Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions).

PURPOSE: The second International Consensus Conference on B3 lesions was held in Zurich, Switzerland, in March 2018, organized by the International Breast Ultrasound School to re-evaluate the consensus recommendations. METHODS: This study (1) evaluated how management recommendations of the first Zurich Consensus Conference of 2016 on B3 lesions had influenced daily practice and (2) reviewed current literature towards recommendations to biopsy. RESULTS: In 2018, the consensus recommendations for management of B3 lesions remained almost unchanged: For flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL) and radial scars (RS) diagnosed on core-needle biopsy (CNB) or vacuum-assisted biopsy (VAB), excision by VAB in preference to open surgery, and for atypical ductal hyperplasia (ADH) and phyllodes tumors (PT) diagnosed at VAB or CNB, first-line open surgical excision (OE) with follow-up surveillance imaging for 5 years. Analyzing the Database of the Swiss Minimally Invasive Breast Biopsies (MIBB) with more than 30,000 procedures recorded, there was a significant increase in recommending more frequent surveillance of LN [65% in 2018 vs. 51% in 2016 (p = 0.004)], FEA (72% in 2018 vs. 62% in 2016 (p = 0.005)), and PL [(76% in 2018 vs. 70% in 2016 (p = 0.04)] diagnosed on VAB. A trend to more frequent surveillance was also noted also for RS [77% in 2018 vs. 67% in 2016 (p = 0.07)]. CONCLUSIONS: Minimally invasive management of B3 lesions (except ADH and PT) with VAB continues to be appropriate as an alternative to first-line OE in most cases, but with more frequent surveillance, especially for LN.

Correction to: Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions).

The article Second International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions), written by Christoph J Rageth, Elizabeth AM O'Flynn, Katja Pinker, Rahel A Kubik-Huch, Alexander Mundinger, Thomas Decker, Christoph Tausch, Florian Dammann, Pascal A. Baltzer, Eva Maria Fallenberg, Maria P Foschini, Sophie Dellas, Michael Knauer, Caroline Malhaire, Martin Sonnenschein, Andreas Boos, Elisabeth Morris, Zsuzsanna Varga, was originally published electronically on the publisher's internet portal (currently SpringerLink) on November 30, 2018 without open access.

First International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions).

The purpose of this study is to obtain a consensus for the therapy of B3 lesions. The first International Consensus Conference on lesions of uncertain malignant potential in the breast (B3 lesions) including atypical ductal hyperplasia (ADH), flat epithelial atypia (FEA), classical lobular neoplasia (LN), papillary lesions (PL), benign phyllodes tumors (PT), and radial scars (RS) took place in January 2016 in Zurich, Switzerland organized by the International Breast Ultrasound School and the Swiss Minimally Invasive Breast Biopsy group-a subgroup of the Swiss Society of Senology. Consensus recommendations for the management and follow-up surveillance of these B3 lesions were developed and areas of research priorities were identified. The consensus recommendation for FEA, LN, PL, and RS diagnosed on core needle biopsy or vacuum-assisted biopsy (VAB) is to therapeutically excise the lesion seen on imaging by VAB and no longer by open surgery, with follow-up surveillance imaging for 5 years. The consensus recommendation for ADH and PT is, with some exceptions, therapeutic first-line open surgical excision. Minimally invasive management of selected B3 lesions with therapeutic VAB is acceptable as an alternative to first-line surgical excision.

Papillary lesions of the breast: outcomes of 156 patients managed without excisional biopsy.

Papillomas of the breast are benign epithelial neoplasms. Because of the low, but continued potential for malignancy, the treatment options after initial diagnosis remain controversial. The aim of this study was to analyze the clinical course of patients with papilloma who were managed by active surveillance following initial diagnosis by core needle biopsy or vacuum-assisted biopsy. This retrospective study analyzed 174 patients with 180 papillomas that were diagnosed by core needle biopsy (113 cases) or vacuum-assisted biopsy (67 cases) at the Breast Center Seefeld Zurich between February 2002 and May 2011. We excluded 24 cases that underwent excisional biopsy for removal of the lesion. Over a mean follow-up of 3.5 years, 13 further events occurred in 156 cases (8%). These events included two cases of ductal carcinoma in situ (one after 4 and one after 6 years), one case of atypical ductal hyperplasia, one radial scar, eight cases of papilloma, and one case of flat epithelial atypia. No invasive carcinomas occurred during the follow-up period. Conservative management of 156 papillary lesions with removal by vacuum-assisted biopsy and surveillance was not associated with invasive cancer over a median follow-up of 3.5 years. Therefore, this approach seems to be a safe option for the clinical management of papillary lesions.

Fluctuating mastectomy rates across time and geography.

In 2009, 2 single-institution studies from the United States reported increasing mastectomy rates during the last decade. We have recently reported unilateral mastectomy trends from a European database and demonstrated a significant trend of decreasing mastectomy rates from 38.1 % in 2005 to 13.1 % in 2010. A recent study from the SEER registry in the United States confirmed a previously reported decrease in mastectomy rates from 40.1 % in year 2000 to 35.6 % in 2005, but showed a statistically significant increase in mastectomy rates up to 38.4 % in 2008. This report provides evidence that mastectomy trends may be in opposite directions in different geographical areas. The sharpest increase in mastectomy rates across all ages in the recent SEER study occurs right after year 2005, which interestingly corresponds with the time of publication of the meta-analysis by the EBCTCG that highlighted the importance of local control in breast cancer. The coincident timing raises the question of whether this evidence may have indirectly triggered an increase in mastectomy rates in the United States that would partially explain the observed trend, and more importantly, of whether an increase would be justified on this basis. Multiple factors influence the proportion between mastectomy and breast conservation, so it may be unreasonable to think of an optimal cutoff. There is not necessarily a right or wrong direction for mastectomy trends, but aiming to determine explanations for these differences may help provide a clearer insight of the decision-making process involved in the surgical management of breast cancer.

Atypical ductal hyperplasia and the risk of underestimation: tissue sampling method, multifocality, and associated calcification significantly influence the diagnostic upgrade rate based on subsequent surgical specimens.

BACKGROUND: Risk assessment and therapeutic options are challenges when counselling patients with an atypical ductal hyperplasia (ADH) to undergo either open surgery or follow-up only. METHODS: We retrospectively analyzed a series of ADH lesions and assessed whether the morphological parameters of the biopsy materials indicated whether the patient should undergo surgery. A total of 207 breast biopsies [56 core needle biopsies (CNBs) and 151 vacuum-assisted biopsies (VABs)] histologically diagnosed as ADH were analyzed retrospectively, together with subsequently obtained surgical specimens. All histological slides were re-analyzed with regard to the presence/absence of ADH-associated calcification, other B3 lesions (lesion of uncertain malignant potential), extent of the lesion, and the presence of multifocality. RESULTS: The overall underestimation rate for the whole cohort was 39% (57% for CNB, 33% for VAB). In the univariate analysis, the method of biopsy (CNB vs VAB, p = 0.002) and presence of multifocality in VAB specimens (p = 0.0176) were significant risk factors for the underestimation of the disease (ductal carcinoma in situ or invasive cancer detected on subsequent open biopsy). In the multivariate logistic regression model, the absence of calcification (p = 0.0252) and the presence of multifocality (unifocal vs multifocal ADH, p = 0.0147) in VAB specimens were significant risk factors for underestimation. CONCLUSIONS: Multifocal ADH without associated calcification diagnosed by CNB tends to have a higher upgrade rate. Because the upgrade rate was 16.5% even in the group with the lowest risk (VAB-diagnosed unifocal ADH with calcification), we could not identify a subgroup that would not require an open biopsy.

[Sentinel lymphonodectomy in breast cancer - our own experience. Part 2]. / Sentinel-Lymphonodektomie beim Mammakarzinom - Eigene Erfahrungen. 2. Teil.

UNLABELLED: The aim of this investigation was to document the personal learning curve of the sentinel lymphonodectomy in breast surgery and to compare it with the experiences of other authors. RESULTS: Between July 1999 and May 2004, the authors performed 218 sentinel lymphonodectomies, 48 of them during the 24-month evaluation period with consecutive full axillary dissection. The overall detection rate was 212/218 or 97.2%, while during the evaluation period it was 38/48 or 89.6% (failures were procedures No. 6, 7, 22, 24 and 47). Among the first 48 cases, 24 had histologically proven metastasis to one or more of the axillary lymph nodes. In 3 of these cases, we were not able to detect a sentinel lymph node, and 4 times the sentinel lymph node was false-negative after rapid section. The false-negative results during the learning period belonged to cases No. 2, 10, 23 and 29 (4/21 or 19%). From September 2001 until May 2004, the detection rate was over 99% (165/166). DISCUSSION: Our own experience documents the initial difficulties and insecurities with this operative procedure. The common recommendations, i.e. that sentinel lymphonodectomy without axillary clearance should not be offered before having completed one's own learning curve with the aid of experienced surgeons, are to be supported.

[Sentinel lymphonodectomy -- new surgical standard for the evaluation of the axilla:an overview. Part 1]. / Sentinel-Lymphonodektomie -- Der neue operative Standard fur die Evaluation der Axilla: Ein Uberblick. 1.Teil.

Complete axillary dissection is still integral component of breast cancer treatment, but significant morbidity is associated with this procedure. Sentinel lymphonodectomy can replace complete axillary dissection in selected cases and can significantly reduce morbidity. Sentinel lymphonodectomy has become a new surgical standard and should be offered to all patients with unicentric tumors of less than 3 cm in diameter. Open questions concern the localization of the market injection, the significance of detecting and extirpation of extra-axillary lymph nodes, the applicability of the method to multicentric tumors, after neoadjuvant chemotherapy, after previous breast biopsy, to DCIS and tumors of more than 3 cm in diameter. Clinical trials have to establish whether axillary dissection after finding a micrometastasis in the sentinel node is necessary or not.

Mastectomy trends for early-stage breast cancer: a report from the EUSOMA multi-institutional European database.

INTRODUCTION: Recent single-institution reports have shown increased mastectomy rates during the last decade. Further studies aiming to determine if these reports could be reflecting a national trend in the United States of America (US) have shown conflicting results. We report these trends from a multi-institutional European database. PATIENTS AND METHODS: Our source of data was the eusomaDB, a central data warehouse of prospectively collected information of the European Society of Breast Cancer Specialists (EUSOMA). We identified patients with newly diagnosed unilateral early-stage breast cancer (stages 0, I or II) to examine rates and trends in surgical treatment. RESULTS: A total of 15,369 early-stage breast cancer cases underwent surgery in 13 Breast Units from 2003 to 2010. Breast conservation was successful in 11,263 cases (73.3%). Adjusted trend by year showed a statistically significant decrease in mastectomy rates from 2005 to 2010 (p = 0.003) with a progressive reduction of 4.24% per year. A multivariate model showed a statistically significant association of the following factors with mastectomy: age < 40 or ≥ 70 years, pTis, pT1mi, positive axillary nodes, lobular histology, tumour grade II and III, negative progesterone receptors and multiple lesions. CONCLUSION: Our study demonstrates that a high proportion of patients with newly diagnosed unilateral early-stage breast cancer from the eusomaDB underwent breast-conserving surgery. It also shows a significant trend of decreasing mastectomy rates from 2005 to 2010. Moreover, our study suggests mastectomy rates in the population from the eusomaDB are lower than those reported in the US.

Intramammarian flap reconstruction (IFR) technique in breast conserving surgery.

As large segmentectomies often lead to asymmetries and indentations in the breast, numerous oncoplastic reconstruction methods have been published over the past years. Many of these involve additional skin incisions, resulting in more and larger scars.This article presents a method, which uses the same incision as for the segmentectomy and does not lead to additional scars. First, the breast gland body is being detached from the pectoralis major muscle; then the largest part of the remaining gland body is being cut horizontally parallel to the thoracic wall, exactly in the middle between the skin and the pectoralis major muscle. The pectoral part of the gland body can then be placed into the tumor bed without tension as a f;ap with a length of approximately 7-14 cm and a width of approximately 4-10 cm. In 2007, the first author performed a total of 134 breast conserving surgeries (9 benign and 125 malignant diagnoses) which have been prospectively documented. The intramammarian f;ap reconstruction technique was applied 87 times (65% of all cases), with three cases of postoperative infection and two cases needing surgical evacuation of a hematoma. In 131 cases the cosmetic results were considered favorable or moderate. The results in the 4 remaining patients were cosmetically unsatisfactory; 3 were treated with and 1 without the intramammarian flap reconstruction.In most cases the technique leads to a quick and acceptable filling of the defect and avoids nipple deviation even after a large segmentectomy, so that the breast shape can be preserved and the original breast size is being only marginally reduced. A short video demonstrates the technique on youtube and yahoo (search terms: oncoplastic, ifr).