RESUMO
BACKGROUND: Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. METHODS: NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. RESULTS: A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. CONCLUSIONS: Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment.
Assuntos
Neoplasias da Mama , Carcinoma Intraductal não Infiltrante , Margens de Excisão , Recidiva Local de Neoplasia , Mamilos , Tratamentos com Preservação do Órgão , Humanos , Feminino , Mamilos/cirurgia , Mamilos/patologia , Neoplasias da Mama/cirurgia , Neoplasias da Mama/patologia , Pessoa de Meia-Idade , Carcinoma Intraductal não Infiltrante/cirurgia , Carcinoma Intraductal não Infiltrante/patologia , Recidiva Local de Neoplasia/cirurgia , Recidiva Local de Neoplasia/patologia , Seguimentos , Adulto , Tratamentos com Preservação do Órgão/métodos , Carcinoma Ductal de Mama/cirurgia , Carcinoma Ductal de Mama/patologia , Prognóstico , Taxa de Sobrevida , Idoso , Estudos Prospectivos , Mastectomia Subcutânea/métodos , Invasividade Neoplásica , Neoplasia Residual/cirurgia , Neoplasia Residual/patologiaRESUMO
BACKGROUND: There are limited data examining racial disparities in locoregional recurrence (LRR) among women with access to high-quality care. We aimed to examine differences in late LRR by race in patients with stage I-IIIA, hormone receptor-positive (HR+) breast cancer enrolled in the National Surgical Adjuvant Breast and Bowel (NSABP) B-42 trial. METHODS: From 2006 to 2010, 3966 postmenopausal women with stage I-IIIA HR+ breast cancer who were disease-free after 5 years of endocrine therapy were randomized to an additional 5 years of endocrine therapy or placebo. Patients were excluded if multi-racial or if race was unknown. Kaplan-Meier curves were used to estimate 6-year LRR from the time of trial registration and according to race. Cox proportional hazards models were used for adjusted survival analyses. RESULTS: Overall, 3929 NSABP B-42 patients were included: 3688 (93.9%) White, 151 (3.8%) Black, and 90 (2.3%) Asian patients. Median follow-up was 75.2 months. Overall estimated 6-year LRR from trial registration was 1.8% and differed by race: LRR rates were 1.7% in White women, 4.9% in Black women, and 0% in Asian women (p = 0.046). Adjusted Cox proportional hazards analysis found Black race to be independently associated with LRR (hazard ratio [HzR] 2.36, 95% confidence interval [CI] 1.01-5.49; p = 0.047). Node-positivity was also associated with increased LRR (HzR 1.75, 95% CI 1.07-2.86; p = 0.025). Adjusted Cox analysis found LRR (HzR 2.32, 95% CI 1.33-4.06; p = 0.003) to be associated with increased overall mortality; however, race was not independently associated with mortality. CONCLUSION: Among postmenopausal patients with stage I-IIIA HR+ breast cancer in the NSABP B-42 trial, racial differences in late LRR were present, with the highest LRR in Black women.
Assuntos
Neoplasias da Mama , Humanos , Feminino , Neoplasias da Mama/cirurgia , Pós-Menopausa , Recidiva Local de Neoplasia , MamaRESUMO
BACKGROUND: Randomized trials have established the safety of observation or axillary radiation (AxRT) as an alternative to axillary lymph node dissection (ALND) in patients with limited nodal disease who undergo upfront surgery. Variability remains in axillary management strategies in cN0 patients undergoing mastectomy found to have one to two positive sentinel lymph nodes (SLNs). We examined the impact of intraoperative pathology assessment in axillary management in a national cohort of AMAROS-eligible mastectomy patients. METHODS: The National Cancer Database was used to identify AMAROS-eligible cT1-2N0 breast cancer patients undergoing upfront mastectomy and SLN biopsy (SLNB) and found to have one to two positive SLNs, from 2018 to 2019. We constructed a variable defining intraoperative pathology as 'not performed/not acted on' if ALND was either not performed or performed at a later date than SLNB, or 'performed/acted on' if SLNB and ALND were completed on the same day. Adjusted multivariable analysis examined predictors of treatment with both ALND and AxRT. RESULTS: Overall, 8222 patients with cT1-2N0 disease underwent upfront mastectomy and had one to two positive SLNs. Intraoperative pathology was performed/acted on in 3057 (37.2%) patients. These patients were significantly more likely to have both ALND and AxRT than those without intraoperative pathology (41.0% vs. 4.9%; p < 0.001). On multivariate analysis, the strongest predictor of receiving both ALND and AxRT was use of intraoperative pathology (odds ratio 8.99, 95% confidence interval 7.70-10.5; p < 0.001). CONCLUSIONS: We advocate that consideration should be made for omission of routine intraoperative pathology in mastectomy patients likely to be recommended postmastectomy radiation to minimize axillary overtreatment with both ALND and AxRT in appropriate patients.
Assuntos
Neoplasias da Mama , Linfonodo Sentinela , Humanos , Feminino , Neoplasias da Mama/cirurgia , Neoplasias da Mama/patologia , Mastectomia , Biópsia de Linfonodo Sentinela , Axila/patologia , Metástase Linfática/patologia , Excisão de Linfonodo , Linfonodo Sentinela/cirurgia , Linfonodo Sentinela/patologiaRESUMO
BACKGROUND: Management of patients with classic lobular carcinoma in situ diagnosed on core needle biopsy remains controversial, in part because of clinicopathologic overlap with atypical lobular hyperplasia. Although atypical lobular hyperplasia on core needle biopsy is observed because of its low upgrade rate (~1%), consensus is lacking for lobular carcinoma in situ. Therefore, we evaluated lobular carcinoma in situ upgrade rates. METHODS: With institutional review board approval, we identified 90 patients (from October 2008 to December 2019) with lobular carcinoma in situ on core needle biopsy as their highest-risk lesion. We excluded patients with concurrent ipsilateral cancer. Variables associated with upgrade were assessed with logistic regression. RESULTS: Of the 90 patients, 81 (90%), median age 55 y, underwent surgical excision. Indications for diagnostic core needle biopsy included mammographic calcifications (48, 53.3%), mass/distortion (28, 31.1%), and non-mass enhancement (12, 13.3%). Final surgical pathology upgraded 11 of 81 patients (13.6%, 95% CI: 7.8%-22.7%) to cancer: invasive lobular (n = 7), invasive ductal (n = 1), and ductal carcinoma in situ/pleomorphic lobular carcinoma in situ (n = 3). Only 1 patient with invasive cancer was node-positive. Concurrent contralateral cancer (OR 4.41, 95% CI: 1.06-17.38, P = .04) and larger lesion size (OR 1.78 per 1 cm, 95% CI: 1.19-2.95, P = .005) predicted upgrade. CONCLUSION: Our data suggest that, unlike atypical lobular hyperplasia, lobular carcinoma in situ identified on core needle biopsy should be surgically excised. The high proportion of upgrades to early stage invasive lobular carcinoma underscores the value of this approach.
Assuntos
Carcinoma de Mama in situ/diagnóstico , Carcinoma Lobular/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Biópsia com Agulha de Grande Calibre , Carcinoma de Mama in situ/terapia , Carcinoma Lobular/terapia , Terapia Combinada , Gerenciamento Clínico , Feminino , Humanos , Imageamento por Ressonância Magnética , Mamografia , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Carga TumoralRESUMO
BACKGROUND: Post-esophagectomy patients who develop high-output chylous fistula and chylothorax can be successfully treated with percutaneous ablation thereby avoiding reoperation. METHODS: Five patients with refractory chylous fistula post-esophagectomy were treated with percutaneous embolization. Fistula outputs, evaluation of lymphatic access sites, agents used and additional procedures were analyzed. RESULTS: Successful ablation of the chylous fistula was achieved in 4 of the 5 (80%) patients. Pretreatment chylous output averaged 1,756 mL/day. Cumulative chylous output (resection to ablation) averaged 28 L/patient. A modified technique is detailed, which utilizes direct puncture of groin lymph nodes to facilitate opacification of the thoracic duct. CONCLUSIONS: Percutaneous embolization strategies to treat chylothorax should be considered initial therapy before reoperation and direct ligation. Opacification of the thoracic duct to facilitate direct transhepatic cannulation can be accomplished with direct lymph node cannulation in the groin. Successful ablation of chylothorax following percutaneous embolization is predictable in a high percentage of cases.