Stephanie A. Valente

A Review of Treatment for Breast Cancer-Related Lymphedema: Paradigms for Clinical Practice

Objectives: Breast cancer–related lymphedema (BCRL) represents a major complication of breast cancer treatment, impacting the quality of life for breast cancer survivors that develop it. The purpose of this review is to evaluate the literature surrounding BCRL treatment modalities to guide clinicians regarding risk-stratified treatment options. Methods: A review of studies over a 10-year period (January 2006 to February 2016) was performed. Noninvasive strategies evaluated included compression therapy, manual lymphatic drainage, and complex decongestive therapy (CDT). Invasive modalities evaluated included liposuction and lymphatic bypass/lymph node transfer (LNT). Our search yielded 149 initial results with 45 studies included. Results: A number of prospective studies have found that CDT is associated with volume reduction in the affected limb as well as improved quality of life, particularly in patients with early stage BCRL. With regards to invasive treatment options, data support that lymphatic bypass and LNT are associated with symptomatic and physiologic improvements, particularly in patients with more advanced BCRL. In addition, a small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe BCRL. Conclusions: CDT is an effective treatment modality for early stage BCRL. For more advanced BCRL, LNT has demonstrated efficacy. Further study is required with respect to comparing BCRL treatment modalities.

Determinants of short and long term outcomes in patients undergoing immediate breast reconstruction following neoadjuvant chemotherapy

We evaluated oncologic outcomes and complications of skin‐sparing mastectomy (SSM) and nipple‐sparing mastectomy (NSM) with immediate reconstruction (IR) after neoadjuvant chemotherapy (NAC) in patients with early‐stage and locally advanced breast cancer (BC).

Fifteen-Year Decrease in General Surgery Resident Breast Operative Experience: Are We Training Proficient Breast Surgeons?

OBJECTIVE The goal of the study was to evaluate trends in general surgery resident breast cases over the past 15 years. STUDY DESIGN The Accreditation Council for Graduate Medical Education (ACGME) Case Logs Statistics Reports from 2000 to 2015 were reviewed for average breast-specific case numbers and trends over time. ACGME data were available for all cases and breast-specific cases including the following: excisional biopsy/lumpectomy, simple mastectomy, modified radical mastectomy, and sentinel lymph node excision. SETTING The study evaluation was conducted at Cleveland Clinic, Cleveland, Ohio. PARTICIPANTS No individuals directly participated in this project. However, all general surgery residents at ACGME-accredited programs are represented in this analysis by virtue of the ACGME Case Logs Statistics Reports. RESULTS Total residency case volume increased by 2% (2000-2015, p = 0.0159), with 2015 graduates logging 985.5 cases. In contrast, breast cases decreased by 17.1%. The largest drops were in modified radical mastectomy (61.5% decrease, p = 0.0001) and excisional biopsy/lumpectomy (25.8% decrease). Simple mastectomy increased from 6.0 to 10.8 cases (p = 0.0001). Sentinel lymph node excision fluctuated, but has been down-trending recently (67.3% decrease from 2010 to 2015, p = 0.0001). Decreased experience is occurring at both junior and senior resident levels. CONCLUSIONS Breast case operative experience for general surgery residents decreased by 17% between 2000 and 2015, despite increase in overall operative volume. Residents have less experience in more advanced cases including axillary management, raising concern about the proficiency of graduating surgeons with respect to these procedures. It is reasonable to set national minimums for resident breast operative experience to ensure that individuals are appropriately trained to perform these cases in practice.

Milk Fistula: Diagnosis, Prevention, and Treatment.

Milk fistula is an uncommon condition which occurs when there is an abnormal connection that forms between the skin surface and the duct in the breast of a lactating woman, resulting in spontaneous and often constant drainage of milk from this path of least resistance. A milk fistula is usually a complication that results from a needle biopsy or surgical intervention in a lactating patient. Here, the authors present an unusual case of a spontaneous milk fistula which developed from an abscess in the breast of a lactating woman. The patient initially presented to the office with a large open wound on her breast, formed from skin breakdown, within which milk was pooling. She was treated with local wound care and cessation of breastfeeding, with appropriate healing of the wound and closure of the fistula with 6 weeks. Diagnosis, prevention, and treatment of milk fistula were reviewed.

False‐positive Extra‐Mammary Findings in Breast MRI: Another Cause for Concern

Breast magnetic resonance imaging (MRI) has been repeatedly shown to have a high false‐positive rate for additional findings in the breast resulting in additional breast imaging and biopsies. We hypothesize that breast MRI is also associated with a high rate of false‐positive findings outside of the breast requiring additional evaluation, interventions, and delays in treatment. We performed a retrospective review of all breast MRIs performed on breast cancer patients in 2010 at a single institution. MRI reports were analyzed for extra‐mammary findings. The timing and yield of the additional procedures was also analyzed. Three hundred and twenty‐seven breast cancer patients (average age = 53.53 ± 11.08 years) had a breast MRI. Incidental, extra‐mammary findings were reported in 35/327 patients (10.7%) with a total of 38 incidental findings. The extra‐mammary findings were located in the liver (n = 21, 60.0%), thoracic cavity (n = 12, 34.3%), kidneys (n = 1, 2.9%), musculoskeletal system (n = 3, 8.6%), and neck (n = 1, 2.9%). Eighteen of the 35 patients (51.4%) received additional radiographic imaging, 3 (8.6%) received additional laboratory testing, 2 (5.7%) received additional physician referrals and 2 (5.7%) received a biopsy of the finding. The average time to additional procedures in these patients was 14.5 days. None of the incidental, extra‐mammary findings were associated with breast cancer or other malignancy. Breast MRI was associated with a high rate (10.7%) of extra‐mammary findings, which led to costly additional imaging studies, referrals, and tests. These findings were not associated with breast cancer or other malignancies. Extra‐mammary findings highlight an unrecognized adverse consequence of breast MRI.

Surgeon-associated variation in breast cancer staging with sentinel node biopsy

Background: Sentinel lymph node biopsy is the gold standard for axillary staging in early‐stage, clinically node‐negative breast cancer, so it is paramount that this operation be both precise and accurate, because excessive sentinel lymph node removal increases morbidity, whereas understaging risks inadequate treatment. The goal of this study was to assess surgeon variation in the number of sentinel lymph nodes removed and the oncologic yield of sentinel lymph node biopsy for breast cancer. Methods: All patients in the Surveillance, Epidemiology, and End Results–Medicare database who underwent operative treatment for breast cancer from 2007–2011 were eligible for inclusion. Deidentified provider codes were used to track operations performed by individual surgeons. Only records in which an individual surgeon could be linked to a specific breast cancer operation were analyzed. The total number of sentinel lymph nodes removed and the number that were pathologically positive (oncologic yield) were recorded. Surgeon variation by T stage was analyzed using linear mixed‐effects regression and logistic mixed‐effects regression models. Results: Query of the database identified 15,571 patients who met inclusion criteria, representing 2,478 providers. The mean number of sentinel lymph node procedures performed per provider per year was 1.3 (range 1–103). The lowest quartile of providers performed 1 or fewer sentinel lymph node procedures per year. The highest quartile of providers performed >8 sentinel lymph node procedures per year. The average number of sentinel lymph node removed per operation increased with increasing T stage for all providers (P < .001), including when N0 (P < .001) and node‐positive (P=.003) patients were evaluated separately. There was surgeon‐associated variation in the number of sentinel lymph node removed for each T stage (P < .001). In addition, there was surgeon‐associated variation in the oncologic yield (sentinel lymph node positivity rate) by T stage (P < .001). Conclusion: This study found surgeon‐associated variation in axillary sentinel lymph node staging of breast cancer patients, which suggests the need to improve standardization of surgical practices to optimize the oncologic yield of these procedures and ensure accurate staging.

Oncotype testing in patients undergoing intraoperative radiation for breast cancer

Oncotype DX recurrence score (RS) predicts risk of distant disease recurrence, and can guide chemotherapy recommendations in hormone positive, human epidermal growth factor 2-negative, early stage breast cancer. The present study aimed to evaluate the pattern of oncotype testing, RS and adjuvant treatment in patients undergoing intraoperative radiotherapy (IORT). Single center prospective data registry was queried for patients receiving IORT between October 2011 and February 2017. Patient demographics, tumor characteristics, RS, systemic therapy and recurrence information were analyzed. A total of 150 women with mean age of 70.8 years were included. The majority had invasive ductal cancer (60.6%) with 1.0 cm average tumor size and no lymph node involvement (99%). Oncotype testing was performed in 36 patients (24.3%). Low risk score (<18) was confirmed in 19 women (53%); intermediate risk score (18-30) in 16 women (44%); and high risk score (>30) in one woman (3%). Patients with RS testing had significantly increased tumor sizes (1.2 vs. 1.0 cm; P<0.001) and were younger (68.5 vs. 71.3 years; P=0.02) compared with those not tested. A total of 4/150 patients (2.6%) received chemotherapy; two received chemotherapy based on RS testing. Based on the current selection criteria for IORT, oncotype testing rarely results in a high-risk score or utilization of chemotherapy for IORT patients. The present study supports selective use of RS testing in IORT patients and confirms that biologically low-risk patients are being selected for IORT based on current guidelines.

Evaluation of recurrence patterns and survival in modern series of young women with breast cancer

The data on oncologic outcomes in young women with breast cancer (BC) are dated as it relates to recurrences and mortality. Our goal was to assess these outcomes in a modern series of young women with BC. A retrospective chart review identified women ≤40 years old with stage I‐III BC diagnosed from 2006 to 2013 at our institution. Demographics, tumor biology, type of operation, recurrence, and survival were analyzed. Overall, 322 women were identified. Most had ER+(70%) infiltrating ductal tumors (88%) with low stage (42% T1; 41% T2; 56% N0). Follow‐up was 4.2 years with 5.6% local‐regional recurrence (LRR), 15.2% metastatic recurrence (MR), and 8% mortality. There was no survival difference based on demographics, tumor biology, or type of operation. T3 tumors (P < .001) and node positivity (P < .001) were associated with worse disease‐free survival. In this modern series of young women with BC, stage rather than tumor biology or surgical choice has more effect on recurrence‐free survival. MR was more common than LRR, with most MR occurring within the first 2 years after surgery.

Triple Mapping to Optimize Axillary Management in Breast Cancer Patients After Neoadjuvant Therapy

Sentinel lymph node (SLN) biopsy is an option after neoadjuvant chemotherapy in patients who are clinically node negative. False negative rates decrease with dual mapping and identification of more than three SLNs. Patients with positive SLNs require axillary lymph node dissection (ALND). Axillary reverse mapping (ARM) with lymphovenous bypass (LVB) is a lymphedema prevention technique that can be performed in patients who require ALND. It entails injection of isosulfan blue into the proximal extremity to identify lymph nodes and lymphatics draining the arm. LVB performed at the initial surgery reestablishes the drainage of cut lymphatics, potentially decreasing the risk of subsequent lymphedema. We describe a triple mapping technique that can be used to perform both SLN biopsy and subsequent ALND.

The effect of wound complications following mastectomy with immediate reconstruction on breast cancer recurrence

INTRODUCTION The aim of this study was to determine whether complications following mastectomy with immediate breast reconstruction (IBR) were associated with breast cancer recurrence. METHODS A retrospective review was performed of women diagnosed with stage I-III breast cancer who underwent mastectomy with IBR between 2005 and 2010. Patient demographics, tumor data, surgical wound complications, treatment details and timing were recorded and analyzed. RESULTS We identified 458 women with a median follow up time of 7.6 years. A total of 22% of patients experienced IBR complications. There was a delay in initiation of adjuvant therapy in patients who had a complication (52 vs 41 days, p < 0.001). There was no significant difference in recurrences between groups with and without complications (p = 0.65). CONCLUSIONS In breast cancer patients who undergo mastectomy with IBR, wound complications delayed initiation of adjuvant systemic therapy, but were not associated with an increased risk of cancer recurrence.