G. Querci della Rovere

Management of the axilla in women with breast cancer.

The approach towards axillary surgery should be selective and flexible, with its management tailored to patient choice and tumour characteristics, and concordant with local practice guidelines and available resources. Sentinel-lymph-node biopsy has been embraced as a standard of care in many centres around the world and has revolutionised management of the axilla during the past decade. Nonetheless, data for long-term outcomes remain scarce, and there are persistent variations in practice and inconsistencies in methodology. An international perspective has been sought on important issues relating to management of the axilla, which includes not only the indications and techniques for sentinel-lymph-node biopsy, but also lymph-node sampling, axillary-lymph-node dissection, and observation alone. In this Review, we initially present an overview, which focuses on biological models of lymphatic networks within the breast and patterns of tumour dissemination. A set of key questions are posed with preliminary comments from the authors, followed by a series of collective viewpoints from experts within several different countries.

How safe is oncoplastic breast conservation?: Comparative analysis with standard breast conserving surgery

AIM Oncoplastic techniques are increasingly used to facilitate breast conservation and maintain breast aesthetics but evidence with regards to the oncological safety of oncoplastic breast conservation surgery (oBCS) remains limited. The aim of this study was to compare re-excision and local recurrence rates for oBCS with standard breast conserving surgery (sBCS). METHODS From June 2003 to Feb 2010 data was obtained from contemporaneously recorded electronic patient records on patients who had oBCS and sBCS within a single breast cancer centre. Re-excision rates and local recurrence rates were compared. RESULTS A total of 440 sBCS and 150 oBCS (in 146 women) were included in this study. Median tumour size and specimen weight was 21 mm and 67 g for oBCS and 18 mm and 40 g in the sBCS group (p < 0.001). Re-excision was 2.7% (4/150) and 13.4% (59/440) for oBCS and sBCS respectively (p < 0.001). At a median follow-up of 28 months, local relapse was 2.7% (4) and 2.2% (10) and distant relapse 1.3% (2) and 7.5% (33) for oBCS and sBCS respectively. CONCLUSIONS Oncoplastic breast conserving techniques decrease re-excision rates. Early follow up data suggests oncological outcomes of oncoplastic breast conservation surgery are similar to standard breast conservation.

Localization of impalpable breast lesions a surgical approach

The conventional approach to localization of impalpable breast lesions, i.e. employing a hooked wire with either stereotaxis or a perforated plate, has potential disadvantages for the operating surgeon. Often the entry point of the wire lies some distance from the site of projection of the lesion on the skin. The guide-wire should pierce the skin at, or close to, the site of any proposed surgical incision and proceed along the shortest and most direct course towards the lesion. Ideally, the wire should lie within a radial distance of between 1 and 2 cm from its target. A method is described which achieves these objectives and involves both radiological and clinical measurements. A total of 665 guide-wire localized biopsies have been carried out at the above institutions between 1 November 1987 and 31 March 1995 and between 1 January 1994 and 31 March 1996. In only 4% of cases was re-positioning of the wire required. Excision of the radiological lesion was obtained with a single biopsy in 99% of cases. A second or third biopsy was indicated in 0.7% and 0.3% of cases, respectively. Migration of the wire occurred in two patients and no cases of wire transection or pneumothorax were reported. This method of localization facilitates subsequent excision and permits the most appropriate incision consistent with optimal cosmesis.

Radial scars : a review of 30 cases

Radial Scars/Complex Sclerosing Lesions are benign breast lesions that are seen more frequently now with the advent of screening mammography. These lesions need to be excised surgically in the absence of classical diagnostic features.

Ipsilateral local recurrence of breast cancer: determinant or indicator of poor prognosis?

The importance of ipsilateral local recurrence within a conserved breast depends on the micrometastatic environment at the time of initial clinical presentation. In the absence of micrometastases, local recurrence would be a determinant of distant disease; however, in the presence of micrometastases, it represents a marker of distant relapse. Maximum locoregional treatment at primary diagnosis would be appropriate in the former group, whereas minimum treatment would be sufficient in the latter group, with full treatment prescribed at the time of local recurrence. As an indicator of poor prognosis, the presence of local recurrence permits a more selective approach to therapies that would otherwise result in overtreatment for some patients. We, therefore propose a trial that compares conventional treatment with minimum therapy at presentation plus maximum therapy at local relapse in postmenopausal women with small tumours.

Ipsilateral breast cancer recurrence

The overview by the Early Breast Cancer Trialists Collaborative Group on the impact of loco-regional treatments for breast cancer on long term survival was a milestone publication which partially clarified the significance of ipsilateral breast tumour recurrence (IBTR). In the aftermath of this overview, a conference was convened in London in October 2006 to discuss various aspects of IBTR and in particular whether this represents a marker or determinant of risk for distant metastases. An international panel of speakers covered a range of issues including biological paradigms, the effect of IBTR on survival and whether surgery itself can have a detrimental effect on patient outcome. Other topics included the limits to breast conserving surgery, systemic treatments for IBTR and the role of radiotherapy in minimising IBTR. It was concluded that IBTR is a determinant of distant relapse in approximately 25% of cases and a marker of risk in 75% of cases. However, current surgical practice should not favour increased rates of mastectomy on the basis of the recent meta-analysis of randomised trials.

Management of the axilla

Methods for accurately staging the axilla continue to evolve but remain dominated by sentinel lymph node biopsy (SLNB) which is now widely practiced and accepted as standard of care worldwide. Dual localization methods with blue dye and radioisotope are associated with optimal performance parameters such as shorter learning curve, higher identification rates and low false-negative rates. Several issues relating to surgical technique and choice of tracer agent remain unresolved, and the role of intra-operative nodal assessment remains unclear. Indications for SLN biopsy have broadened and now include some tumours larger than 5-cm, multifocal tumours and higher grades of ductal carcinoma undergoing mastectomy. The complexity of axillary management has been compounded with realization that completion axillary lymph node dissection may not be essential for all SLNB-positive cases containing macro- or micrometastases; adjuvant therapies may adequately deal with modest degrees of tumour burden in non-sentinel lymph nodes without compromise of regional control nor overall survival. Patient selection and timing of SLNB in the context of primary chemotherapy is shifting towards SLNB post-chemotherapy. Downstaging of biopsy-proven nodal disease may allow SLNB to be safely performed after chemotherapy with acceptable false-negative rates. Outstanding questions relate to management of SLNB-positive patients post-chemotherapy and whether recommendations for radiotherapy should be based on nodal stage at presentation or following induction chemotherapy.

A way to reduce the number of benign breast biopsies in a screening programme

Analysis of ductal carcinoma in situ detected at screening has shown bias towards high grade disease; the consensus of opinion amongst pathologists is the detection of high grade DCIS is important in preventing the subsequent development of invasive cancer some years later. Similarly our analysis his shown that identification of high grade DCIS as microcalcitications facilitates the detection of small high grade invasive tumours at a stage when treatment is much more likely to be effective. There is increasing interest in the role of screening in the surveillance of patients at increased risk of breast cancer those with a significant family history and those with previous biopsy showing epithelial changes associated with increased risk. As yet there is no consensus on how the two manage these patients. Women shown to be genetically predisposed as carriers of the BRCAl or BRCA2 gene should be counselled for possible bilateral mastectomies while those with lesser risk may benefit from regular mammographic screening. However, the evidence for any mortality benefit from such screening remains sparse. Achieving pre-operative diagnosis is important for patient well being and the reintroduction of core biopsy using rapid fire guns has allowed many centres to improve their pre-operative diagnosis rates to above 95% and at the same time dramatically reduce the number of diagnosis surgical biopsies performed for what proves to be benign disease. More recently in the UK some analysis of overall breast cancer mortality benefit has suggested that breast cancer screening may be showing early signs in effect with mortality rates falling, particularly in women in the 50 to 70 age range. Analysis has shown that this fall in mortality is associated with improvement in breast cancer stage rather than being attributable to improved treatment. Similarly data in Nottingham over a 20 year period has demonstrated a dramatic fall in breast cancer mortality which correlates closely with a significant fall in tumour size at the time of diagnosis. This data is very encouraging for a predicted significant fall in mortality attributable to earlier diagnosis by screening.