Intraoperative evaluation of surgical margins in breast cancer.

Achieving clear resection margins at the time of lumpectomy is essential for optimal patient outcomes. Margin status is traditionally determined by pathologic evaluation of the specimen and often is difficult or impossible for the surgeon to definitively know at the time of surgery, resulting in the need for re-operation to obtain clear surgical margins. Numerous techniques have been investigated to enhance the accuracy of intraoperative margin and are reviewed in this manuscript.

Nipple necrosis rate with submuscular versus prepectoral implant-based reconstruction in nipple sparing mastectomy: Does it differ?

BACKGROUND: This study aims to compare the rate of nipple necrosis between the submuscular (SM) versus the prepectoral (PP) implant placement after immediate breast reconstruction (IBR). METHODS: An institutional review board-approved database was reviewed of patients who underwent nipple sparing mastectomy (NSM) with IBR at our institution between 2016 and 2019. Patients who had SM versus PP IBR were compared. Incidence of nipple necrosis was evaluated between the two groups. RESULTS: A total of 525 NSM with IBR were performed in 320 patients with SM reconstruction in 61% (n â€‹= â€‹322) and PP in 39% (n â€‹= â€‹203) of the mastectomies. Overall, 43 nipples experienced some form of necrosis with 1% of mastectomies experiencing nipple loss. There was no difference between SM group and PP group at the rate of nipple necrosis (9 â€‹% vs 7 %, P â€‹= â€‹0.71). CONCLUSION: In patients undergoing NSM with IBR, the rate of nipple necrosis, nipple loss or complications did not differ between groups whether the implant was placed SM or PP, supporting the safety of this newer procedure.

Association of body composition and surgical outcomes in patients with early-stage breast cancer.

BACKGROUND: Breast cancer is a disease that requires multimodality treatment, and surgical resection of the tumor is a critical component of curative intent treatment. Obesity, defined as a body mass index (BMI) > 30, has been associated with increased surgical complications. Additionally, sarcopenia, a condition of gradual loss of muscle mass, has been associated with worse breast cancer treatment outcomes. Sarcopenia occurs with increased age, inactivity, and poor diet leading to patient frailty, which can increase medical treatment complications. Even patients with high BMI can have sarcopenia (termed sarcopenic obesity). We investigated the association of sarcopenia with surgical complications for breast cancer. METHODS: A retrospective review was performed of patients diagnosed with breast cancer who received bioelectrical impedance spectrometry analysis of skeletal muscle mass and had surgery at our institution. Patient characteristics, treatment data, surgical type and complications were obtained from medical records. Multivariate logistic regression models were used to associate sarcopenia status and BMI with surgical complications, adjusted for other patient characteristics. RESULTS: We analyzed 682 patients with stage I to III breast cancer. On multivariable logistic regression controlling for age, BMI, comorbidities, and types of surgeries (lumpectomy, mastectomy with or without reconstruction), sarcopenia (p = 0.66) was not associated with surgical complications. Obesity was associated with a higher rate of surgical complications in patients who received mastectomy with reconstruction (p = 0.01). More complex surgical approaches were associated with a higher risk of surgical complications in our series. CONCLUSION: Compared with those undergoing lumpectomy or mastectomy without reconstruction, patients undergoing mastectomy with reconstruction were more likely to experience postoperative complications and obesity was associated with higher risk of complication in the latter group. We did not identify a correlation between sarcopenia and rate of adverse surgical outcomes.

Mastectomy margins for ductal carcinoma-in-situ (DCIS): 18 Years of follow-up.

BACKGROUND: In patients undergoing mastectomy for ductal carcinoma in situ (DCIS), the significance of a positive or close (<2 mm) margin and associated recurrence risk is unclear. The study sought to evaluate risk of recurrence in relation to the mastectomy surgical margin. METHODS: A single institution retrospective review of patients with DCIS who underwent mastectomy between 2000 and 2010 was performed. Patient demographics, tumor biology, margin status and adjuvant therapy were recorded. The incidence of local recurrence (LR), distant metastasis were analyzed. RESULTS: A total of 282 patients with DCIS were identified. Overall, 12.3% of patients had a pathological positive/close margin (n = 9 tumor on ink and n = 36 <2 mm). Adjuvant radiation was administered to 11 patients with a positive or close margin. At a median follow-up of 12 years, LR was 3.4% (n = 10). None of the patients with LR had a positive or close margin. Additionally, none of the patients who received radiation developed LR. CONCLUSION: Risk of recurrence after mastectomy for DCIS is low and appears to be unrelated to margin status or the use of radiation therapy.

Simultaneous contralateral prophylactic mastectomy compared to unilateral nipple-sparing mastectomy for breast cancer surgical treatment: Are complications higher?

BACKGROUND: This study compared post-operative reconstructive complications and oncologic treatment between patients who underwent unilateral versus bilateral nipple sparing mastectomy (NSM) with implant based reconstruction (IBR). METHODS: Patients diagnosed with unilateral breast cancer who underwent NSM with IBR between 2010 and 2019 were reviewed. Patient demographics, surgical details, adjuvant therapy and postoperative complications were analyzed. RESULTS: A total of 434 NSM with IBR were performed in 269 patients, 24% unilateral, and 76% bilateral. The bilateral group received a direct implant significantly more frequently and were younger compared to unilateral (p < 0.001). The unilateral group received post-mastectomy radiation therapy at significantly higher rate (p < 0.001) with no difference in receipt of adjuvant chemotherapy. Overall, 11% of mastectomies developed a 30-day complication requiring reoperation and that extended to 13% at 120 days. There was no difference regarding the incidence of complications requiring reoperation (p = 0.84) or complications type between the two groups (p = 0.29). CONCLUSION: These findings support the oncologic and reconstructive equivalence to support patient choice in CPM.

Inflammatory breast cancer and the importance of skin punch biopsy.

BACKGROUND: The oncologic outcomes of patients diagnosed with inflammatory breast cancer (IBC) based on clinical exam only versus those with dermal lymphatic invasion on skin punch biopsy may be different and are worth further investigation. METHODS: Patients diagnosed from 2006 to 2021 with IBC at our institution were grouped according to clinical diagnosis or skin biopsy performed. Oncologic and survival outcomes among groups were compared. RESULTS: A total of 72 IBC patients were identified and grouped into 3 categories based on method of diagnosis: skin biopsy positive (n = 24), skin biopsy negative (n = 10) and no biopsy performed (n = 38). Skin biopsy positive patients had a higher incidence of lymphovascular invasion identified on final pathology and were more likely to experience a chest wall recurrence. At 5.1 yrs of follow-up, 40% of patients experienced recurrence, with 61% overall survival. CONCLUSION: Clinical diagnosis remains diagnostic for IBC, but skin punch biopsy allows for improved oncologic insight.

Sarcopenia detected with bioelectrical impedance versus CT scan and chemotherapy tolerance in patients with early breast cancer.

BACKGROUND: Early breast cancer (EBC) is a potentially curable disease. Some patients with EBC require chemotherapy, exposing patients to undesirable side effects. Loss of muscle mass, or sarcopenia, has been associated with worse outcomes in patients with EBC and worse treatment-related toxicity in patients with advanced breast cancer. CT scans can identify sarcopenia; however, most patients with EBC do not require routine CT scans. Bioelectrical impedance spectrometry (BIS) is another method to detect sarcopenia and can be performed quickly in the office without radiation exposure. We sought to investigate whether sarcopenia measurements by CT scan versus BIS correlated with each other and whether sarcopenia identified by each method is associated with chemotherapy toxicity and adherence in patients with EBC. METHODS: This is a retrospective study; eligible patients received chemotherapy treatment for EBC and had undergone BIS. A subset of patients had also had a CT abdomen with a Lumbar L3 level. Measures of sarcopenia were obtained from the BIS and CT data. In addition, patient characteristics, treatment, and toxicity-related outcomes were obtained from medical records. Multivariate logistic regression models were used to associate sarcopenia status with toxicity endpoints, adjusted for other patient characteristics. RESULTS: There was a moderate correlation between sarcopenia detected by CT scan and BIS (r = 0.64 p < 0.0001). Patients with sarcopenia detected by BIS had more chemotherapy toxicity (OR = 2.56; CI 1.72-3.84), dose reductions or dose delays (OR = 1.58; CI 1.06-2.38), and hospitalizations (OR = 2.38; CI 1.33-4.16) due to side effects than patients without sarcopenia. CONCLUSION: The presence of sarcopenia in patients with EBC is associated with worse chemotherapy tolerance. BIS represents a high-value alternative to CT scans for sarcopenia assessment.

Management of Mastalgia.

Breast pain is a common symptom in most women during their lifetime, and many times is self-limited. Mastalgia is categorized into 3 main groups: cyclic, noncyclic and extramammary. A good history, examination and targeted imaging can help to delineate the underlying cause of mastalgia and therefore guide treatment options. Diet, medications, stress, hormonal fluctuations, and an ill-fitting bra can be contributing factors for physiologic causes of mastalgia. Breast cancer is rarely a cause but should be excluded. Reassurance, support, dietary changes, nonsteroidal anti-inflammatory drugs and occasionally hormonal medications are options to help with improving breast pain.

Oncologic safety of axillary lymph node dissection with immediate lymphatic reconstruction.

PURPOSE: Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) can reduce the incidence of lymphedema in patients with breast cancer. The oncologic safety of ILR is unknown and has not been reported. The purpose of this study was to evaluate if ILR is associated with increased breast cancer recurrence rates. METHODS: Patients with breast cancer who underwent ALND with ILR from September 2016 to December 2020 were identified from a prospective institutional database. Patient demographics, tumor characteristics, and operative details were recorded. Follow-up included the development of local recurrence as well as distant metastasis. Oncologic outcomes were analyzed. RESULTS: A total of 137 patients underwent ALND with ILR. At cancer presentation, 122 patients (89%) had clinically node positive primary breast cancer, 10 patients (7.3%) had recurrent breast cancer involving the axillary lymph nodes, 3 patients (2.2%) had recurrent breast cancer involving both the breast and axillary nodes, and 2 patients (1.5%) presented with axillary disease/occult breast cancer. For surgical management, 103 patients (75.2%) underwent a mastectomy, 22 patients (16%) underwent lumpectomy and 12 patients (8.8%) had axillary surgery only. The ALND procedure, yielded a median of 15 lymph nodes pathologically identified (range 3-41). At a median follow-up of 32.9 months (range 6-63 months), 17 patients (12.4%) developed a local (n = 1) or distant recurrence (n = 16), however, no axillary recurrences were identified. CONCLUSION: Immediate lymphatic reconstruction in patients with breast cancer undergoing ALND is not associated with short term axillary recurrence and appears oncologically safe.

Association of sarcopenia with endocrine therapy toxicity in patients with early breast cancer.

BACKGROUND: Endocrine therapy reduces recurrence risk and improves survival in women with hormone receptor-positive breast cancer; however, side effects can decrease quality of life, leading to reduced treatment adherence. Sarcopenia is the loss of skeletal muscle mass that happens with age; it is associated with worse survival and reduced chemotherapy adherence in patients with breast cancer. The impact of sarcopenia on endocrine therapy tolerance has not been investigated. The current study evaluates the associations of sarcopenia with endocrine therapy toxicity and treatment tolerance. METHODS: Skeletal muscle mass was measured by bioelectrical impedance spectrometry. Skeletal muscle index (SMI) was calculated to assess for sarcopenia: SMI = (SMM kg)/(patient height, m2). Patients with SMI ≤ 6.75 kg/m2 were considered sarcopenic. A chart review was performed to obtain patient characteristics, endocrine therapy toxicity, and early treatment change or termination. Fisher's exact test was performed to associate patient characteristics and outcomes with sarcopenia status. RESULTS: Four hundred eighty-two patients with stage I-III breast cancer were prescribed endocrine therapy and had undergone sarcopenia evaluation. The median age was 61 years (29-88 years). Sarcopenia was identified in 35% of patients. Twelve percent of patients experienced grade 3-4 endocrine-related toxicities. On multivariable logistic analysis, sarcopenia was associated with increased odds of experiencing endocrine-related side effects (p = 0.006). In addition, patients with sarcopenia stopped or changed their medication due to side effects more often than those without sarcopenia (p = 0.03). CONCLUSION: The presence of sarcopenia in patients with EBC represents a potentially modifiable risk factor for more significant endocrine therapy side effects and reduced treatment tolerance.

Reducing rates of chronic breast cancer-related lymphedema with screening and early intervention: an update of recent data.

PURPOSE: Breast cancer-related lymphedema (BCRL) represents a dreaded complication of breast cancer treatment that can lead to morbidity, diminished quality of life, and psychosocial harm and is associated with increased costs of care. Increasingly, data has supported the concept of prospective BCRL surveillance coupled with early intervention to mitigate these effects. METHODS: We performed a systematic review of the literature searching for published randomized and prospective data evaluating prospective BCRL surveillance with early intervention. RESULTS: We identified 12 studies (2907 patients) including 4 randomized trials (1203 patients) and 8 prospective studies (1704 patients). Randomized data consistently demonstrate that early intervention reduces rates of progression to chronic BCRL with multiple paradigms and diagnostic modalities utilized; the strongest data comes from the randomized PREVENT trial, which demonstrated early detection with bioimpedance spectroscopy (BIS), coupled with early intervention with a compression garment applied for 12 h a day over 4 weeks, significantly reduced the rate of chronic BCRL compared to tape measurement coupled with early intervention. CONCLUSIONS: Current data support the role of prospective BCRL surveillance with early detection and intervention to reduce rates of chronic BCRL. Breast cancer patients at risk for BCRL should undergo prospective surveillance as part of survivorship. Because level 1 data demonstrate that BIS is superior to conventional tape measure, it should be included as the standard BCRL diagnostic modality unless an equally effective modality is employed. IMPLICATIONS FOR CANCER SURVIVORS: Breast cancer survivor should undergo prospective BCRL screening with BIS.

Stage IV Non-breast Cancer Patients and Screening Mammography: It is Time to Stop.

BACKGROUND: Patients diagnosed with metastatic cancer have shortened life expectancy with questionable benefit of routine screening mammography (SM). The aim of this study was to evaluate the incidence and consequences of continued SM in the setting of reduced survival from stage IV non-breast cancer. METHODS: Women diagnosed with Stage IV non-breast cancer at a single institution from 2015 to 2019 were queried from the institutional tumor registry for demographics, stage IV cancer diagnosis, and survival. Incidence and timing of SM after stage IV diagnosis and further diagnostic workup were extracted from the medical record. RESULTS: 790 women with Stage IV non-breast cancer were identified, 109 (14%) had at least 1 SM, 23% required diagnostic mammography, 7% breast biopsy, and 1% breast surgery. No breast cancers were identified. SM was ordered most often in stage IV gynecological cancers (28%), with more common cancers still seeing a high percentage of patients screened (lung 10%, colorectal 15%). Study 3-year survival was 26% (95% confidence interval [CI] 23-30%), with 74% mortality during follow up and median time from Stage IV diagnosis to death of 1.2 years (CI 0.4-2.3 years). Of patients screened, 41/109 died within 2 years of undergoing SM. CONCLUSIONS: Despite low overall survival for patients diagnosed with metastatic non-breast cancer, 14% of women underwent SM which resulted in additional imaging, biopsies, and surgery with no new breast cancers identified. Continued SM in this population offers risk without benefit of reduced breast cancer mortality and should no longer continue in women with stage IV non-breast cancer.

Outcomes of ipsilateral breast tumor recurrence after breast conserving surgery: Repeat lumpectomy as an alternative to salvage mastectomy.

BACKGROUND: We examined the outcomes of salvage mastectomy and repeat lumpectomy for management of ipsilateral breast tumor recurrence. METHODS: Between 2013 and 2019, 113 patients with an ipsilateral breast tumor recurrence after breast conserving surgery were identified. Patients and tumor characteristics at initial diagnosis and at recurrence were collected. Outcomes evaluated included second recurrence and overall survival. Complications at 30-days and 90-days after surgery for ipsilateral breast tumor recurrence were evaluated. RESULTS: Seventy-two percent of patients underwent salvage mastectomy (n = 84) and 28% underwent repeat lumpectomy (n = 32 overall, n = 13 reirradiation). Salvage mastectomy patients were younger at initial diagnosis (P = .007) with longer time to ipsilateral breast tumor recurrence from first diagnosis (P = .03). At 2.5 years median follow-up, the overall incidence of second recurrence was 8% with 5% rate (n = 4) in salvage mastectomy group versus 16% (n = 5) in repeat lumpectomy group; however, among patients undergoing repeat lumpectomy with reirradiation (n = 13), only one patient developed a second recurrence (8%). There was no significant difference in rates of second local recurrence (P = .11), disease free survival (P = .13), or overall survival (P = .95) between repeat lumpectomy with reirradiation and salvage mastectomy. CONCLUSION: At a short-term follow-up, repeat lumpectomy with reirradiation could be considered in a select group of patients presenting with an ipsilateral breast tumor recurrence with multidisciplinary input with low rates of postoperative complications and equivalent survival outcomes.

Trends of Contralateral prophylactic mastectomy at the time of ipsilateral breast tumor recurrence.

BACKGROUND: Contralateral prophylactic mastectomy rates have substantially increased. The study aimed to examine contralateral prophylactic mastectomy (CPM) at the time of ipsilateral breast tumor recurrence (IBTR) and evaluate factors contributing to CPM decision making process. METHOD: Patients who developed IBTR after BCS from 2011 to 2019 were reviewed. Patient and tumor characteristics, genetic testing and reconstruction details were analyzed. RESULTS: Ninety-six patients had IBTR after BCS and were treated with mastectomy, with 30% electing for a CPM. Patients who underwent CPM were younger, had higher BMI and less comorbidities. A genetic mutation was identified in 19% of patients who underwent testing at the time of IBTR. Tumor characteristics and performing surgeon were not predictors for CPM, however, patients were more likely to undergo CPM if they received reconstruction of the ipsilateral breast with IBTR. CONCLUSION: This study shows that age, BMI, genetic testing and breast reconstruction are factors contributing to CPM decision at the time of IBTR.

Mastectomy options for the treatment of ipsilateral breast cancer recurrence after lumpectomy.

BACKGROUND: Mastectomy is the recommended treatment for ipsilateral breast tumor recurrence (IBTR) in patients who initially received breast conservation surgery (BCS) and radiation. We evaluated the 3 types of mastectomies performed for the surgical treatment of IBTR (nipple sparing (NSM), skin sparing (SSM) and total mastectomy (TM)) to assess surgical complications and local control outcomes among groups. METHODS: Patients who developed IBTR after BCS and received mastectomy from 2011 to 2019 were reviewed. Patient characteristics and treatment were analyzed. The incidence of postoperative complications and second breast cancer recurrence were compared. RESULTS: Mastectomy was performed in 113 patients presenting with isolated IBTR (17 NSM, 48 SSM and 48 TM). There was no difference in post-operative complications between groups. At 3-year follow-up, 5 (4%) patients had a second recurrence. Tumor size at IBTR was the only predictor for second recurrence and not mastectomy type or receipt of reconstruction. CONCLUSION: In patients initially treated with BCS who experienced an IBTR, NSM or SSM mastectomy with immediate reconstruction had low complication rates and no increase in local recurrence compared to the TM group.

Nipple-Sparing Mastectomy: Are We Providing Proper Prophylactic Antibiotic Coverage?

BACKGROUND: Infection after nipple-sparing mastectomy (NSM) and implant-based reconstruction (IBR) can be a devastating complication. The retained nipple may act as a portal or nidus for different ductal organisms, and as such, the bacteriology of surgical-site infections (SSIs) in this setting may not be adequately covered by current antibiotic recommendations. This study sought to evaluate SSI and reconstruction outcomes in relation to antibiotic choice and identify the different microbial species implicated. METHODS: A prospective database was reviewed for patients who underwent NSM with IBR from 2010 to 2019. Patient characteristics, operative details, antibiotic regimens, and subsequent treatment details were evaluated. The study analyzed SSI incidence, timing, and type of causative organisms. RESULTS: The study analyzed 571 NSMs with IBR performed for 347 patients (55% with direct implants and 45% with tissue expanders). The preoperative antibiotics consisted of cephalosporin alone for 65% of the patients, a more broad single-antibiotic use for 12% of the patients, and dual-coverage antibiotics for 20% of the patients. During a median follow-up of 1.7 years, SSI developed in 12% of the reconstructions, with 6% requiring prosthesis removal. The most common SSI organism cultured was Staphylococcal species. Neither pre- nor postoperative antibiotic choice was associated with incidence of infection, type of bacteria, or need for prosthetic explanation. CONCLUSION: For patients undergoing NSM with IBR, a more aggressive antibiotic choice is not associated with an improved SSI rate. Patient and treatment factors continue to carry the highest risk for SSI.