision-making. Citation Format: John Pfeiffer, Matthew Biancalana, Dorys Lopez-Ramos, Bradley Feiger, Anuja Antony. Applying the Alliance Trial Guidelines in Multi-focal Breast Disease Using an Artificial Intelligence Computational Platform: Economic Analysis and Cosmetic Sensitivity [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 PO2-07-04.

Abstract PO5-23-05: The Impact of Bi-Annual Diagnostic Imaging on Detecting Ipsilateral Breast Recurrence in Patients Undergoing Breast Conserving Surgery for Breast Cancer

Abstract Introduction: Breast conserving surgery (BCS) represents the preferred option for surgical treatment for a majority of patients with early-stage breast cancer who are eligible for this approach. When compared with mastectomy approaches, BCS provides patients with equivalent survival while preserving the affected breast. It is necessary to achieve clear surgical margins as positive lumpectomy margins are associated with an increased risk for ipsilateral breast tumor recurrence. With advances in imaging techniques, as well as effective systemic therapy and contemporary radiation therapy, local recurrence after BCS has decreased and overall survival for patients has improved. Retrospective studies have quantified the recurrence rate in unifocal breast cancer as 8 - 15% at 20 years. The NCCN recommends annual mammography at least 6 months after post-lumpectomy radiation therapy, but there is little data regarding more frequent surveillance after lumpectomy in the early post-operative setting. The purpose of this study was to evaluate the impact of short interval surveillance mammography on the detection of early in-breast recurrence in patients undergoing BCS. Methods: Our IRB-approved Breast Cancer Database was queried for patients enrolled from 11/2009 to 6/2023 who underwent breast conservation surgery for a diagnosis of in situ or invasive breast cancer in this retrospective analysis. Per our institutional protocol, patients were recommended to undergo diagnostic mammography of the treated breast(s) every 6 months for 2 years after BCS. After the initial 2 year period, bilateral mammography was performed annually in the absence of other indications. Additional supplemental imaging such as breast ultrasound and MRI were performed at physician discretion and based on patient risk and breast density. Variables of interest included the presence of pathogenic germline mutations, family history of breast cancer, and disease characteristics. Our primary endpoint was ipsilateral breast tumor recurrence. Results: Of 2491 patients who underwent breast conservation surgery for in situ or invasive breast cancer, 191 (7.7%) developed recurrent disease, including ipsilateral and contralateral recurrence, and distant disease, in the study period. A total of 83 (3.2%) patients developed ipsilateral breast recurrence during the entire study period. Of those, 19 (22.9%) were detected within the first two years after surgery. Six of the 19 patients (31.6%) had their recurrences detected on yearly diagnostic mammography while 6 (31.6%) patients had their recurrences detected on interval 6-month unilateral diagnostic imaging. In both groups, 5/6 recurrences were invasive disease after an original diagnosis of invasive cancer, and the remaining patient had recurrent DCIS. The remaining 7/19 patients (36.8%) had their ipsilateral recurrences detected on palpation or other diagnostic imaging. In this group as well, there was one case of recurrent DCIS, with the remaining 6 cases representing recurrent invasive cancer. Of the 19 patients with ipsilateral recurrences, none had pathogenic germline mutations. 4 of the 19 patients (21%) had positive margins after their initial lumpectomy surgery with re- excisions required to achieve clear margins. Conclusion: Interval diagnostic surveillance imaging every 6 months after breast conserving surgery identified almost one-third of the ipsilateral breast tumor recurrences that occurred within the first 2 years after surgery in our population. While our numbers are small, the relationship of re-excision lumpectomy surgery to subsequent risk for local recurrence has been described by others, and bears further study. Particularly in view of our observation that the majority of in-breast recurrences were invasive, our data supports the practice of more frequent imaging follow up in the first 2 years after breast conserving surgery. Citation Format: Pabel Miah, Laura Fiedler, Anthony Baez, Athanasios Sevdalis, Alyssa Marmer, Charles DiMaggio, Linda Pak, Richard Shapiro, Karen Hiotis, Deborah Axelrod, Amber Guth, Freya Schnabel. The Impact of Bi-Annual Diagnostic Imaging on Detecting Ipsilateral Breast Recurrence in Patients Undergoing Breast Conserving Surgery for Breast Cancer [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 PO5-23-05.

Nipple-Sparing Mastectomy and Adequate Margins for Patients With Ductal Carcinoma In Situ.

For patients with ductal carcinoma in situ (DCIS) undergoing breast conservation surgery (BCS), guidelines advise a margin width of at least 2mm, with studies demonstrating decreased recurrence risk compared to narrower margins. However, limited data exist establishing if this margin is appropriate in mastectomies, and specifically for nipple-sparing mastectomy (NSM). Consequently, we evaluated the margins of DCIS patients undergoing NSM and resulting oncologic outcomes. A single-institution retrospective review was performed in patients with DCIS or DCIS with microinvasion (DCIS + MI) undergoing NSM from April 2010 to December 2021. Patient and tumor characteristics, margin status, treatment, and outcomes information were collected. The association between margins and local-regional (LRR) and distant recurrence (DR) were examined. 161 patients were included, comprising 284 NSM (164 therapeutic, 120 prophylactic). 153 patients had DCIS and 8 had DCIS + MI. Most patients had hormone sensitive, 123 (76.4%), and nuclear grade 2, 72 (44.7%), disease. In total, 35 (21.7%) patients had positive or <2mm margins. Of these, 21 (60%) involved the anterior margin. At a median follow-up of 45 months (range 0-151), 2.5% (n = 4) had a LRR and .6% (n = 1) had a DR. Of patients with a recurrence, only 2 had positive or <2mm margins, 1 had received endocrine therapy, and none received adjuvant radiation. No specific margin status was found to correlate with recurrence for patients with DCIS or DCIS + MI undergoing NSM, with an altogether low recurrence risk. Overall, this suggests that recommended DCIS margins in BCS doesn't necessarily apply in NSM, where margins of <2mm may be acceptable.

Surveillance Imaging in Breast Cancer Patients Undergoing Breast Conserving Surgery With Chest Wall Perforator Flap Reconstruction

Surveillance Imaging in Breast Cancer Patients Undergoing Breast Conserving Surgery With Chest Wall Perforator Flap Reconstruction

Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome.

Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs. The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14. 150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively. BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

Abstract A037: Prostate Specific Membrane Antigen Targeted Photodynamic Therapy Agent for the Treatment of Breast Cancer

Abstract Introduction: Breast cancer (BCa) is a solid cancer where 65% of all BCa cases, women with stages 1-3 of BCa undergoing Breast Conserving Surgery (BCS) as the primary form of treatment with incomplete resections occurring in 20-60% of BCS leading to repeat procedures[1]. Local recurrence, an indication of “surgically missed” cancerous tissues, occurs in 5-16% of patients with clean margins [1], indicating regions of tumor not resected during analysis of excised tissues. This demonstrates an unmet clinical need for technologies to identify and destroy cancerous tissues in the margins of BCa specimens. Prostate Specific Membrane Antigen (PSMA) is known to be overexpressed in prostate cancer and on the neovasculature of many solid human tumors, including breast tumors [2]. Photodynamic therapy (PDT) is a minimally invasive phototherapy used in the treatment of cancers and other diseases. Previously, we combined a potent Photodynamic Therapy (PDT) agent and highly selective PSMA ligand invented in our lab, to develop a theranostic agent to selectively identify and destroy prostate cancer (PCa) [3]. We have characterized PSMA expression in BCa tumor neovascualture in our novel syngeneic mouse model and show how PSMA-1-Pc413 is an effective strategy in visualizing and treating BCa tumors. Methods: 20 female BALB/c mice were inoculated with 10,000 4T1 – i.e., metastatic mouse cancer cell line – via injection into the mammary pads to create a syngeneic mouse model. We allowed the tumors to grow till an average of 50mm3. Mice were randomly separated into 3 treatment groups based on PSMA-1-Pc413 and PDT irradiation dose, a combination of 0.75mg/kg or 1.0mg/kg at 100Jcm−2 or 150Jcm−2. A 4th control group that received PBS irradiated with 150jcm−2 of light. PSMA-1-Pc413 was injected via tail vein and fluorescence images were taken till 24hr. 24hours post-injection, we irradiated the tumors at the given dose with a 672 nm laser. Tumor growth was tracked via calipers. The endpoint was 28days after treatment. Mice were euthanized, and their lung nodules quantified through counting. Results: Fluorescence images of a representative mouse from the group show positive accumulation of probe within the tumor which was subsequently bleached after PDT treatment, signified by a dark area. Compared to our control group, we see a significant reduction in tumor growth rate with all 5 mice in each of the treatment groups surviving longer than the control group. Groups that received a higher dose of agent and irradiation showed further improved response. Additionally, after euthanizing animals 4 weeks after PDT treatment and quantifying lung nodules we can see a significant decrease in lung metastases which contributes to improved survival outcomes. Conclusions: From the results provided that PSMA can be used as an in vivo target for treating Breast Cancer and that our PSMA-1-Pc413 agent is effective in non-prostatic cancer models. Even a single dose of PDT with our agent has significant impact in reducing tumor growth rate and lung metastases formation. Citation Format: Aditi A Shirke, Xinning Wang, James P Basilion. Prostate Specific Membrane Antigen Targeted Photodynamic Therapy Agent for the Treatment of Breast Cancer [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor Immunology and Immunotherapy; 2023 Oct 1-4; Toronto, Ontario, Canada. Philadelphia (PA): AACR; Cancer Immunol Res 2023;11(12 Suppl):Abstract nr A037.

Effectiveness of a Decision Aid Plus Standard Care in Surgical Management Among Patients With Early Breast Cancer

Patients with early breast cancer must choose between undergoing breast conservation surgery or mastectomy. This decision is often difficult as there are trade-offs between breast conservation and adverse effects, and women with higher decisional conflict have a harder time choosing the therapy that suits their preferences. To study the impact of a decision aid with a patient preference assessment tool for surgical decision-making on patients' decisional conflict scale (DCS) score. This 3-group randomized clinical trial was conducted between June 2017 and December 2019 at a single high-volume tertiary care cancer center in Mumbai, India. A research questionnaire comprising 16 questions answered on a Likert scale (from 1, strongly agree, to 5, strongly disagree) was used to measure DCS scores and other secondary psychological variables, with higher scores indicating more decisional conflict. The Navya Patient Preference Tool (Navya-PPT) was developed as a survey-based presentation of evidence in an adaptive, conjoint analysis-based module for and trade-offs between cosmesis, adverse effects of radiotherapy, and cost of mandatory radiation following breast-conserving surgery. Adult patients with histologically proven early breast cancer (cT1-2, N0-1) who were eligible for breast-conserving surgery as per clinicoradiological assessment were included. Those who were pregnant or unable to read the research questionnaire or who had bilateral breast cancer were excluded. Data were analyzed from January to June 2020. Patients were randomized 1:1:1 to study groups: standard care including clinical explanation about surgery (control), standard care plus the Navya-PPT provided to the patient alone (solo group), and standard care plus the Navya-PPT provided to the patient and a caregiver (joint group). The primary end point of the study was DCS score. The study was 80% powered with 2-sided α = .01 to detect an effect size of 0.25 measured by Cohen d, F test analysis of variance, and fixed effects. A total of 245 female patients (median [range] age, 48 [23-76] years) were randomized (82 to control, 83 to the solo group, and 80 to the joint group). The median (range) pathological tumor size was 2.5 (0-6) cm. A total of 153 participants (62.4%) had pN0 disease, 185 (75.5%) were hormone receptor positive, 197 (80.4%) were human epidermal growth factor receptor 2 negative, 144 (58.6%) were of middle or lower socioeconomic status, and 114 (46.5%) had an education level lower than a college degree. DCS score was significantly reduced in the solo group compared with control (1.34 vs 1.66, respectively; Cohen d, 0.50; SD, 0.31; P < .001) and the joint group compared with control (1.31 vs 1.66, respectively; Cohen d, 0.54; SD, 0.31; P < .001). The results of this study demonstrated lower decisional conflict as measured by DCS score following use of the online, self-administered Navya-PPT among patients with early breast cancer choosing between breast-conserving surgery vs mastectomy. Clinical Trials Registry of India Identifier: CTRI/2017/11/010480.

Incidence, Radiologic and Dosimetric Parameters Associated with Radiation Induced Breast Lymphedema

Radiation induced breast lymphedema (BL) is an underreported but common finding. This study aimed to report the incidence of clinical BL and investigate the radiologic and dosimetric parameters associated with higher risk of BL. This IRB approved study included women with breast cancer who underwent breast conservative surgery followed by adjuvant radiation therapy between 2019 and 2021 at our institution. We reviewed the eligible patients' charts for incidence of clinical BL resulting in symptoms and requiring physical therapy referral. Thickness of the skin at defined center and bottom points of the breast was measured for patient' baseline and follow up mammograms. Dosimetric parameters were imported from patients' radiation plans including mean, maximum doses, and volumes receiving 20, 30, 40, & 50 Gy (V20, V30, V40, & V50), of the whole breast (WB), breast_eval (BE), and breast skin (BS) (defined as the superficial 5 mm of the skin). A chi-square test was used to test the association between clinical BL and radiation treatment regimens and beam energies and the association of skin thicknesses between those who had clinical BL and those who did not. A Wilcoxon rank sum test was used to test the association of the dosimetric parameters with clinical BL. We identified 268 patients who were eligible for the study. After chart and radiologic review, 119 patients had complete records available and were included in this study. Twenty-nine patients (24.4%) of the patients presented with symptomatic BL. Most patients (68%) received hypofractionated (42.56 Gy with or without 10 Gy boost), while 25% received conventional and 7% received ultra-hypofractionated radiotherapy. There was no association between the fractionation and incidence of BL (p = 0.4). There was no association between breast size and BL (mean 1065 cc vs 1232 cc, p = 0.35). There was significant association between BL and BS V30 (142cc vs 162 cc, p = 0.02), and BS V40 (82 cc vs 102 cc, p = 0.02), and a trend towards significant association with BS V20 (172cc vs. 193cc, p = 0.08), BS V50 (8 cc vs. 16 cc, p = 0.06). There was no significant association between BL and BS mean dose (36.9 Gy vs 39 Gy p = 0.11), or BS max dose (53.9 Gy vs 54.1 Gy, p = 0.21). None of the dosimetric parameters of WB and BE had significant association with clinical BL. Utilizing ROC analysis, there was significant association between clinical BL and the change of baseline mammogram breast skin thickness and skin thickness at 6 months follow up mammograms (+13 mm center point p = 0.04, +9 mm bottom point p<0.5), and at 12 months mammograms (+15 mm center point p<0.5, +11 mm bottom point p<0.5). Almost 1 in 4 women experienced radiation induced BL in our cohort. BS V30 & V40 are significantly associated with higher risk of BL. There was significant association between increased skin thickening in 6- and 12-months follow up mammograms and BL. Further analysis will follow to assess the association between surgical and clinical characteristics and BL.

Heart Dose Uncertainty Caused by Heartbeat during Adjuvant Breast Radiotherapy

Adjuvant radiotherapy is a crucial treatment option for breast cancer. Owing to the long survival after treatment, heart toxicity has become a critical issue in those who receive radiotherapy. The heart dose is calculated using the computed tomography (CT) images acquired during simulation. The heart volume is quite different between the systolic and diastolic phases. This study used four-dimensional (4D) CT to capture the heart image and determine the ranges of the heart dose in different phases of the heart. Patients with left-sided breast cancer who underwent breast conservative surgery followed by adjuvant radiotherapy to the entire breast between January 2016 and December 2021 were identified. The three-dimensional (3D) CT and 4DCT datasets of the patients were acquired to evaluate the variation in the heart dose. The heart volume in each respiratory phase was depicted in a box plot along with the dice similarity coefficient (DCS). A total of 32 patients met the inclusion criteria. The DCS of the heart in each respiration phase was within the range of 0.91 to 0.95. Variations in the heart volume and morphology were not evident. However, these variations were not influenced by the respiratory cycle. The median relative variations in the 4DCT volume, mean dose, V20 (≥20 Gy), and V40 (40 Gy) were 6%, 14%, 19%, and 32%, respectively. All parameters showed significant variation between the maximum values in 4DCT and planning 3DCT. When parameters in planning 3DCT were compared to minimum values in 4DCT, the heart volume and V20 still showed significant differences, whereas the mean dose (p = .052) and V40 (p = .151) did not. We found that the median variation in the heart volume during the respiratory cycle was 6%, which led to a 14% variation in the mean heart dose, 19% in V20, and 32% in V40. Dose variation should not be ignored. A more precise method for estimating the heart dose during treatment should be investigated.

Oncoplastic breast conserving surgery versus standard breast conserving surgery for early and locally advanced breast cancer: a retrospective analysis from Sri Lanka

BackgroundBreast aesthetics is becoming increasingly important in breast cancer surgery due to changes in patient expectations and greater emphasis been placed on the psychosocial outcomes. Studies have shown no difference in local recurrence risk between mastectomy and breast conserving surgery (BCS) and also a higher overall survival rate after BCS. Breast preservation improves the quality of life substantially compared to mastectomy. Oncoplastic breast-conserving surgery (O-BCS) involves tumour excision whilst overcoming the limitations of standard breast conserving surgery (S-BCS) by allowing larger resection volumes, avoiding deformities with better aesthetic results. Our study aims to compare the oncosurgical and aesthetic outcomes of O-BCS versus S-BCS among women in Sri Lanka.MethodsWe conducted a retrospective study over a 4-year period including patients who underwent breast conservation surgery for primary non-metastatic breast cancer in two tertiary care units. We assessed outcomes in terms of re-excision rates, resection margin, complications and aesthetic outcomes using a Likert scale questionnaire to grade specific outcomes such as symmetry, volume, nipple position, scar visibility. Non-parametric tests were used for statistical analyses.ResultsFifty-four and seventy-three patients underwent S-BCS and O-BCS respectively. The median specimen volume and the maximum tumour diameter were significantly higher in O-BCS [160(range:65–220); 4.2(range: 1.2–5.2)] compared to S-BCS [65(range:45–86); 2.4(range: 1.0-2.6)]. The median closest tumour margin was 16 mm (range:4-25 mm) in O-BCS while 6 mm (range:<1 – 12 mm) in S-BCS (p = 0.01). Close (< 1 mm) and positive margins needing re-excision were seen mostly in S-BCS. Superior aesthetic outcomes with statistical significant difference were reported in the O-BCS compared to S-BCS group with better symmetry, volume, nipple position and scar visibility. The re-excision rates were significantly lower in O-BCS group. There was no significant difference in the operative time and complications while the aesthetic outcomes were significantly superior in OBCS.ConclusionsOverall, Level 2 perforator flap based reconstruction had superior aesthetic outcomes. O-BCS is safe and more aesthetically acceptable with no difference in oncological outcome and operative time. More consideration should be given to aesthetic parameters such as scar visibility, nipple position, breast volume and shape when considering the best surgical option for the patients.

Magnetic seed versus skin tattoo localization of non-palpable breast lesions: a single institution cohort study.

The objective of this retrospective study was to investigate the accuracy and feasibility of magnetic seed compared to skin tattoo in preoperative localization of impalpable breast lesions in terms of accuracy of placement, re-excision and positive margins rates, and breast/surgical specimen volume ratio. We retrospectively analyzed 77 patients who underwent breast conservative surgery in our center from November 2020 to November 2021, with previous localization with skin tattoo or magnetic seed. Thirty-seven magnetic seeds were placed in 36 patients (48.6%) and 40 skin tattoos were performed in the remaining cases (51.4%). The seeds were placed correctly at the two-view mammogram acquired after the insertion in 97.6% (36/37) of cases. With both methods, 100% of the index lesions were completely removed and found in the surgical specimen. The reported re-excision rate was 0% for both groups. A significant difference was observed in the volume of breast parenchyma removed between the two groups, inferior in the seed group (p = 0.046), especially in case of voluminous breasts (p = 0.003) and small lesions (dimension < 8mm, p = 0.019). Magnetic seed is a non-radioactive localization technique, feasible to place, recommended in case of non-palpable breast lesions, saving the breast parenchyma removed compared with skin tattoo, without reducing the accuracy. Our findings contribute to the current evidence on preoperative localization techniques for non-palpable breast lesions, highlighting the efficacy of magnetic seed localization for deep and small lesions. • Magnetic seed is a non-radioactive technique for the preoperative localization of non-palpable breast lesions studied in comparison with skin tattoo. • Magnetic seed is feasible to place in terms of post-placement migration and distance from the target lesion. • Magnetic seed is recommended in case of non-palpable breast lesions, saving the breast parenchyma removed without reducing the accuracy.

An Overview of Psychological Analysis of Breast Cancer Patients undergoing Modified Radical Mastectomy and Breast Conservation Surgery and its impact on Objectified Body Consciousness at a Tertiary Care Cancer Centre in South India

BackgroundBreast cancer is the most common cancer among females, and surgery plays a central role in its treatment. Surgical treatments may have a negative psychological impact on women's mental health regarding their body image. The purpose of this study was to compare the psychological health insights pertaining to objectified body consciousness scores before and after the surgery and also to observe whether these scores were comparable across the surgery types. Materials and MethodsThis retrospective analysis of prospectively maintained data included 706 breast carcinoma patients who underwent either Breast Conservation Surgery or Modified Radical Mastectomy at tertiary care Cancer Centre, between the years 2020 to 2021. A validated questionnaire of Objectified Body Consciousness was used to obtain responses at diagnosis and at 6 months postsurgery and final scores were calculated for both instances. Two sample t-tests/analysis of variance and Chi-square tests were used to compare continuous and categorical variables respectively. ResultsOut of total 706 breast cancer patients, 402 patients underwent Breast Conservation Surgery and 304 underwent Modified radical mastectomy procedure. A statistically significant change was seen in the mean Objectified Body Consciousness Score (14.22 ± 15.44) for all patients when compared preoperatively(72.72 ± 11.38) and postoperatively(60.15 ± 17.58). This change was higher in the Modified Radical Mastectomy group(29.38 ± 11.53). Also, statistically significant rise in scores was seen with increasing age. ConclusionWe could affirmatively conclude in our study that younger breast cancer patients and all patients who underwent a Modified Radical Mastectomy, had more psychological apprehension with the body image postsurgery, signifying these groups should be encouraged by healthcare professionals to reach out for counselling at the earliest.

10-year mastectomy trends among breast cancer phenotypes: A national cohort study.

584 Background: Breast cancer tumor phenotype has prognostic value with triple negative (TN) cancers having higher rates of distant metastases early. While tumor phenotypes are prognostic, published data demonstrates that the choice of local therapy does not affect this predisposition or affect survival. This study was performed to determine whether mastectomy is being performed more frequently for TN or HER2+ phenotypes, relative to hormone receptor positive (HR+) phenotypes despite the lack of benefit this should provide. Methods: Data from the National Cancer Database (NCDB) was analyzed from 2010 through 2019 to assess mastectomy trends and associations with patient and tumor characteristics. Women with invasive breast cancer were included. Women with Stage IV disease were excluded. Patients were categorized as mastectomy or breast conservation surgery. Patient and tumor characteristics were compared across groups using chi-square and Wilcoxon rank sum tests, and a multivariable logistic regression model was fit to assess the association between mastectomy and tumor phenotype controlling for patient and tumor characteristics. Results: 543,590 patients were evaluated. 173,380 (31.9%) patients underwent mastectomy, and 370,210 (68.1%) patients underwent breast conservation surgery. Mean age at diagnosis was 56. There were 425,174 HR+, 64,960 HER2+, and 53,456 TN tumors. The proportion of patients undergoing mastectomy peaked in 2013 at 36.14% before declining. Compared to HR+, HER2+ patients were more likely to undergo mastectomy, OR 1.39 p &lt; 0.0001 (95% CI 1.35 – 1.43); however, there was no significant difference in mastectomy between HR+ patients and TN patients. Compared to whites, black patients were less likely to undergo mastectomy, OR 0.71 p &lt; 0.0001 (95% CI 0.69 – 0.74), and individuals of Hispanic ethnicity less likely to undergo mastectomy, OR 0.92 p &lt; 0.0001 (95% CI 0.89 – 0.95). Compared to private insurance, Medicare had a greater association with mastectomy, OR 1.2 p &lt; 0.0001 (95% CI 1.18 – 1.23). There was no significant difference between other forms of insurance (Medicaid, other government insurance, no insurance) and private insurance. Education and income were not associated with different frequencies of mastectomy. Patients with higher comorbidity scores were more likely to undergo mastectomy. Conclusions: Mastectomy rates have been declining since 2013 at CoC centers. While TN breast cancer is not associated with increased mastectomy percent, mastectomy continues to be performed more frequently for HER2+ positive phenotype when adjusting for tumor and patient characteristics. These data suggest a need for education about HER2 positive phenotype due to a possible lack of understanding about the why such tumors pose a risk, and the role of local therapy in treating them.

Clinical utility of abbreviated breast MRI based on diffusion tensor imaging in patients underwent breast conservative therapy.

To evaluate the added value of the diffusion tensor imaging (DTI) parameters to abbreviated breast MRI protocol in differentiating recurrent breast cancer from post-operative changes in cases of breast conservative surgery (BCS). This prospective study was approved by our institutional review board. Written informed consent was obtained in all patients. 47 female patients (mean age, 49years; range, 32-66years) that previously underwent breast conservative surgery with a palpable mass were included in this study (62 breast lesions). Two abbreviated MRI protocols were compared using 1.5 Tesla MRI, AB-MRI 1 (axial T1, T2, pre-contrast T1, 1st post-contrast and subtracted images) and AB-MRI 2 (same sequences plus adding DTI). In both protocols, the wash-in rate was calculated. Histopathology was used as the standard of reference. Appropriate statistical tests were used to assess sensitivity, specificity, and diagnostic accuracy for each protocol. The mean total acquisition time was of 6min for AB-MRI 1 and 10min for AB-MRI 2 protocols while the mean interpretation time was of 57.5 and 75s, respectively. Among analyzed DTI parameters, MD (mean diffusivity) showed the highest sensitivity (96.43%) and specificity (91.18%) (P value = < 0.001). FA (fractional anisotropy), AD (axial diffusivity) and RD (radial diffusivity) showed sensitivity = (78.57%, 82.14% and 85.71%), specificity = (88.24, 85.29% and 79.41%), respectively, P value (< 0.001). DTI may be included in abbreviated MRI protocols without a significant increase in acquisition time and with the advantage of increasing specificity and clinical utility in the characterization of post-conservative breast lesions.

Postoperative cosmetic outcome of intraoperative radiotherapy in comparison to whole breast radiotherapy in early stage breast cancer; a retrospective cohort study

BackgroundIn this study, we aim to evaluate the cosmetic outcome differences between Intraoperative electron beam radiation therapy (IOERT) and whole breast radiotherapy (WBR) with further investigation of boosted IOERT.MethodsThis retrospective cohort study was conducted in two referral centers in Tehran, Iran. 116 women aged 30 to 79 with early-stage breast cancer (T0-2N0-1M0) eligible for breast conservation were divided into two groups of 58 based on the intervention they received, and further subgroups were defined based on receiving boosted IOERT. Patients in both groups underwent breast conservation surgery and those in the IOERT group received either a 21 Gy radical dose (radical IOERT) or 12 Gy boosted electron beam radiotherapy and a routine fractionated dose of 50 Gy in 25 sessions of WBR (boosted IOERT). Those in the WBR group were administered 50Gy in 32 sessions. Physician-assessed cosmetic outcome was defined as the primary result and incidence of fat necrosis and fibrosis and post-operative chronic pain were secondary outcomes.ResultsPost-operative cosmetic outcome scores and chronic pain, showed no significant difference between the two groups. The median cosmetic score in both groups was 9. Fat necrosis and fibrosis had significantly higher rates in the IOERT group (P. Value: 0.001). However, the majority (21/34 or 61.8%) of this complication was observed in the boosted IOERT subgroup and no statistical significance was recorded between the radical IOERT subgroup and the WBR group.ConclusionsIn early-stage breast cancer treatment, radical IOERT has noninferiority compared to WBR in terms of cosmesis. Regarding fat necrosis and fibrosis, boosted IOERT was associated with higher rates in comparison to other groups. Therefore, radical IOERT seems to be a better treatment option for selected patients.

Sarcopenia using pectoralis muscle area and lymphocyte-to-monocyte ratio (LMR) are independent prognostic factors in patients for nonmetastatic breast cancer.

Sarcopenia is defined as loss of skeletal muscle mass and strength. This can lead to adverse clinical outcomes in patients with advanced cancer. The lymphocyte-to-monocyte ratio (LMR), a converted inflammatory response, is associated with poor prognosis in patients with malignancies. Herein, we examined the prognostic influence of sarcopenia status assessed by pectoralis muscle area (PMA), inflammatory status calculated by LMR, and its association with disease-free survival (DFS) in a cohort of women diagnosed with nonmetastatic breast cancer. A total of 293 patients with nonmetastatic breast cancer who underwent primary mass resection and radiotherapy between January 2011 and December 2017 were enrolled. The cross-sectional area of the muscle (cm2) at PMA was measured using computed tomography before radiation therapy. Baseline monocyte and lymphocyte counts were obtained from the complete blood count to calculate the LMR. Most of the patients (248/293, 84.6%) underwent breast conservation surgery. Lymph node involvement at diagnosis (hazard ratio [HR], 5.08; P < .001), low LMR (HR, 2.79; P = .007), and low PMA (HR, 3.80; P < .001) were independent poor prognostic factors in multivariate analysis. The mean DFS of sarcopenic and nonsarcopenic patients was 89.8 months and 118.8 months, respectively (P < .001). Sarcopenic patients with low LMR showed the worst outcomes, whereas nonsarcopenic patients with high LMR showed the best outcomes. Low PMA and low LMR were independent poor prognostic factors for DFS in patients with nonmetastatic breast cancer.