Weihong Sun

Prospective evaluation of skin and nipple-areola sensation and patient satisfaction after nipple-sparing mastectomy.

Sensation and quality of life (QOL) before and after nipple sparing mastectomy (NSM) are poorly understood.

Ipsilateral nodal recurrence after axillary dissection for breast cancer

INTRODUCTION Level I/II axillary lymph node dissection (ALND) is the standard operation for patients with node-positive breast cancer. The objective of this study was to assess the incidence of regional nodal recurrence (RNR) after ALND performed for definitive operative treatment for primary breast cancer. MATERIALS AND METHODS A retrospective, Institutional Review Board-approved query of our single-institution National Comprehensive Cancer Network database was performed for patients undergoing ALND who developed subsequent RNR. All patients were treated from 1999 to 2009. A detailed chart review was performed and clinical, pathologic, treatment, and outcome data were collected. RESULTS A total of 1614 patients had an ALND for initial staging; 14/1614 (0.9%) patients had RNR. Two other patients had contralateral breast/axillary recurrences and were excluded. The mean age at diagnosis for the sample group was 52.7 y (range 34-77); mean follow-up time was 47.1 mo (range 12.6-114.6). The median number of nodes for ALND was 16 (range 8-27). The median number of positive nodes was 2.5 (range 0-7). Nine (64.3%) cases were estrogen receptor/progesterone receptor negative. Twelve (85.7%) patients had axillary recurrences, and six of 12 (50.0%) had concurrent chest wall lesions. Twelve patients (85.7%) had distant metastases; nine of 12 (75.0%) died; two were lost to follow-up. Mean time from RNR to distant recurrence was 6.0 mo (range 0-29.3 mo). CONCLUSIONS RNR after ALND is rare but a harbinger of poor outcome. This is apparent regardless of treatment used for initial disease or recurrence. Specifically, RNR after primary ALND is related to increased risk of mortality and distant metastatic disease.

Intraoperative radiotherapy for early breast cancer and age: clinical characteristics and outcomes

BACKGROUND Eligibility criteria for intraoperative radiation therapy (IORT) for breast cancer are being established. Impact of age, one criterion, on short-term complications/outcomes was evaluated. METHODS Institutional Review Board approved retrospective review of early-stage breast cancer patients undergoing breast conserving surgery and IORT from January 2011 to June 2013 were reviewed. Data collected were demographics, comorbidities, histopathology, intraoperative data, adjuvant treatment, and outcomes. Local recurrence (LR), re-excision rates, and complications were evaluated by age group using descriptive statistics. RESULTS The total number of patients was 100 (43 patients <70, 57 patients ≥70). No significant differences existed between groups in tumor size, operative time, estrogen receptor status, nodal status, tumor grade, or margin excision. Wound infection rates were low for both groups (P = .21). Two LR occurred (both patients ≥70). Median follow-up time was 24 months. CONCLUSION IORT with its low rate of LR and wound complications may be a reasonable alternative to whole breast irradiation for early-stage breast cancer, regardless of age.

Outcomes with and without axillary node dissection for node-positive lumpectomy and mastectomy patients.

BACKGROUND American College of Surgeons Oncology Group Z0011 trial of select node-positive breast cancer patients demonstrated no survival or recurrence differences between SLN/axillary lymph node dissection (ALND) vs SLN. Our comparable node-positive lumpectomy and mastectomy populations should have similar outcomes. METHODS An Institutional Review Board approved, retrospective review of pathologic SLN (N1) cases was performed. Treatment, recurrence, and survival were collected. Statistics was analyzed via exact chi-square test with Monte Carlo estimation, Kaplan-Meier curves, and log-rank tests. RESULTS Of 528 node-positive patients, 318 patients met criteria: 28 (21.7%) lumpectomy, 32 (16.9%) mastectomy had SLN; 101 (78.2%) lumpectomy, 157 (83.0%) mastectomy had SLN + ALND. Median age was 57.5 years for SLN and 53 years for SLN + ALND (P = .003). Mean positive nodes were 1.1 for SLN and 1.47 for SLN + ALND (P = .0018). Chemotherapy use differed (SLN = 73.5%, SLN + ALND = 89.7%, P = .0032). Stage and recurrence were higher for SLN + ALND (P = .0001, P = .007). No difference in comorbidities, nodes retrieved, extracapsular extension, radiation, hormone therapy, or overall survival was observed. CONCLUSION In clinically node-negative breast cancer patients, ALND for N1 disease has no impact on short-term recurrence or survival.

Comparison of Reconstructive Outcomes in Breast Cancer Patients With Preexisting Subpectoral Implants: Implant-Sparing Mastectomy With Delayed Implant Exchange Versus Immediate Tissue Expander Reconstruction.

BackgroundWomen who have undergone prior augmentation mammoplasty represent a unique subset of breast cancer patients with several options available for breast reconstruction. We performed a single institution review of surgical outcomes of breast reconstruction performed in patients with breast cancer with prior history of subpectoral breast augmentation. MethodsInstitutional review board–approved retrospective review was conducted among patients with previously mentioned criteria treated at our institution between 2000 and 2014. Reconstructions were grouped into 2 categories as follows: (1) removal of preexisting subpectoral implant during mastectomy with immediate tissue expander placement and (2) implant-sparing mastectomy followed by delayed exchange to a larger implant. We reviewed demographics, tumor features, and reconstruction outcomes of these groups. ResultsFifty-three patients had preexisting subpectoral implants. Of the 63 breast reconstructions performed, 18 (28.6%) had immediate tissue expander placed and 45 (71.4%) had implant-sparing mastectomy followed by delayed implant exchange. The groups were comparable based on age, body mass index, cancer type, tumor grade, TNM stage at presentation, and hormonal receptor status. No significant difference was noted between tumor margins or subsequent recurrence, mastectomy specimen weight, removed implant volume, volume of implant placed during reconstruction, or time from mastectomy to final implant placement. Rates of complications were significantly higher in the tissue expander group compared to the implant-sparing mastectomy group 7 (38.9%) versus 4 (8.9%) (P = 0.005). ConclusionsImplant-sparing mastectomy with delayed implant exchange in patients with preexisting subpectoral implants is safe and has fewer complications compared to tissue expander placement. There was no difference noted in the final volume of implant placed, time interval for final implant placement, or tumor margins.

Menopausal status does not predict Oncotype DX recurrence score

BACKGROUND Adjuvant treatment for early stage, estrogen receptor (ER) positive invasive breast cancer has been based on prognosticators such as menopausal status. The recurrence score (RS) from the 21-gene assay Oncotype DX (ODX) is predictive of a 10-y distant recurrence in this population but is rarely applied to premenopausal patients. The relationship between menopausal status and RS was evaluated. MATERIALS AND METHODS An institutional review board-approved retrospective review was conducted of invasive breast cancer patients with known RS. ODX eligibility was based on National Comprehensive Cancer Network guidelines or physician discretion. Perimenopausal women were classified as premenopausal for statistical analyses. Comparisons of menopausal status and RS were made using general linear regression model and the exact Wilcoxon rank-sum test. RESULTS Menopausal status was available for 575 patients (142 premenopausal, 433 postmenopausal). Median age was 46 y for premenopausal and 62 y for postmenopausal. Median invasive tumor size was 1.5 cm for both cohorts. Mastectomy rate was higher in the premenopausal group (54.8%) than postmenopausal (42%; P = 0.0001). Premenopausal women had a higher local-regional recurrence rate (2.8% versus 0%; P = 0.0384) but distant recurrence and overall survival were not statistically different (P = 0.6808). Median ER H-score was lower in premenopausal (H-score = 270) than postmenopausal women (H-score = 280; P < 0.0001). Median RS was 16 for both premenopausal (range, 0-54) and postmenopausal (range, 0-63) women. Menopausal status as a categorical variable was not predictive of RS (P-value = 0.6780). CONCLUSIONS Menopausal status has limited predictive power for distant recurrence. Therefore, menopausal status alone should not preclude performance of ODX in ER-positive, early stage breast cancer.

Genomic Assays in Ductal Carcinoma In Situ: Implications for Management Decisions

Objectives Breast cancer is the most common cancer in women and a leading cause of cancer death worldwide. The management of breast cancer depends on clinical and pathologic prognostic factors that help guide patient treatment. Ductal carcinoma in situ (DCIS) is a noninvasive form of breast cancer with an unpredictable risk of either progression to invasive disease or recurrence. To evaluate the utilization of the DCIS score in a large single-institution population and understand reasons for avoidance in eligible patients. Methods A retrospective chart review of eligible patients with pure DCIS treated by lumpectomy (January 2011–May 2015) was performed. Patients were considered eligible for the assay if they met the Eastern Cooperative Oncology Group E5194 pathology criteria. All of the patients underwent breast-conserving surgery and were estrogen receptor positive. Results Of 182 estrogen receptor–positive patients with DCIS who underwent breast-conserving surgery, 31 (17%) had a DCIS assay performed; however, most of the patients did not have a DCIS score assay performed, yet 47.9% of this cohort would have met the pathologic eligibility criteria. Conversely, 82.5% of the patients having the DCIS score evaluated actually met these criteria. Conclusions Tumor size, grade, ER status, and calcifications were drivers of patient selection for 12-gene assay use. E5194 eligibility criteria selected for low risk population. Although a large proportion of patients met eligibility criteria, DCIS Score was infrequently considered for recurrence risk estimation. When performed, assay scores supported omission of radiation for over 75% of cases.

Single Institution Review of Patients With Prior Breast Augmentation Undergoing Breast Conservation Therapy for Breast Cancer

Background Increasing number of patients with preexisting breast implants desire breast conservation therapy for breast cancer. There is paucity of comparative data on tumor margins and re-excisions in these patients. High re-excision rates up to 25% have been reported in breast conservation therapy patients; efforts to obtain cosmesis and avoid implant rupture might increase this further. We analyzed tumor margins, re-excision rates, and recurrence in previously augmented versus non-augmented patients undergoing lumpectomy for breast cancer. We preserved preexisting implants if feasible with oncologic clearance and cosmesis. Methods Institutional review board–approved retrospective analysis was performed on patients undergoing lumpectomy with history of prior breast augmentation (N = 52) and consecutively selected non-augmented patients (N = 51). Based on tumor distance to inked margin, we grouped margins as negative (≥2 mm), close (<2 mm), and positive. Patients were followed up clinically and with imaging in the outpatient clinic, and recurrences were documented. Results Patients in the non-augmented group were significantly more likely to have larger tumors (T2 and above; P = 0.05) compared with the augmented group. Although more patients in the augmented group had positive margins, this was not statistically significant (6 vs 3, P = 0.86). No difference was noted between re-excision rates among the augmented versus non-augmented groups (21.1% vs 19.6%, respectively; odds ratio, 0.91; 95% confidence interval, 0.35–2.37; P = 0.85); these remained unchanged even when adjusting for tumor stage (P = .75) and margins (P = 0.73). Although more patients in the augmented group recurred (4 vs 0), this was not statistically significant (P = 0.1). Conclusions Our results indicate that, from the oncological standpoint, patients with prior augmentation can undergo lumpectomy with equivalent tumor margins and re-excision rates. To the best of our knowledge, this is the first reported comparative study between these 2 groups.

Factors predictive of failure to complete planned intraoperative breast radiation using the intrabeam® system.

Intraoperative radiation therapy (IORT) is a form of breast irradiation that is delivered in a single session at the time of partial mastectomy. In up to 10% of patients, planned IORT is not completed; this leads to wasted resources and decreased patient satisfaction. Our objective was to evaluate factors associated with failure to complete planned IORT.

Distant recurrence risk with prospective use of the 21-gene assay at a single institution.

131 Background: Distant recurrence (DR) is the cause of most breast cancer deaths. The 21-gene assay (ODX) Recurrence Score (RS) result predicts both 5 and 10-yr DR risk and can guide adjuvant chemotherapy (CT) recommendations to mitigate this risk. This study analyzed the use of the RS result to guide adjuvant treatment decisions in a large single-institution, prospective cohort of patients (pts). METHODS This is an IRB-approved review of a prospective database of pts receiving ODX on an initial primary breast cancer. Data collected included demographics, primary operation, margin status, receptor status, RS, adjuvant treatment, recurrence, and survival. Pts were stratified as low risk (RS < 18), intermediate risk, or high risk (RS > 30). The primary analysis computed Kaplan-Meier estimates for rate of DR at 5 yrs when pts were stratified by RS. RESULTS From 2003 to 2009, a RS result was obtained on 606 pts. Median follow up was 2.9 yrs (0.1-9.7) and median age was 58 yrs (27-84). Median RS result was 16 (0-63); 344(57%) pts were low, 212(35%) intermediate, 50(8%) high. Endocrine therapy was given to 92.4%, 94.3%, and 87.5% low, intermediate, and high risk pts, respectively. Adjuvant CT was given to 8.6%, 47.6%, and 70.8% low, intermediate, and high risk pts, respectively. There were 8 DR events with 1.8% 5-yr estimated risk of DR. The 5-yr estimated risk of DR was 0.7% for low risk (344) pts, 3.4% for intermediate risk (211) pts, and 2.6% for high risk (50) pts. Among node negative [N(-)] pts (502), the 5-yr estimated risk of DR was 0.8% for low risk (287) pts, 3.7% for intermediate risk (174) pts, and 3.3% for high risk (41) pts. Among node positive [(N+)] pts (54) there was only 1 DR, which was in a high risk pt. Of pts with unknown nodal status (50), there were no DRs. CONCLUSIONS The RS result is predictive of DR at 5 yrs as shown in historical datasets (Table). The use of ODX to guide adjuvant treatment recommendations in our contemporary, prospective cohort resulted in a much lower 5-year DR rate and thus supports its use to guide adjuvant treatment decisions. [Table: see text].