The evolution in management of patients with subcentimeter, node-negative, triple-negative breast cancer.

BACKGROUND: The aim of this study was to determine the evolution in treatment recommendations and outcomes for patients with subcentimeter, node-negative, triple-negative disease. METHODS: Patients were divided into a remote (diagnosed from 1997 to 2003) and a recent (diagnosed from 2004 to 2011) group. Demographics, tumor size, surgical treatment, use of adjuvant chemotherapy, survival, and disease recurrence were evaluated. RESULTS: Thirty patients were placed in the remote group and 31 in the recent group. Demographics, tumor sizes, and surgical treatment were similar between groups. The use of adjuvant chemotherapy increased from 7% to 42% in the recent group (P < .002). Disease-free survival and recurrence (7%) was not influenced by the use of chemotherapy. CONCLUSIONS: This study demonstrates that adjuvant chemotherapy is increasingly used in patients with the triple-negative phenotype, regardless of other favorable prognostic variables. The value of adjuvant chemotherapy for the subgroup of patients in our study is unclear and mandates further investigation.

Reducing the risk of nipple necrosis: technical observations in 340 nipple-sparing mastectomies.

Optimizing cosmesis is a common goal of breast surgery. In support of immediate breast reconstruction, nipple-sparing techniques have evolved. There is still a lack of agreement on the optimal technique and skin flap necrosis can be problematic. In this study, we review our experience with 340 NSM. Between March 2006 and February 2011, 340 NSMs were performed. Mammography, ultrasonography and magnetic resonance imaging were reviewed. Patient demographics and surgical techniques were reviewed. Anatomic observations were made and supported by breast images. A total of 340 NSMs in 231 patients by a single surgeon (AJS) were reviewed. Risk reduction was the indication for surgery in 59% with 50 patients (21.6%) testing positive for a BRCA1/2 gene mutation. There were two flap losses and 14 hematomas. Complete nipple necrosis occurred in three cases (0.8%) and partial loss in six patients. Recommendations are made to reduce the risk of nipple necrosis included the following: (a) preserving major perforating vessels (b) elevating skin flaps in the plane between the subcutaneous fat and the breast glandular tissue (c) the use of incisions that do not devascularize the nipple-areola complex. Nipple-sparing mastectomy can be performed with an acceptably low risk of nipple necrosis. Attention to detail including preserving major perforating vessels, elevating skin flaps in the appropriate plane and careful attention to incision planning are all required for a consistently good cosmetic outcome.

Nipple-sparing mastectomy and immediate free-flap reconstruction in the large ptotic breast.

Because of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

Technical considerations in nipple-sparing mastectomy: 82 consecutive cases without necrosis.

BACKGROUND: Even without comparative trials, nipple-sparing mastectomy (NSM) is gaining traction in the treatment of established breast cancer and in the prophylactic setting. As yet, there are no established techniques that are universally applied to NSM. Herein we describe our surgical approach. METHODS: All mastectomies performed by a single surgeon (AJS). Reconstructions performed included synthetic implants, deep inferior epigastric (DIEP) and gluteal artery perforator flaps (GAP). A lateral incision (12.1%) and a 6:00 radial incision (87.9%) were used in all patients. The areola was elevated just beneath the deep dermis and ductal tissue within the nipple papilla was "cored". RESULTS: Fifty-eight patients underwent 82 NSMs for both cancer and prophylaxis. No patient developed necrosis of the nipple-areola complex (NAC). Minor skin-edge necrosis not involving the NAC occurred in 2 patients. Four patients developed a hematoma, 2 requiring re-operation. One patient required re-operation to correct a vein problem. There were no flap losses. CONCLUSIONS: NSM can be performed with a minimal incidence of skin-flap related complications. In our hands, radial incisions perform well in this regard. Indications for NSM and the optimal technique are yet to be determined.

Terminal duct lobular units are scarce in the nipple: implications for prophylactic nipple-sparing mastectomy: terminal duct lobular units in the nipple.

BACKGROUND: The use of nipple-sparing mastectomy (NSM) for both breast cancer treatment and risk reduction is increasing. There is no randomized data comparing nipple-sparing mastectomy with standard mastectomy techniques. There is evidence to suggest that ductal and lobular breast cancer arises in the terminal duct/lobular unit (TDLU). This study was undertaken to determine whether TDLUs exist in the nipple and if so, to what extent. METHODS: At the time of mastectomy the nipple papilla was excised and submitted for separate pathological examination. The presence or absence of TDLUs was noted. RESULTS: Thirty-two nipples were studied in 22 patients. There were no TDLUs in 29 specimens. Three of 32 nipple specimens were found to contain TDLUs. The three nipples contain one, two, and three TDLUs respectively. All TDLUs were found at the base of the nipple, with none located near the tip. CONCLUSIONS: The infrequent occurrence of TDLUs in the nipple papilla supports the use of NSM for risk reduction surgery, including for those women with BRCA1/2 mutations.

Postlumpectomy Insertion of the MammoSite brachytherapy device using the scar entry technique: initial experience and technical considerations.

For women undergoing breast-conserving surgery, recent reports suggest that in selected cases accelerated partial breast irradiation may yield results equal to that of whole breast irradiation. Over 31 months, 19 patients underwent accelerated partial breast irradiation using the MammoSite as the sole radiation treatment following breast-conserving surgery. Seventeen patients had the MammoSite inserted postoperatively using the scar entry technique (SET). Treatments were delivered using high dose rate iridium 192 given twice a day for 5 days. Three complications (two minor, one major) occurred. Late radiation morbidity and overall cosmetic results were evaluated. Eighty percent of patients had either no change from baseline or slight change in skin pigment. More than 90% had good or excellent overall cosmetic outcomes. Patients undergoing accelerated partial breast irradiation with the MammoSite inserted using SET had excellent overall cosmetic results. Advantages of the SET over intraoperative placement are presented.

Newly diagnosed breast cancer patients choose bilateral mastectomy over breast-conserving surgery when testing positive for a BRCA1/2 mutation.

In women diagnosed with breast cancer and testing positive for a BRCA1/2 mutation, decisions as to whether to undergo prophylactic risk-reduction surgery may differ from those women who test positive in a presymptomatic phase. Eighty-four women were identified who had undergone genetic testing at the time of breast cancer diagnosis. The study group consisted of 46 of these women who had initially undergone breast-conserving surgery. Eight patients (17.4%) tested positive for a mutation. Seven of the eight underwent bilateral prophylactic mastectomy prior to receiving radiation therapy. The only patient not undergoing bilateral mastectomy was awaiting liver transplant. Women who are candidates for breast-conserving surgery and who test positive for a breast cancer gene mutation choose mastectomy over surveillance.

Initial experience with surgical treatment planning in the newly diagnosed breast cancer patient at high risk for BRCA-1 or BRCA-2 mutation.

Despite an abundance of information available for dealing with patients with BRCA-1 and BRCA-2 mutations, little guidance is available to assist the surgeon in dealing with the genetically high-risk patient recently diagnosed with breast cancer. A retrospective review was undertaken of 170 patients who underwent genetic counseling and testing over a 3-year period from March 2000 to March 2003. Forty-three of the 170 patients tested were diagnosed with breast cancer prior to genetic testing. Nine patients (20.9%) tested positive for a deleterious mutation. Fifty-eight percent underwent genetic counseling prior to definitive cancer surgery. Five of the 25 patients who underwent lumpectomy tested positive for a deleterious mutation. Testing results became available during systemic therapy or radiation was delayed until results were known. After counseling, all five patients testing positive went on to bilateral prophylactic mastectomy and reconstruction. None had radiation therapy. Because of a strong family history, eight patients elected to undergo prophylactic mastectomy and reconstruction prior to obtaining genetic test results; and despite compelling histories, all eight tested negative for a mutation. Treatment algorithms are developed to manage patients that are first discovered to be at high risk for a BRCA-1 or BRCA-2 mutation at the time they are diagnosed with breast cancer. Patients diagnosed with breast cancer who are discovered to be at high risk for a genetic mutation should undergo counseling prior to definitive surgery. This maximizes the time that patients have to consider options for prophylaxis and monitoring should their test be positive. It also prevents women who would otherwise be candidates for breast preservation from undergoing unnecessary radiation therapy should they chose prophylactic mastectomy in the face of a positive test.

A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping.

BACKGROUND: When lymphazurin became unavailable to our institution, we elected to employ methylene blue to perform sentinel node mapping for patients with breast cancer. The purpose of this study was to compare methylene blue and lymphazurin for performing sentinel node mapping for breast cancer. METHODS: We evaluated our sentinel node mapping experience from April 1, 2001 to March 31, 2002. Patients were divided into two groups based on the dye used for lymphatic mapping. The two groups were compared to evaluate the results of the sentinel node mapping procedure. RESULTS: During the study period a total of 199 patients were evaluated with sentinel node mapping, 87 with lymphazurin and 112 with methylene blue. The two groups were similar in demonstrating the success of the sentinel node procedure, nodes identified per case, and technique used for node identification (colloid or dye, or both). CONCLUSIONS: In our initial experience, methylene blue appears to be equivalent to lymphazurin for sentinel node mapping in breast cancer.

Postmastectomy radiation in patients with four or more positive nodes.

Postmastectomy radiotherapy (PMR), a local therapeutic modality, is recommended to treat breast cancer patients with multiple involved axillary lymph nodes (a marker of increased systemic risk). Bothered by this conceptually flawed treatment approach we evaluated the impact of PMR on the treatment of women with four or more involved axillary lymph nodes. We identified 1164 patients treated from 1982 through 1999 with mastectomy. We reviewed the records of the 223 who demonstrated four or more positive axillary lymph nodes. Of these 128 were treated by mastectomy only and 95 by PMR. The mastectomy-only group demonstrated a mean tumor size of 3.5 cm, a median of seven axillary nodes involved, and a median of 24.9 nodes harvested. The PMR group had a mean tumor size of 4.3 cm with nine positive nodes out of a median total of 23.3 harvested. The difference in mean tumor size was statistically significant (P = 0.01). The locoregional recurrence (10.9% vs 12.6%), distant recurrence rates (42.2% vs 35.8%), and 5-year survival (51% vs 55%) were not statistically different between the mastectomy-only group versus the PMR group, respectively. Adding PMR to breast cancer treatment demonstrated no improvement in outcome. Despite limitations of this retrospective study the results strongly support evaluation of PMR by a high-quality randomized prospective trial.