Sheila Stallard

Use of boost radiotherapy in oncoplastic breast-conserving surgery – A systematic review

BACKGROUND The use of local boost radiotherapy to the tumour bed has been demonstrated in randomised-controlled trials to reduce local recurrence rates following breast-conserving surgery (BCS) and is the standard of care. Oncoplastic BCS techniques with parenchymal rearrangement present new challenges to the localisation of the tumour bed and therefore delivery of local boost radiotherapy. The aim of this review was to evaluate the reporting of boost radiotherapy in the oncoplastic BCS literature. METHODS Pubmed, Ovid MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for studies reporting oncoplastic BCS using volume displacement techniques. RESULTS 24 studies met the inclusion criteria (n = 1933 patients). Use of boost radiotherapy was reported in 11 studies, in 2 of which it was for the treatment of incomplete or close margins, and marking of the tumour bed was only reported in 8 studies. None of the studies reported the number of patients where the tumour bed could not be localised. CONCLUSIONS The use of local boost radiotherapy and tumour bed marking was not reported in the majority of studies of oncoplastic BCS. Future studies need to provide detailed information regarding the use of boost radiotherapy and difficulties determining the target volume so that current radiotherapy approaches can be reviewed and improved for these advanced techniques.

Imaging Results Following Oncoplastic and Standard Breast Conserving Surgery.

Background: Oncoplastic breast-conserving surgery (OBCS) requires more complex surgical techniques than standard wide local excision (WLE) and the postoperative complication rate may be higher. Since these can have an impact on postoperative imaging, we compared imaging and biopsy results after OBCS and WLE. Methods: Findings for patients undergoing OBCS (n = 83) or standard WLE (n = 128) were compared. Numbers, indications and outcomes of mammograms, breast ultrasounds, magnetic resonance imaging scans and biopsies done within 2 years after surgery were analysed. Results: OBCS was applied for more advanced malignancy. Significantly more patients required breast ultrasound after OBCS than WLE (20/71 vs. 17/116; p = 0.024). Breast Imaging Reporting and Data System (BI-RADS) category 3 or 4 ultrasound results were found only in patients with OBCS (6/29 vs. 0/19; p = 0.034). Significantly more biopsies were required after OBCS (9/71 vs. 3/116; p = 0.006). New lumps or lumpiness were the commonest indications, and pathology confirmed fat necrosis in the majority (7/12). The rate of fat necrosis after OBCS was 18% on clinical examination (13/71), 15% with ultrasound (11/71) and 7% confirmed on pathology (5/71). Conclusion: Patients treated with OBCS require significantly more ultrasound scans and consequent biopsies than patients who underwent WLE. This is mainly due to fat necrosis developing after OBCS in the majority of cases.

Six-year follow-up of patients treated with oncoplastic reduction mammoplasty: A cohort study

BACKGROUND Current evidence for the oncological safety of oncoplastic breast conservation is poor as it is based mostly on short-term follow-up data. Hence, we report long-term recurrence rates in patients treated with oncoplastic reduction mammoplasty (ORM). METHODS A prospectively maintained database was searched to identify patients who underwent ORM between 2005 and 2010. A retrospective review of medical records was carried out, including patients with ductal carcinoma in situ and invasive breast cancer. RESULTS Follow-up data from 65 consecutive patients with ORM were reviewed, of which 50 patients were eligible to measure long-term recurrence rates. The average weight of the resected tissue was 272 g altogether. The mean preoperative tumour size was 2.95 cm on imaging. 64% of patients had stage II - III cancers. Incomplete excision rate after ORM was 16.1%, completion mastectomy rate was 10.7%. During a median follow-up of 72 months, 2% local, 6% distant recurrence rates were detected. The breast cancer-specific survival rate was 96% per cent. CONCLUSIONS Based on these long-term follow-up data, ORM is an oncologically safe treatment option.

Oncological Outcomes and Complications After Volume Replacement Oncoplastic Breast Conservations—The Glasgow Experience

Introduction Oncoplastic breast conservation surgery (OBCS) combines the principles of surgical oncology and plastic surgery. OBCS has now become a growing option for the treatment of breast cancer and forms a part of breast-conserving therapy (BCT). We sought to investigate and report our experience in two breast units in Glasgow (Victoria Infirmary and Western Infirmary) on volume replacement OBCS. Materials and Methods Details of patients treated with volume replacement OBCS were identified from a prospectively recorded database from November 2010 to October 2015. The clinical records included in the oncoplastic dataset were analyzed for demographics, tumor, treatment characteristics, and recurrences. The data were analyzed for follow-up to determine the pattern and timing of recurrence up to April 2016. The primary outcome of this study was tumor-free margin resection rates, and the secondary outcomes were locoregional and distant recurrence rates as these correlate with the overall oncological safety of volume replacement oncoplastic breast surgery (OPBS). Results A total of 30 volume replacement oncoplastic breast conservation procedures have been carried out in this time period. The mean age of the former group was 51 years. Twice as many patients presented symptomatically than had tumors detected on screening. The mean preoperative tumor size on radiology was 25.4 mm. Patients underwent 13 thoracoepigastric flaps, 5 lateral intercostal artery perforator (LICAP) flaps, 2 thoracodorsal artery perforator (TDAP) flaps, 1 lateral thoracic artery perforator (LTAP) flap, 1 crescent flap volume replacement surgery, and 8 matrix rotations. Two patients had neoadjuvant chemotherapy. Fourteen patients had adjuvant chemotherapy, and all patients were treated with adjuvant radiotherapy. Twenty-two patients were treated with hormonal therapy and four patients were treated with Herceptin. The rate of incomplete excision was 10%. Median follow-up time was 48.5 months. Only one regional recurrence was detected. Eight patients encountered some form of complication. Conclusion This study continues to show the relative oncological safety of volume replacement oncoplastic conservations as an option for reconstruction in breast cancer patients. Further research is urgently needed to build robust evidence supporting the long-term oncological safety.

P3-07-30: Applying the Findings of the Z11 Trial to a UK Practice.

Introduction: The finding of a positive sentinel node is currently managed by further Level III axillary lymph node clearance (ALNC). The rationale behind this approach is that of local disease control, but there is little evidence that axillary lymph node clearance results in a reduction in axillary recurrence or in mortality. ALNC is however associated with increased morbidity (lymphoedema, nerve damage, reduced shoulder function) and significantly prolongs hospital stay. The Z11 trial suggests that ALNC following positive sentinel node biopsy does not result in lower axillary recurrence rates compared to the group in whom clearance was not undertaken and has obvious implications for evidence-based practice. The Z11 trial has strict inclusion criteria (T1/T2 tumour, breast conservation surgery) with all patients receiving adjuvant whole breast radiotherapy and systemic chemotherapy or endocrine therapy. For patients who do not meet the patient population of Z11, such as women undergoing mastectomy, the Sloane-Kettering predictive normogram provides an estimate of risk for residual axillary disease after positive sentinel node biopsy and the estimate of this risk may inform the clinical decision to clear the axilla based on individual cancer characteristics. Methods: Our population comprises both symptomatic and screening patients, with an axillary positivity rate of approximately a third. This study was undertaken to assess the impact that Z11 would have on our practice. Our prospectively maintained records were searched for ALNC patients treated between 2003 and 2011. We assessed the number of node-positive patients conforming to Z11 criteria and the number who demonstrated residual axillary positivity at clearance after a positive sentinel node. The axillary recurrence rate for this group after ALNC was recorded. We calculated the number of clearances that could have been avoided, and extrapolated the reduction in morbidity in lymphodema and nerve damage using the audited incidence of these complications in our institution. We calculated the financial cost saving in terms of theatre usage and hospital stay. In addition, we assessed whether the Memorial Sloane Kettering predictive normogram is useful in the prediction of residual axillary disease for the group of patients excluded from the Z11 cohort. Results: 1601 patients underwent axillary staging. 65% of our patients with node-positive disease were identified pre-operatively with ultrasound and biopsy and proceeded directly to ALNC. Our overall axillary recurrence rate was low ( Discussion: Using these criteria nearly 25% of axillary clearances in our population of breast cancer patients could be avoided with obvious cost savings both in terms of morbidity and finance, considerations that are important in planning our service for the future. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-30.

[Intraoperative, postoperative and long-term oncosurgical safety of therapeutic mammaplasty].

INTRODUCTION (Pre)malignant lesion in the breast requiring mastectomy conventionally may be treated with breast conservation by using oncoplastic breast surgical techniques, which is called therapeutic mammaplasty. However, no reliable data has been published so far as regards the oncological safety of this method. AIM The aim of the authors was to analyse the oncological safety of therapeutic mammaplasty in a series of patients. METHOD 99 patients were treated with therapeutic mammaplasty and data were collected in a breast surgical database prospectively. Results were analysed with respect to intraoperative, postoperative and long-term oncological safety. RESULTS Incomplete resection rate was 14.1%, which correlated with tumour size (p = 0.023), and multifocality (p = 0.012). Time between surgery (therapeutic mammaplasty) and chemotherapy was similar to time between conventional breast surgeries (wide excision, mastectomy, mastectomy with immediate reconstruction) and chemotherapy (mean 29-31 days; p<0.05). Overall recurrence rate was 6.1%, locoregional recurrence rate was 2% during 27 month (1-88) mean follow-up. CONCLUSIONS Since literature data are based on relatively short follow-up and low patient number, it is highly important that all data on therapeutic mammaplasty is collected in a prospectively maintained breast surgical database in order to determine true recurrence after long-follow-up.

Abstract P2-12-14: Therapeutic mammoplasty reduces high incomplete excision rate in lobular cancer

Introduction: Incomplete excision rate for lobular cancer is much higher compared to other types of breast cancer, since lobular cancer is frequently occult on imaging. This, and the inability to downstage lobular cancer with neoadjuvant therapy lead to the highest mastectomy rate of all subtypes. Here, we investigated the association between histopathological characteristics and incomplete excision as well as mastectomy rates. Further, we investigated whether the application of level 2 therapeutic mammoplasty (TM) would extend the indication for conservation with lobular cancers. Methods: Data of 1389 consecutive patients underwent surgery for (non)invasive breast cancer between January 2008 and June 2012 was analysed. Pathological and preoperative radiological results were analysed in the context of final surgery and tumour excision margins. Statistical significance was calculated using Chi-square, Mann-Whitney and Z-tests with a significance Results: Overall incomplete excision rate was 13.74% (131/953), and mastectomy rate was 35.35% (491/1389). Higher incomplete excision and mastectomy rates were strongly associated with lobular subtype (IE: 26.03% (19/73)); M: 51.22% (63/123); p 135 patients underwent surgery for lobular cancer (simple wide excision: 66; TM:19; mastectomy: 50). TM was offered for significantly larger tumours than lumpectomy (28.29mm (10-62) vs. 19.96mm(5-57);p Conclusion: Higher incomplete excision rate is strongly associated with lobular subtype, node positivity and tumour size, but independent of hormonal end HER-2 expression, while tumour grade is not a strong predictor. All histopathological characteristics are strong predictors of final mastectomy rate. Using TM, breast conservation can be achieved for significantly larger lobular cancers, and incomplete excision rate decreased in smaller cancers, which are routinely treated with wide excision. Citation Format: Romics L, Kabir SA, Mansell J, Mallon EA, Stallard S, Doughty JC. Therapeutic mammoplasty reduces high incomplete excision rate in lobular 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 P2-12-14.

Abstract P2-13-14: Does therapeutic mammoplasty reduce mastectomy rates?

Introduction: Therapeutic mammoplasty (TM) is increasing in popularity as a method for enhancing breast conserving surgery. Studies have shown it’s oncologically safe, whilst improving cosmetic outcome1,2,3. Therapeutic mammoplasty has been gaining popularity in West of Scotland over the past five years. Initially it was thought this may reduce requirement for mastectomy and immediate reconstruction. We have recorded type of surgery patients would have required had they not been suitable for TM, looking at changing demographic of surgical workload. Methods: Prospective data collected about patients undergoing TM in West of Scotland since 2011 in Victoria Infirmary, Western Infirmary and in NHS Lanarkshire. We reviewed clinical indications for TM, surgical alternative, Body Mass Index (BMI) and smoker status. Results: Seventy-nine patients were identified. In 67 cases, alternative surgical option of mastectomy or standard conservation was recorded. Mean BMI was 29. 41% of patients had contralateral surgery for symmetry at the same time. In 28 cases (35%) TM avoided need for mastectomy. In 39 cases (49%) it was felt that cosmetic result would be improved by TM compared with standard conservation. During the study period, rates of mastectomy with immediate reconstruction as a proportion of total number of treated cancers have remained similar. Conclusions: Whilst introduction of therapeutic mammoplasty in our region has improved options offered to patients and likely cosmetic outcomes, it has not had a major impact in reducing mastectomy rates or demand for immediate reconstruction. It has probably increased surgical workload of plastic surgeons as these cases are often performed as joint procedures. References: 1. Iwuchukwu OC, Harvey JR, Dordea M, Critchley AC, Drew PJ. The role of oncoplastic therapeutic mammoplasty in breast cancer surgery – A review. Surgical Oncology. 2012;21:133-141 2. McCulley SJ, Macmillan RD. Planning and use of therapeutic mammoplasty – Nottingham approach. British Journal of Plastic Surgery. 2005;58:889-901 3. Clough K, Lewis J, Couturand B, Fitoussi A, Nos C, Falcou M. Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas. Annals of Surgery. 2003;237(1):26-34. Citation Format: Jennifer Pollard, Pang Wong, James Mansell, Juliette Murray, Alison Lannigan, Julie Doughty, Laszlo Romics, Sheila Stallard, Christopher Wilson. Does therapeutic mammoplasty reduce mastectomy rates? [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 P2-13-14.

Abstract P5-15-07: Therapeutic mammaplasty - Radical breast conservation or conservative mastectomy? A comperative analysis of 1000 patients’ pathology results

Background: oncological principles of therapeutic mammaplasty (TM) is based on evidence arising from studies on the oncological safety of traditional breast conservation, i.e. wide local excision (WLE). Hence, oncological safety of TM is benchmarked to patients treated with WLE. However, TM can also be defined as a conversion of mastectomy (Ms) to breast conservation surgery applying plastic surgical techniques in patients conventionally requiring mastectomy. The aim of this study was to decide if TM was similar to WLE or Mx in terms of pathological characteristics. Methods: 1006 consequtive patients were involved in the analysis, who were treated with TM, WLE or Ms in two Glasgow breast units between 2008 and 2011. Histopathological characteristics of patients treated with TM were compared to those treated with WLE or Ms. Statistical calculations were carried out with Chi-square test. The difference was considered statistically significant if p>0.05. Results: 121 patients were treated with TM, while 600 patients were treated with WLE and 285 with Ms. Tumour size of TM was significantly different from WLE as well as Ms, although the difference between TM and WLE was more significant than between TM and Ms (TM/Ms/WLE: T1: 43.8%, 34%, 78%; T2: 52.1%, 54.7%, 21%; T3: 4.1%, 11.2%, 1%; TM vs. WLE: p 3: 2%, 4%, 0.2%; TM vs. WLE: p Discussion: pathological characteristics of patients treated with therapeutic mammaplasty is similar to patients treated with mastectomy, but significantly different from patients who were treated with WLE. Pathology after WLE is significantly more favourable compared to TM. Hence, studies investigating oncological safety of TM comparing to patients treated with WLE only may not be adequate, and Ms patients should be included in the analyses. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-15-07.

Abstract P4-14-13: Therapeutic mammaplasty does not cause a delay in the delivery of chemotherapy in high risk breast cancer patients

Introduction: oncosurgical safety of therapeutic mammaplasty (TM) is widely investigated. The interval between surgery and delivery of adjuvant chemotherapy is an integral part of overall oncological safety. Therefore, we examined the time between TM and AC, and compared it to wide local excision (WLE) and mastectomy (Mx) with or without immediate breast reconstruction (IBR), respectively. Methods: data of 174 patients who underwent TM, WLE and Mx±IBR was analyzed retrospectively. All patients were operated within three breast units of Glasgow during a period of 48 months. Time between decision to offer adjuvant chemotherpay and delivery of the first cycle of chemotherapy was analyzed. Significance was calculated with Mann-Whitney and Kruskal-Wallis tests (two and four groups compared, respectively). Results: median time to adjuvant chemotherapy after TM (n = 36) was 29 [16–58] days, WLE (n = 66) was 29.5 [15–105], Mx only (n = 56) was 29 [15–57], and Mx and IBR (n = 16) was 31 [15–58] days. No significant difference was found in terms of time to adjuvant chemotherpay in patients treated with TM compared to WLE (p = 0.384), Mx only (p = 0.828) or Mx and IBR (p = 0.366). Further, there was no significant difference when a cumulative comparison of the four groups was carried out (p = 0.507). Conclusions: our data indicate that oncosurgical safety of TM in terms of time to chemotherapy is similar to other high risk breast cancer patients treated WLE and Mx with or without IBR. This also suggests that there is no significant difference in postoperative complication rates after these four ways of surgical treatment of breast cancer, which would possibly be the primary cause for a delay in delivering adjuvant chemotherapy. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-14-13.