Ranjna Sharma

High body mass index and smoking predict morbidity in breast cancer surgery: a multivariate analysis of 26,988 patients from the national surgical quality improvement program database.

Objective:The purpose of this study was to examine the incidence of complications of breast cancer surgery in a multi-institutional, prospective, validated database and to identify preoperative risk factors that predispose to these complications. Background:There is an increased emphasis on clinical outcomes to improve the quality of surgical care. Although mastectomy and breast conserving surgery have low risk for complications, few US studies have examined the incidence of these complications in large, multicenter patient populations. The broad scale of the National Surgical Quality Improvement Program (NSQIP) data set facilitates multivariate analysis of patient characteristics that predispose to development of postoperative complications in breast cancer surgery. Methods:A prospective, multi-institutional study of patients undergoing mastectomy and breast conserving surgery was performed from the National Surgical Quality Improvement Program from 2005 to 2007. Study subjects were selected as a random sample of patients at more than 200 participating community and academic medical centers. Thirty-day morbidity was prospectively collected and the incidence of postoperative complications was determined, with particular emphasis on superficial and deep surgical site infections. Multivariate logistic regression was performed to identify independent risk factors for postoperative wound infections in each. Results:A total of 26,988 patients were identified who underwent mastectomy (N = 10,471) and breast conserving surgery (N = 16,517). As expected, the overall 30-day morbidity rate for all procedures was low (5.6%), with significantly higher morbidity for mastectomies (4.0%) than breast conserving surgery (1.6%, P < 0.001). The most common complications in all procedures were superficial surgical site infections and deep surgical site infections. Independent risk factors for development of any wound infection in patients undergoing mastectomy were a high body mass index, smoking, and diabetes (ORs = 1.8, 1.6, 1.8). In patients who had a lumpectomy, a high body mass index, smoking, and a history of surgery within 90 days prior to this procedure (ORs = 1.7, 1.9, 2.0) were independent risk factors. Conclusions:Although complication rates in breast cancer surgery are low, wound infections remain the most common complication. A high body mass index and current tobacco use were the only independent risk factors for development of a postoperative wound infection across all procedures. This study highlights the benefit of a multi-institutional database in assessing risk factors for adverse outcomes in breast cancer surgery.

Ablative Therapies of the Breast

Minimally invasive ablative therapy techniques are being used in research protocols to treat benign and malignant tumors of the breast in select patient populations. These techniques offer the advantages of an outpatient setting, decreased pain, and improved cosmesis. These therapies, including radiofrequency ablation, cryotherapy, interstitial laser therapy, high-intensity focused ultrasonography, and focused microwave thermotherapy, are reviewed in this article.

Management of local-regional recurrence following immediate breast reconstruction in patients with early breast cancer treated without postmastectomy radiotherapy

Background: Young age is an independent risk factor for local-regional recurrence after mastectomy in patients with T1/T2 tumors with zero or one to three positive lymph nodes. The authors evaluated the current incidence and management of local-regional recurrence after immediate breast reconstruction in patients with T1/T2 tumors and zero to three positive lymph nodes who did not receive postmastectomy radiotherapy. Methods: Clinical and pathologic factors were identified for 495 patients with T1/T2 tumors and zero to three positive lymph nodes who were treated with mastectomy and immediate breast reconstruction between 1997 and 2002 and did not receive primary systemic chemotherapy or postmastectomy radiation therapy. Results: Autologous tissue–based reconstruction was performed in 70 percent of patients, and 30 percent had tissue expander placement. At a median follow-up of 7.5 years, local-regional recurrence had occurred in 16 patients (3.2 percent). Independent predictors of local-regional recurrence were age 40 years or less, estrogen receptor–negative tumors, and T2 (versus T1) tumors (p < 0.05). Multimodality therapy was utilized for all 16 patients with local-regional recurrence. Nine patients (56.3 percent) who had an isolated local-regional recurrence had a 100 percent local control rate and were treated with curative intent. The 10-year overall survival rate for patients with an isolated local-regional recurrence (87.5 percent) was not significantly different from that for patients without a local-regional recurrence (90.3 percent; p = 0.234). Conclusions: Routine use of postmastectomy radiation therapy in this heterogeneous patient population should be discouraged to allow more patients to undergo immediate breast reconstruction and ease the burden on plastic surgeons who have had to confront the problems of reconstruction in the face of perioperative radiation in an ever-increasing number of patients.

Surgical upgrade rate of breast atypia to malignancy: An academic center's experience and validation of a predictive model

Atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), and lobular carcinoma in situ (LCIS) are commonly seen on breast core needle biopsy (CNB). Many institutions recommend excision of these lesions to exclude malignancy. A retrospective chart review was performed on patients who had ADH, ALH, or LCIS on breast CNB from 1/1/08 to 12/31/10 who subsequently had surgical excision of the biopsy site. Study objectives included determining upgrade to malignancy at surgical excision, identification of predictors of upgrade, and validation of a recently published predictive model. Clinical and demographic factors, pathology, characteristics of the biopsy procedure and visible residual lesion were recorded. T test and chi‐squared test were used to identify predictors. Classification tree was used to predict upgrade. 151 patients had mean age of 53 years. The mean maximum lesion size on imaging was 11 mm. The primary atypia was ADH in 63.6%, ALH in 27.8%, and LCIS in 8.6%. 16.6% of patients had upgrade to malignancy, with 72% DCIS and 28% invasive carcinoma. Risk factors for upgrade included maximum lesion size (P = .002) and radiographic presence of residual lesion (P = .001). A predictive model based on these factors had sensitivity 78%, specificity 80% and AUC = 0.88. Validating a published nomogram with our data produced accuracy figures (AUC = 0.65) within published CI of 0.63‐0.82. In CNB specimens containing ADH, ALH, or LCIS, initial lesion size and presence of residual lesion are predictors of upgrade to malignancy. A validated model may be helpful in developing patient management strategies.

Oncoplastic breast surgery: Achieving oncological and aesthetic outcomes

Oncoplastic reconstruction allows more patients to become candidates for breast‐conserving surgery (BCS). Oncologic resection of a breast lesion is combined with plastic surgical techniques to improve aesthetic results. Choosing the best oncoplastic method is essential to optimize outcomes, improve cosmesis, and minimize postoperative complications. The aim of this study is to present a treatment algorithm incorporating oncoplastic techniques based on diagnosis, tumor size, tumor location, and breast size and shape.

The Future of Quality Improvement in Breast Cancer: Patient-Reported Outcomes

October 2017 marks the 33rd anniversary of National Breast Cancer Awareness Month since its inception in 1985 by the American Cancer Society. Breast cancer care is “ubiquitous” in our health system, as the management of breast disease involves many different specialties, spans a variety of health care settings, and crosses the full cancer spectrum from prevention, screening, treatment, and survivorship, to end of life. Given the high incidence of breast cancer, together with its inherent complexity and cost, some argue that the quality of breast care serves as a meaningful barometer for the quality of the overall health system. With that in mind, there are significant implications for monitoring the effectiveness of breast care and guiding quality improvement. Several implementations in breast cancer quality have been responsible for advancing outcomes in breast care. These include efforts focused on multidisciplinary care, patient navigation, shared decision making, evidencebased guidelines, public awareness, and outcomes registries. More patterns-of-care research has taken place in breast cancer than in any other oncologic condition. Performance metrics in breast care have traditionally focused on structure (eg, multidisciplinary teams, patient volumes), process (eg, administration of radiation following breast-conserving surgery), and outcomes (eg, disease-free and overall survival). Continued strides in the quality of breast cancer care will require us to move ever closer to the end results directly affecting patients, and outcomes that matter most to breast cancer survivors. Patients often prioritize outcomes that differ from those prioritized by clinicians. For example, a recent study identified that patients valued the avoidance of severe pain greater than a 2-year improvement in survival. Another study demonstrated how asymmetry following breast surgery increased anxiety and fear of death from cancer recurrence. In one study, time delays in receiving biopsy results led to significant increases in markers of biochemical distress monitored in patients. The future of quality improvement in breast cancer will require an even greater focus on patient-centered factors affecting patient experience and clinical outcomes. Systematically collected patient-reported outcomes (PROs) will be critical to accomplish this goal. Patient-Reported Outcomes

Abstract P5-17-03: The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility

Background: In the management of DCIS clinicians and patients (pts) must choose between the various options for breast conservation treatment based on an assessment of local recurrence (LR) risk. Traditional clinicopathologic (CP) factors such as age, size, grade, margin width or comedo necrosis, provide an average LR risk derived from clinical trials and population studies. The Oncotype DX® 12-gene assay for DCIS gives individual 10-yr LR risk estimates and has now been validated in two studies in a total of 893 pts. We report the 2nd study assessing the impact of the DCIS Score result on XRT recommendations. In addition, surveys assessing pt and physician confidence will provide insight into the overall clinical utility of the DCIS Score result. Baseline characteristics including the pre-assay LR risk and XRT recommendation are described here; final results on change in XRT recommendation from pre- to post-assay and distribution of the score across the CP factors will be presented. Methods: 13 U.S. sites enrolled pts with DCIS from 3/2014-5/2015. Pts with LCIS but no DCIS, invasive BC, or planned mastectomy were excluded. Data were prospectively collected on CP factors, physician estimates of LR risk, DCIS score, and pre/post XRT recommendation. Each pt had a surgeon and radiation oncologist complete study surveys. Pt surveys were also administered pre/post assay for decision conflict and the STAIT anxiety survey. The LR risk estimates and XRT recommendations were analyzed for all physicians as well as by specialty. Descriptive statistics summarized study variables. 95% Clopper-Pearson Exact CIs were calculated for percent change in XRT recommendation. McNemar9s test was used to determine if the proportion of pts had a significant change in XRT recommendation post assay. Paired t-tests were used to compare physician estimates of recurrence risk pre/post assay. Results: Of the 121 pts enrolled, median age was 61y (34-83) and 80.2% were postmenopausal. Median size was 8mm and 40% were Conclusions: The role of new molecular tools such as the DCIS Score assay that provide individual risk estimates for LR on treatment decisions is evolving. The DCIS pts enrolled in the study reveal inclusion of baseline features like higher nuclear grade (26%), comedo necrosis (55%) and margin width of 1-3mm (47%) that have historically been associated with XRT use. This represents a continued broadening of the assay use from the predominantly lower risk DCIS cohort in the 1st validation study (E5194). The impact on XRT decisions is critical to establishing the clinical utility of the assay. The decision impact analysis, differences in use of the assay among surgeons and radiation oncologists and the impact on overall confidence with the treatment decision will be presented. Citation Format: Manders JB, Kuerer HM, Smith BD, McCluskey C, Farrar WB, Frazier TG, Li L, Leonard CE, Carter DL, Chawla S, Medeiros LE, Guenther JM, Castellini LE, Buchholz DJ, Mamounas EP, Wapnir IL, Horst KC, Chagpar A, Evans SB, Riker AI, Vali FS, Solin LJ, Jablon L, Recht A, Sharma R, Lu R, Sing AP, Hwang ES, White J. The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility. [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 P5-17-03.

Small bowel obstruction from breast cancer metastasis: A case report and review of the literature

Small bowel obstruction from luminal gastrointestinal metastasis is a rare, but recognized, presentation of metastatic breast cancer. Herein, we report a case of a small bowel obstruction from lobular breast cancer metastasis to the terminal ileum, occurring over a decade after diagnosis and treatment of the initial primary cancer. Our review highlights the presentation and management of this unusual disease manifestation, including diagnosis of the gastrointestinal process, identification of the primary cancer, surgical treatment of the abdominal pathology, systemic therapy for metastatic disease, and survival data for patients with this disease process.

Comparison of risk factors and complications in patients by stratified mastectomy weight: An institutional review of 1041 consecutive cases

This study aims to investigate the specific complication rates, reconstructive differences, and delineate the pertinent independent risk factors in patients with different mastectomy weights.

Unresolved, atraumatic breast hematoma: post-irradiation or secondary breast angiosarcoma.

Post-irradiation or secondary angiosarcoma of the breast was first described in the 1980s in patients treated with breast conserving therapy for cancer. The primary management of radiation-induced breast angiosarcoma has focused on surgical resection with an emphasis on achieving negative tumor margins. While surgery remains a key component of treatment, novel therapeutic approaches have surfaced. Despite such advances in treatment, prognosis remains poor.