Ingrid Lizarraga

Axillary lymph node dissection for breast cancer: Primum non nocere

The role of axillary lymph node dissection (ALND) in the surgical management of breast cancer has evolved. Although ALND provides excellent local control and staging, it is associated with significant comorbidity, including a reported incidence of lymphedema of 13e23%. With the advent of sentinel lymph node biopsy (SLNB), the need for ALND has diminished, and increasingly, the benefit of completion ALND after a positive SLNB has been challenged. In 2008 the ACOSOG Z0011 trial reported no differences in locoregional recurrence or survival in patients having breast conservation who were randomized to completion ALND vs. no further axillary surgery after finding 1 to 2 positive SLNs. The metaanalysis by Li et al. published in this issue explores the evolving indications for axillary surgery by examining both retrospective and prospective studies comparing ALND vs. SLNB alone for axillary nodal disease in SLN-positive early stage breast cancer. The current arguments for performing completion ALND after identification of a positive SLN are twofold. The first is to allow more accurate staging, prognostication and tailoring of therapy. Delivery of post mastectomy radiation, for example, has been shown to have a clear survival benefit in the presence of 4 or more positive axillary lymph nodes. However, as our understanding of tumor biology grows, it has become increasing clear that stage alone is inadequate in predicting tumor behavior. This has led to an expansion of the indications for post mastectomy radiation, so that the number of lymph nodes involved is only one factor in the decision. Furthermore, as the use of neoadjuvant chemotherapy expands, the paradigm for nodal radiation has shifted to include the response to chemotherapy, and the presence of any residual nodal disease will often prompt radiation delivery. The same holds true for the delivery of adjuvant systemic therapy. The identification of any nodal disease by SLNB should prompt consideration of adjuvant therapy.

Nipple-Sparing Mastectomy is Not Associated with a Delay of Adjuvant Treatment

BackgroundHigh-volume single-institution studies support the oncologic safety of nipple sparing mastectomy (NSM). Concerns remain regarding the increased potential for complications, recurrence, and delays to subsequent adjuvant therapy. A national database was used to examine treatment and outcomes for NSM patients.MethodsWomen undergoing unilateral NSM or skin sparing mastectomy (SSM) for stage 0–4 breast cancer from 2004 to 2013 were identified from the National Cancer Database. Demographic and oncologic characteristics, short-term outcomes and time to local and systemic treatment were compared.ResultsNSM was performed on 8173 patients: 8.7% were node positive, and for stage 1–4 disease, 10.6% were triple negative (TN) and 15.3% were HER2-positive. NSM patients were less likely than SSM patients to receive chemotherapy [CT] (37.4 vs. 43.4%) or radiation [PMRT] (15.6 vs. 16.9%), and were also more likely to present with clinically early-stage disease. NSM patients with high-risk features were more likely to receive CT in the neoadjuvant [NCT] than adjuvant setting [AC] (OR 3.76, 1.81, and 1.99 for clinical N2/3, TN, and HER2-positive disease, all p < 0.001). On multivariate analysis, NSM patients had a higher rate of pathologic complete response [pCR] (OR 1.41, p < 0.001). Readmission rate, positive margin rate and time to CT, PMRT or hormonal therapy were not increased for NSM compared to SSM patients.ConclusionsOver one third of NSM patients received chemotherapy and/or radiation. NSM patients with high-risk features were more likely to receive NAC and obtain a pCR. NSM patients did not experience worse outcomes or delayed adjuvant therapy compared to SSM.

Total Simple Mastectomy

Total (simple) mastectomy is used for ductal carcinoma in situ/invasive cancer not amenable to breast conservation, when patient expresses a preference for mastectomy over breast conservation, or as prophylaxis of carcinoma in selected high-risk women. It may be combined with axillary sentinel lymph node dissection. This chapter describes indications, essential steps, variations, and complications of this procedure. It provides a detailed template operative note for the procedure. Skin-sparing and nipple-sparing mastectomies are detailed in separate chapters, as is breast reconstruction.

Intraoperative Radiation Therapy (IORT)

Intraoperative radiation therapy is used for selected cases of invasive or in situ breast cancer. This chapter lists the indications, essential steps, common variations in technique, and complications of the procedure. A detailed template operative dictation note is included.

Excision of Ducts

Excision of subareolar ducts (ductal excision) is performed for nipple discharge, for suspicion of intraductal papilloma, or to eradicate a mammary fistula. This chapter discusses indications, essential steps, technical variations, and complications of this common procedure. It provides a template operative dictation.

Lumpectomy (Partial Mastectomy)

Breast-conserving therapy is indicated for breast cancer patients in whom the tumor is sufficiently small relative to the breast to allow complete resection with a good cosmetic result. There must not be any contraindication to radiation. This chapter describes lumpectomy (partial mastectomy) guided by palpation or needle localization. Please see Chap. 141 for ultrasound-guided lumpectomy. It lists the indications, essential steps, variations, and complications of the procedure and includes a detailed template operative dictation note.

Axillary Sentinel Node Biopsy for Breast Cancer

Axillary sentinel lymph node biopsy is performed in cases of breast cancer with clinically negative nodes, where there is a desire to avoid lymphadenectomy. This chapter details the indications, essential steps, common variations in technique, and complications of this common procedure. It includes a template operative note.

Invited commentary on “outcomes and feasibility of nipple-sparing mastectomy for node-positive breast cancer patients” by Murphy et al.

Nipple sparing mastectomy (NSM) with immediate reconstruction first developed as a risk-reducing procedure. For that purpose, it has been demonstrated to be safe and effective, as well as cosmetically pleasing, when performed with care. Modern surgical techniques emphasize the creation of thin flaps, more in keeping with traditional therapeutic mastectomy, and removal of the majority of the retro-areolar duct tissue, often with coring of the central nipple ducts.1,2 Therapeutic NSM (sometimes termed total skin sparing mastectomy) arose as a natural extension of developments in skinsparing mastectomy for breast cancer (SSM), with the encouragement of interested patients. It was initially applied to cases of breast cancer in which the risk of nipple involvement was judged to be low, such as tumors <2.5 cm, distance more than 2e4 cm from the NAC, and negative lymph nodes.3,4 Relative risk of nipple involvement increases with larger tumors, central (as opposed to peripheral) tumor location, presence of ductal carcinoma in situ (DCIS), proximity to the nipple, higher tumor stage (including positive axillary lymph nodes), tumor grade, patient age, estrogen receptor (ER) negativity, and her-2-neu positivity.5 Absolute contraindications include clinical involvement of the nipple-areolar complex (NAC), Pagets disease, or inflammatory carcinoma.3,4,6 Recent analyses through the SEER database document that therapeutic NSM is being employed more frequently, and used in more advanced cases of breast cancer.7 Can this procedure be offered safely to selected patients with node positive disease? The

Abstract P1-11-04: Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume

Introduction: Breast conserving therapy (BCT) is considered the treatment of choice for early stage breast cancer by National Cancer Institute guidelines. Little data exists on patient-reported satisfaction and quality of life outcomes after lumpectomy with radiation. This study aims to identify factors influencing satisfaction with cosmetic outcome and quality of life in patients receiving BCT using a validated instrument. Methods: All patients treated with lumpectomy and radiation for breast cancer at our institution from 1997-2012 received a mailed questionnaire containing the BREAST-Q breast conservation module (graciously provided by Dr A. Pusic, Memorial Sloan Kettering Cancer Center), a validated quality of life survey instrument. A retrospective chart review was performed for survey responders for demographic, treatment, and staging information. Scores were calculated for satisfaction with appearance of the breast, adverse effects of radiation, sexual wellbeing, psychosocial wellbeing and physical wellbeing: upper body and arm. Pearson correlation coefficients were obtained. Wilcoxon rank-sum and one-way ANOVA were used to identify associations between patient variables and satisfaction scores. Multivariate regression was used to assess confounding variables. Results: A total of 110 questionnaires (response rate of 29.5%) fit criteria for analysis. The mean age of respondents was 65.9±11.2 yrs, and mean time since diagnosis was 91.8±53.1 mos. We observed the strongest correlations between satisfaction with breast appearance and sexual wellbeing (r=0.66, p Conclusions: In women undergoing BCT, patient satisfaction with appearance of the breast and psychosocial wellbeing at 7.6 years of follow-up correlated with the volume of tissue removed but no other patient or tumor characteristics. Increasing age at diagnosis was associated with greater satisfaction in multiple domains. These results emphasize the importance of precise surgical technique and patient selection in order to achieve long-term patient satisfaction with BCT. Citation Format: Welsh JL, Fu S, Liao J, Sugg SL, Scott-Conner CE, Weigel RJ, Erdahl LM, Lizarraga IM. Long-term patient satisfaction with cosmetic outcome and psychosocial wellbeing after breast conserving therapy is affected only by lumpectomy volume. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-11-04.

Abstract P3-01-11: Sentinel lymph node (SLN) localization is highly successful after neoadjuvant chemotherapy (NCT) for breast cancer

Background: Recent multi-center trial results are concerning for the ability to identify SLNs after NCT. SLN localization was shown to be less successful (80%) after NCT when compared with no NCT (99%) (SENTINA), and the SLN identification rate in Z1071 in which all patients received NCT was 93%. Purpose: To examine the effect of NCT, patient and disease characteristics, imaging and surgical technique on SLN localization rates in breast cancer patients undergoing chemotherapy. Methods: Retrospective, single institution study was performed on patients who underwent surgery for breast cancer from January 2008 to December 2013. All patients who underwent SLN biopsy and either adjuvant chemotherapy (ACT) or NCT, were included. All patients underwent lymphoscintigraphy, and SLN biopsy was performed with the definitive breast surgery. Results: 68 patients underwent NCT, and 133 underwent ACT. Our SLN localization rate was 198/201 (98.5%) overall; 98.6% (67 of 68) with NCT and 97.7% (130/133) with ACT (p=1.0). Compared with the NCT group, the ACT patients were significantly older, white, with more ER/PR positive tumors. The NCT group had more positive nodes on preop imaging (64% v. 20%, p Conclusion: In this single institution series, SLN non-localization was a rare event and not associated with NCT. We were unable to identify any patient or disease characteristics, imaging or surgical techniques associated with SLN non-localization. The etiology of the lower SLN identification rates with NCT in multi-institutional trials remains to be elucidated. Citation Format: Sugg S, Hayes R, Gbenon A, Lizarraga I, Erdahl L, Weigel R, Liao J, Menda Y, Scott-Conner C. Sentinel lymph node (SLN) localization is highly successful after neoadjuvant chemotherapy (NCT) for breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-11.