Lisa M. Sclafani

The Risk of Axillary Relapse After Sentinel Lymph Node Biopsy for Breast Cancer Is Comparable With That of Axillary Lymph Node Dissection: A Follow-up Study of 4008 Procedures

Objective:We sought to identify the rate of axillary recurrence after sentinel lymph node (SLN) biopsy for breast cancer. Summary Background Data:SLN biopsy is a new standard of care for axillary lymph node staging in breast cancer. Nevertheless, most validated series of SLN biopsy confirm that the SLN is falsely negative in 5–10% of node-positive cases, and few studies report the rate of axillary local recurrence (LR) for that subset of patients staged by SLN biopsy alone. Methods:Through December of 2002, 4008 consecutive SLN biopsy procedures were performed at Memorial Sloan-Kettering Cancer Center for unilateral invasive breast cancer. Patients were categorized in 4 groups: SLN-negative with axillary lymph node dissection (ALND; n = 326), SLN-negative without ALND (n = 2340), SLN-positive with ALND (n = 1132), and SLN-positive without ALND (n = 210). Clinical and pathologic characteristics and follow-up data for each of the 4 cohorts were evaluated with emphasis on patterns of axillary LR. Results:With a median follow-up of 31 months (range, 1–75), axillary LR occurred in 10/4008 (0.25%) patients overall. In 3 cases (0.07%) the axillary LR was the first site of treatment failure, in 4 (0.1%) it was coincident with breast LR, and in 3 (0.07%) it was coincident with distant metastases. Axillary LR was more frequent among the unconventionally treated SLN-positive/no ALND patients than in the other 3 conventionally treated cohorts (1.4% versus 0.18%, P = 0.013). Conclusions:Axillary LR after SLN biopsy, with or without ALND, is a rare event, and this low relapse rate supports wider use of SLN biopsy for breast cancer staging. There is a low-risk subset of SLN-positive patients in whom completion ALND may not be required.

The malignant nature of papillary and cystic neoplasm of the pancreas

Two new cases of papillary and cystic neoplasm of the pancreas are reported. One patient was a 20‐year‐old woman with massive unresectable liver metastases, and the other was a 15‐year‐old boy. To study the natural history and malignant potential of this tumor, the English literature was reviewed to obtain an additional 56 cases. Clinical characteristics include pain and a mass in most patients, although many are found incidentally. Jaundice, hemoperitoneum, nausea, and vomiting are unusual findings. Most patients are treated by wide resection with good results. These tumors appear to be indolent. However, 16% of patients had major organ or blood vessel invasion, and 7% had liver metastases at some time during the course of their disease, illustrating the malignant nature of this tumor. Long‐term follow‐up is necessary to evaluate the efficacy of treatment, especially in the case of locally advanced and metastatic disease.

Magnetic Resonance Imaging Detects Unsuspected Disease in Patients With Invasive Lobular Cancer

AbstractBackground: Predicting the extent of disease in the breasts of patients with invasive lobular cancer (ILC) can be difficult because of the limits of physical examination and standard imaging. We determined the utility of magnetic resonance imaging (MRI) in finding otherwise unsuspected cancer in the ipsilateral or contralateral breast of patients with ILC. Methods: Through database review of all breast MRIs performed between January 1, 1999, and December 30, 2002, we identified patients with newly diagnosed ILC who underwent an MRI for extent-of-disease evaluation or contralateral screening. MRI findings separate from the primary tumor were biopsied and correlated with pathology by using MRI-guided biopsy. Results: Sixty-two patients were identified. In all, 59 ipsilateral and 57 contralateral studies were performed. Suspicious lesions separate from the primary tumor were found by MRI in 38 (61%) of 62 patients. Eight patients were excluded from further analysis (seven elected mastectomy without biopsy; one had an unguided excision). Nineteen of 51 patients with an ipsilateral finding underwent MRI-guided biopsy, which revealed cancer in 11, or 22% of those imaged. Twenty of 53 patients with a contralateral finding underwent MRI-guided biopsy, which revealed cancer in 5, or 9% of those imaged. Conclusions: MRI of the breast identifies unsuspected multicentric or contralateral cancer in patients with ILC. These findings support the use of MRI in selected patients with ILC, particularly in the ipsilateral breast.

Breast Cancer Recurrence following Prosthetic, Postmastectomy Reconstruction: Incidence, Detection, and Treatment

Background: The purpose of this study was to evaluate the influence of prosthetic reconstruction on the incidence, detection, and management of locoregional recurrence following mastectomy for invasive breast cancer. Methods: A matched retrospective cohort study was performed. Only patients with invasive breast cancer who had 2 years or more of follow-up and/or patients who had recurrence within 2 years of their primary cancer were included. Results: In total, 618 patients who underwent mastectomy for invasive breast cancer from 1995 until 1999 were evaluated. Three hundred nine patients who had immediate, tissue expander/implant reconstruction were matched to 309 women who underwent mastectomy alone on the basis of age (±5 years) and breast cancer stage (I, II, or III). The incidence of locoregional recurrence following mastectomy was 6.8 percent in patients who had reconstruction and 8.1 percent in patients who had mastectomy alone (log rank p = 0.6015). Median time to detection of a locoregional recurrence was 2.3 years (range, 0.1 to 7.2 years) in the reconstructed cohort and 1.9 years (range, 0.1 to 8.8 years) in the nonreconstructed cohort (p = 0.733). Permanent implants were removed following infection in one patient and patient request in two. Conclusions: These results suggest that there is no difference in the incidence of locoregional recurrence in breast cancer patients who undergo immediate, tissue expander/implant reconstruction compared with those patients who do not have reconstruction. Prosthetic breast reconstruction does not appear to hinder detection of locoregional cancer recurrence. In the majority of patients, management of locoregional recurrence does not necessitate removal of a permanent prosthesis.

A Prospective Analysis of the Effect of Blue-Dye Volume on Sentinel Lymph Node Mapping Success and Incidence of Allergic Reaction in Patients With Breast Cancer

BackgroundThis study examined whether the volume of isosulfan blue dye used in sentinel lymph node (SLN) mapping in breast cancer is related to the SLN identification rate or to the incidence of allergic reactions.MethodsFrom January 2001 to November 2002, 1728 breast cancer patients underwent 1832 SLN mapping procedures with the combined technique of intraparenchymal blue dye and intradermal radioisotope. Details of each procedure and all allergic reactions were prospectively recorded. Bilateral synchronous SLN procedures were considered as one dye exposure but as two distinct procedures for determining mapping success. Dye-only success was defined as the proportion of cases in which the SLN was identified by blue dye alone. Overall dye success was defined as the proportion of cases in which the SLN was identified by blue dye with or without isotope.ResultsWhen stratified by volume of blue dye, there were no significant differences in dye-only successes, overall dye successes, or mapping failures. Allergic reactions were documented in 31 (1.8%) of 1728 patients. Hypotensive reactions occurred in 3 (.2%) of 1728 patients; 2 (.1%) required pressor support. There was a nonsignificant trend toward fewer allergic reactions with smaller volumes of blue dye.ConclusionsIn combined-technique SLN mapping protocols for breast cancer, using smaller volumes of blue dye may represent a means of optimizing the safety of the procedure without compromising its success.

Is pleomorphic lobular carcinoma really a distinct clinical entity

Attempts to define the clinical behavior of pleomorphic lobular carcinoma (PLC) have been limited to small series, and clinical management strategies have yet to be established. We describe our experience with PLC as compared to classic ILC and invasive ductal carcinoma (IDC).

Can Sentinel Lymph Node Biopsy Be Omitted in Patients With Favorable Breast Cancer Histology

BackgroundThe widespread use of sentinel lymph node biopsy (SLNB) to replace axillary dissection has broadened the indications for axillary staging in breast cancer. Recent studies have demonstrated a finite risk of lymphedema and sensory morbidity associated with SLNB. We undertook this study to determine whether SLNB could be omitted in clinically node-negative patients with favorable-histology breast cancer.MethodsWe conducted a retrospective review of a prospective database of SLNBs performed at Memorial Sloan-Kettering Cancer Center from 1996 to 2003 to determine the incidence of lymph node metastases by histological subtype. For the favorable subtypes, the patient’s age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade were compared by nodal status to determine their predictive value.ResultsA total of 196 cases with favorable breast cancer subtypes were identified with a 4.1% (8 of 196) sentinel lymph node (SLN) positivity rate. Each of the histological subtypes included patients with positive SLNs, with the exception of adenoid cystic (n = 4) and secretory (n = 1) breast carcinoma, which were quite rare in our series. When compared by nodal status, the patient’s age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade failed to predict those with positive SLNs.ConclusionsPatients with favorable breast cancer histology have a small risk of axillary SLN metastases. The use of SLNB in these patients should be individualized, taking into consideration the small incidence of axillary metastases and the risks and benefits associated with the SLN procedure.

Axillary Dissection and Nodal Irradiation Can Be Avoided for Most Node-positive Z0011-eligible Breast Cancers: A Prospective Validation Study of 793 Patients.

Objective: To determine rates of axillary dissection (ALND) and nodal recurrence in patients eligible for ACOSOG Z0011. Background: Z0011 demonstrated that patients with cT1-2N0 breast cancers and 1 to 2 involved sentinel lymph nodes (SLNs) having breast-conserving therapy had no difference in locoregional recurrence or survival after SLN biopsy alone or ALND. The generalizability of the results and importance of nodal radiotherapy (RT) is unclear. Methods: Patients eligible for Z0011 had SLN biopsy alone. Prospectively defined indications for ALND were metastases in ≥3 SLNs or gross extracapsular extension. Axillary imaging was not routine. SLN and ALND groups and radiation fields were compared with chi-square and t tests. Cumulative incidence of recurrences was estimated with competing risk analysis. Results: From August 2010 to December 2016, 793 patients met Z0011 eligibility criteria and had SLN metastases. Among them, 130 (16%) had ALND; ALND did not vary based on age, estrogen receptor, progesterone receptor, or HER2 status. Five-year event-free survival after SLN alone was 93% with no isolated axillary recurrences. Cumulative 5-year rates of breast + nodal and nodal + distant recurrence were each 0.7%. In 484 SLN-only patients with known RT fields (103 prone, 280 supine tangent, 101 breast + nodes) and follow-up ≥12 months, the 5-year cumulative nodal recurrence rate was 1% and did not differ significantly by RT fields. Conclusions: We confirm that even without preoperative axillary imaging or routine use of nodal RT, ALND can be avoided in a large majority of Z0011-eligible patients with excellent regional control. This approach has the potential to spare substantial numbers of women the morbidity of ALND.

Training a New Generation of Breast Surgeons: Are We Succeeding?

BackgroundSociety of Surgical Oncology (SSO)-approved fellowships in Breast Oncology began training fellows in 2004. Here we ascertain methods of evaluating and improving the fellowship experience through fellowship alumni experience.MethodsWe conducted an electronic survey of fellowship graduates to learn perceived successes and weaknesses of their fellowship training, as well as their current practice experiences. Our electronic survey focused on their preparedness for practice, their job opportunities, and their use of image-guided biopsies in practice.ResultsBetween 2005 and 2009, 142 fellows graduated and received our survey; 85 (60%) responded. Although 98% of graduates though that they were well prepared by their fellowship for performing breast cancer surgery, fewer thought that they were well prepared to perform oncoplastic techniques (53%), ultrasound (39%), and ultrasound-guided biopsies (28%). Nevertheless, many acquired additional training, and 63% were performing ultrasound-guided biopsies in practice. The majority (76%) were performing breast surgery exclusively, with 14% identifying themselves as director of a breast center and only 29% describing themselves as being in private practice—the rest being employed at a hospital or university. Only 8% of respondents were disappointed with the job market, and 67% stated they had received at least three job offers; 82% were satisfied in their current job.ConclusionsSSO breast oncology fellowships appear to be training confident, well-prepared graduates with good job outlooks, and many are achieving leadership positions. Deficiencies in sonography training, some advanced surgical techniques, and administrative experiences should be addressed by program directors as graduates do perceive the need for such training.

Abstract P2-13-08: Initial experience with an ambulatory extended recovery program for patients undergoing mastectomy

Introduction: An ambulatory surgical program has been introduced at Memorial Sloan Kettering Cancer Center for patients undergoing select procedures that require a single overnight stay. The aim of this study was to review the initial experience with this program for patients undergoing mastectomy and to determine the rate and cause of unanticipated hospital admission. Methods: All patients undergoing mastectomy with or without implant based reconstruction from March 2013 to February 2014 inclusive were entered into the Ambulatory Extended Recovery (AXR) program and data were recorded in a prospectively maintained AXR database. Data on patient demographics, type of procedure performed, and whether the patient remained on the AXR program were extracted. Electronic Medical Records were reviewed for all patients who required hospital admission in order to determine the reasons for this. Results: 926 consecutive patients (905 female, 21 male) requiring mastectomy with or without implant based reconstruction were entered into the AXR program during this one-year period (mean age was 51 years, range 21-90). The procedures performed were as follows: bilateral mastectomy with reconstruction (n=433, 46.8%); bilateral mastectomy without reconstruction (n=48, 5.2%); unilateral mastectomy with reconstruction (n=255, 27.5%); and unilateral mastectomy without reconstruction (n=190,20.5%), with or without axillary procedures. Reconstructive procedures deemed suitable for the AXR program included tissue expander or permanent implant insertion only. 861 of 926 patients (93%) remained on the AXR program and were discharged following overnight stay. 62 patients (6.7%) (61 female, 1 male) did not complete the AXR program and required hospital admission (mean age, 52 years; range, 22-81). 3 additional patients (0.3%) required hospital admission on occasions that the AXR unit was at maximum capacity. Reasons for admission are shown in Table 1. Of the 26 patients with postoperative hematoma, 17 were brought back to the Operating Room for definitive management and 9 patients were treated conservatively. Following admission, most patients (52 of 62, 83.9%) were fit for discharge after 1 day. Of the remaining 10 patients, 9 were discharged after 2 days and 1 after 5 days. Conclusion: Unilateral and bilateral mastectomy, with or without implant based reconstruction, is safely performed in the setting of an AXR program. Only a small minority of patients will subsequently require hospital admission, most commonly for management of postoperative hematoma or inadequate pain control. Citation Format: Aidan T Manning, Danielle Cassella, Stacy Ugras, Beverly Tseng-Reyes, Lisa Sclafani. Initial experience with an ambulatory extended recovery program for patients undergoing mastectomy [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-13-08.