Nickolas Peradze

Unavoidable mastectomy for ipsilateral breast tumour recurrence after conservative surgery: patient outcome

BACKGROUND In the case of ipsilateral breast tumour recurrence (IBTR) after breast-conserving surgery (BCS), a second conservative surgical approach maybe considered in some motivated patients whereas in others mastectomy is unavoidable. PATIENTS AND METHODS From 1997 to 2004, 282 patients presented at the European Institute of Oncology with an operable invasive IBTR after BCS. One hundred and sixty-one (57%) underwent a second conservative surgery, whereas 121 patients (43%) were given a mastectomy and represent the study population. We investigated the prognosis and determined predictive factors of outcome. RESULTS Median time from primary breast cancer to IBTR was 41 months (range 5-213). Recurrences were T2-T4 and/or multifocal in 83 cases (68.6%). With a median follow-up of 5 years after mastectomy, 5-year overall survival (OS) and disease-free survival (DFS) were 73.3% [95% confidence interval (CI) 65.0% to 81.6%] and 50.4% (95% CI 40.9% to 59.8%), respectively. At the multivariate analysis, early onset of IBTR, presence of vascular invasion and Ki67 >or=20 of the recurrent tumour were found to significantly affect both DFS and OS. CONCLUSIONS In women who need mastectomy for IBTR, early onset of the relapse, high proliferation index and presence of vascular invasion represent the worst prognostic factors.

Robotic Nipple-sparing Mastectomy and Immediate Breast Reconstruction With Implant: First Report of Surgical Technique

To the Editor:Technical innovations have made it feasible to conduct endoscopic nipple-sparing mastectomy (NSM), which has been reportedly well tolerated and associated with greater patient satisfaction.1 However, the endoscopic technique (ET) has not had a wide diffusion and many centers have aband

Ipsilateral axillary recurrence after breast conservative surgery: The protective effect of whole breast radiotherapy

BACKGROUND AND PURPOSE Whole breast radiotherapy (WBRT) is one of the possible reasons for the low rate of axillary recurrence after breast-conserving surgery (BCS). PATIENTS AND METHODS We retrospectively collected data from 4,129 consecutive patients with breast cancer ⩽2cm and negative sentinel lymph node who underwent BCS between 1997 and 2007. We compared the risk of axillary lymph node recurrence between patients treated by WBRT (n=2939) and patients who received partial breast irradiation (PBI; n=1,190) performed by a single dose of electron intraoperative radiotherapy. RESULTS Median tumour diameter was 1.1cm in both WBRT and PBI. Women who received WBRT were significantly younger and expressed significantly more multifocality, extensive in situ component, negative oestrogen receptor status and HER2 over-expression than women who received PBI. After a median follow-up of 8.3years, 37 and 28 axillary recurrences were observed in the WBRT and PBI arm, respectively, corresponding to a 10-year cumulative incidence of 1.3% and 4.0% (P<0.001). Multivariate analysis resulted in a hazard ratio of 0.30 (95% CI 0.17-0.51) in favour of WBRT. CONCLUSIONS In this large series of women with T1 breast cancer and negative sentinel lymph node treated by BCS, WBRT lowered the risk of axillary recurrence by two thirds as compared to PBI.

Management of Multifocal-Multicentric Breast Cancer: Current Perspective

The incidence of multifocal (MF) and multicentric (MC) breast cancer has a wide variation among different clinical studies, mostly due to the lack of a standardized classification and definition of these two separate entities. The optimal surgical treatment for multiple ipsilateral breast cancer remains a long debated subject. Multifocal and multicentric breast cancer is usually considered a relative contraindication for breast conserving therapy (BCT). In this narrative review we analyzed differences between MC and MF early breast cancer, the role of magnetic resonance imaging (MRI) in detection of multiple breast lesions, and its role in the surgical approach. We evaluate data from the literature about feasibility of breast conservative surgery and loco-regional treatment modalities. Recent studies brought evidence that treatment of patients with MC/MF breast cancer with BCT plus radiotherapy and adjuvant systemic therapy can have low-rates for in-breast recurrence. Prospective studies are needed to confirm these findings.

Supernumerary Axillary Breast Cancer

To the Editor: This case report presents an opportunity to discuss the treatment of supernumerary breast cancer which is seldom mentioned in the surgical literature, and suggests some novel therapeutic considerations. Supernumerary breast may present characteristics analogous to normal breast tissue in terms of function and, more importantly, pathologic degeneration although treatment option can differ (1). We describe a case of supernumerary axillary breast cancer who needed a reconstruction with latissimus dorsi flap. Accessory breast tissue has a very rare incidence in population with incidence rates of 1–2%. Furthermore, having an accessory breast with concurrent breast cancer is extremely rare with only few articles published in the literature (2). The exact incidence of breast cancer in supernumerary breast tissue is unknown but estimates range in 0.3–0.6%. Both the rarity of the pathology and its sometimes unusual clinical presentation of lumps without nippleareola-complex makes diagnosis very challenging, and the first contact physician is not often including supernumerary breast cancer as part of the differential diagnosis (3). The approach to supernumerary breast cancer should follow the same sequence of clinical examination, mammography, sonogram, and fine-needle aspiration cytology or core needle biopsy as performed usually for anatomic breast cancer. Standard mammograms do not usually show axillary supernumerary breast because of its high location, but with special positioning of the patient, however, ectopic breasts are sometimes imaged. Therapeutic options are also based on standard breast cancer treatment of anatomic breast. Surgical removal is the mainstay of treatment with either mastectomy or wide local excision for a conservative approach, and axillary staging with sentinel lymph node biopsy according to actual evidences (4–7). Some authors recommended radical mastectomy of the ipsilateral breast if the regional lymph nodes are diagnosed with carcinoma (8). However, Evans and Guyton (9) concluded that ipsilateral mastectomy in addition to axillary lymph node dissection was not superior to local excision with node dissection. Thus, it has been proposed that the surgical procedure of choice for ectopic breast carcinoma is wide local excision of the tumor including the skin and the surrounding supernumerary breast tissue, sentinel lymph node sampling and axillary clearance if appropriate (1). Mastectomy of the ipsilateral normal breast gland is not indicated if clinical examination, mammography, and ultrasound of the anatomic breast show no signs of disease, and should only be considered in cases where the differential diagnosis is confusing (2). In all cases careful follow-up is necessary to exclude any late manifestation of an occult primary neoplasm of the breast. Postoperative adjuvant therapy should be based on clinical stage, tumor biology, and patients characteristics. Radiotherapy, chemotherapy regimens, antibodies, and endocrine therapy are usually based on standard treatment for anatomic breast cancer. The exact prognosis of such cases is not known due to the limited data on follow-up and sample size. We discuss a case of a 42-year-old female with cancer arising in supernumerary breast. The patient was seen in our Institution because of complaint regarding a mass located in her right axilla. At her clinical examination a 2 cm hard mass with irregular borders in the right supernumerary breast was detected (Fig. 1). Imaging with mammography and high definition ultrasound revealed a suspicious 1.5 cm hypoechoic mass in the right supernumerary breast, with increased vascularity. The rest of the glandular breast tissue appeared to be normal. Fine-needle aspiration cytology of the tumor was performed, resulting in a C5 category lesion. An interdisciplinary team approach recommended wide local excision of the mass including the involved supernumerary breast, Address correspondence and reprint requests to Antonio Toesca, Division of Breast Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milano, Italy, or e-mail: antonio.toesca@ieo.it