In-laboratory breast specimen radiography reduces tissue block utilization and improves turnaround time of pathologic examination.

BACKGROUND: This study was performed to determine whether in-laboratory specimen radiography reduces turnaround time or block utilization in surgical pathology. METHODS: Specimens processed during a 48-day trial of an in-lab cabinet radiography device (Faxitron) were compared to a control group of specimens imaged in the mammography suite during a prior 1-year period, and to a second group of specimens not undergoing imaging of any type. RESULTS: Cases imaged in the mammography suite had longer turnaround time than cases not requiring imaging (by 1.15 days for core biopsies, and 1.73 days for mastectomies; p < 0.0001). In contrast, cases imaged in-lab had turnaround time that was no longer than unimaged cases (p > 0.05 for core biopsies, lumpectomies and mastectomies). Mastectomies imaged in-lab required submission of fewer blocks than controls not undergoing any imaging (mean reduction of 10.6 blocks). CONCLUSIONS: Availability of in-lab radiography resulted in clinically meaningful improvements in turnaround time and economically meaningful reductions in block utilization.

[Preoperative breast imaging review: Interests and limits of specialized validation in oncology]. / Relecture préopératoire en sénologie : intérêts et limites d'une validation spécialisée en oncologie.

OBJECTIVES: To evaluate the impact of systematic radiological review by breast specialist radiologist of malignant breast lesion imaging on the therapeutic management of patients. MATERIALS AND METHODS: Data collection was performed for patients with histopathologically proved breast cancer or suspicious breast lesion on imaging realized out of our institution. Patients underwent systematic mammary and axillary ultrasound, imaging review and if necessary complementary mammographic images. We analyzed the number of additional breast biopsies and axillary lymph node fine needle aspiration (FNA) with their histopathological results. We assessed their impact by comparing the final surgical treatment to the one planned before review. RESULTS: Two hundred and seventeen patients were included, with a total of 230 BIRADS 0, 4, 5 or 6 breast lesions. Seventy-six additional breast core biopsies were realized, leading to diagnose 43 additional BIRADS 6 lesions (24 infiltrative carcinomas, 9 DCIS and 10 atypical lesions) in 30 patients (13.82%). Thirty-five additional lymph node FNA were realized with 12 metastatic nodes and 3 false negative samples. Imaging review lead to change surgical treatment in 59 patients (27.19%, P<0.01) with modification in breast surgery in 37 patients, axillary surgery in 8 patients and both sites surgery in 12 patients. CONCLUSION: This study shows an impact of systematic radiological review by breast specialist radiologist in therapeutic management of patients treated for malignant breast lesion.

Health-related quality of life following breast reconstruction compared to total mastectomy and breast-conserving surgery among breast cancer survivors: a systematic review and meta-analysis.

The present review evaluated health-related quality of life (HR-QoL) outcomes in surgical breast cancer survivors who received breast reconstruction (BR), breast-conservation surgery (BCS) or mastectomy (M), and whether HR-QoL domains across generic and disease/surgery-specific questionnaires are compatible. Six electronic databases were searched for appropriate observational studies. Standardized scores for different HR-QoL domains in the BR, BCS, and M treatment groups were extracted from each study for the purpose of a meta-analysis. Using Stata version 14.0, a random-effects meta-analysis model was adopted for each outcome variable to estimate the effect size, 95% CI-confidence intervals, and statistical significance. Sixteen of the 18 eligible studies with BR (n = 1474) and BCS (n = 2612) or M (n = 1458) groups were included in the meta-analysis. The BR group exhibited a better physical health (k = 12; 0.1, 95% CI 0.04, 0.24) and body image (k = 12; 0.50, 95% CI 0.10, 0.89) than the M group. However, the two groups exhibited comparable social health (k = 13; 0.1, 95% CI -0.07, 0.37), emotional health (k = 13; -0.08, 95% CI - 0.41, 0.25), global health (k = 7; 0.1, 95% CI - 0.01, 0.27), and sexual health (k =11; 0.2, 95% CI - 0.02,0.57). There was no clear evidence of the superiority of BR to BCS for all the six domains. These results suggest that HR-QoL outcomes in BR and BCS groups are better than the M group. Therefore, women opting for BR or BCS are likely to report fairly better HR-QoL outcomes than M. However, due to the significant heterogeneity observed in most BR versus BCS outcomes, developing a unified questionnaire incorporating both breast/surgery-specific and generic HR-QoL domains is warranted.

How to compare the oncological safety of oncoplastic breast conservation surgery - To wide local excision or mastectomy?

BACKGROUND: Comparative studies suggest that patients treated with oncoplastic breast conservation surgery (OBCS) have similar pathology to patients treated with wide local excision (WLE). However, patients treated with OBCS have never been compared to patients treated with mastectomy. The aim of this study was to identify which control group was comparable to patients undergoing OBCS. METHODS: Commonly reported histopathological variables of patients treated with OBCS, WLE or mastectomy ± immediate reconstruction (Ms ± IR) were compared using Fisher Exact or Chi squared tests. RESULTS: 1000 patients' data were analysed (OBCS: n = 119; WLE: n = 600; Ms ± IR: n = 281). Tumour size was significantly bigger after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.138). Tumour grade was higher after OBCS than WLE (p < 0.001), but similar to Ms ± IR (p = 0.497). More axillary nodes were involved in patients with OBCS than WLE (p < 0.001), but comparable to Ms ± IR (p = 0.175). ER and PR expressions were lower after OBCS compared to WLE (p = 0.007, p = 0.009), but identical to Ms ± IR (p = 1, p = 0.904 respectively). Differences in application of systemic (neo)adjuvant therapy followed the above trend. CONCLUSION: Striking similarities found between OBCS and mastectomy patients' histopathological results are in sharp contrast with previously published data. This study suggests that oncological outcomes following OBCS should be compared to mastectomy besides WLE.

Tumor-to-breast volume ratio as measured on MRI: a possible predictor of breast-conserving surgery versus mastectomy.

BACKGROUND: The surgical approach to breast cancer changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision. OBJECTIVES: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy). METHODS: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy. RESULTS: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001). CONCLUSION: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.

Evaluating population-based breast cancer surgical practice in real time with a web-based synoptic operative reporting system.

BACKGROUND: A Web-based synoptic operative reporting system (WebSMR) incorporates implicit guidelines and real-time feedback of a surgeon's practice compared with provincial data. This study compares rates of total mastectomy (TM) between the overall provincial and WebSMR patients and examines decision-making factors in WebSMR patients. METHODS: Patients treated for invasive breast cancer (2007 to 2011) were identified from WebSMR and the Alberta Cancer Registry. Reports include surgery type and reasons for TM. RESULTS: Among 5,787 patients in WebSMR (2007 to 2011), TM rate decreased from 48% to 42% (P < .001). In 2011, the provincial cancer registry recorded a 56% TM rate compared to 42% in WebSMR patients. Patient preference accounted for 36% in the latter group. CONCLUSIONS: In WebSMR patients, TM rates were lower than the overall provincial rate and decreased significantly during the study period. Reasons are unclear, but guidelines and real-time feedback likely plays a role.

Factors associated with the frequency of initial total mastectomy: results of a multi-institutional study.

BACKGROUND: Several previous studies have reported conflicting data on recent trends in use of initial total mastectomy (TM); the factors that contribute to TM variation are not entirely clear. Using a multi-institution database, we analyzed how practice, patient, and tumor characteristics contributed to variation in TM for invasive breast cancer. STUDY DESIGN: We collected detailed clinical and pathologic data about breast cancer diagnosis, initial, and subsequent breast cancer operations performed on all female patients from 4 participating institutions from 2003 to 2008. We limited this analysis to 2,384 incident cases of invasive breast cancer, stages I to III, and excluded patients with clinical indications for mastectomy. Predictors of initial TM were identified with univariate analyses and random effects multivariable logistic regression models. RESULTS: Initial TM was performed on 397 (16.7%) eligible patients. Use of preoperative MRI more than doubled the rate of TM (odds ratio [OR] = 2.44; 95% CI, 1.58-3.77; p < 0.0001). Increasing tumor size, high nuclear grade, and age were also associated with increased rates of initial TM. Differences by age and ethnicity were observed, and significant variation in the frequency of TM was seen at the individual surgeon level (p < 0.001). Our results were similar when restricted to tumors <20 mm. CONCLUSIONS: We identified factors associated with initial TM, including preoperative MRI and individual surgeon, that contribute to the current debate about variation in use of TM for the management of breast cancer. Additional evaluation of patient understanding of surgical options and outcomes in breast cancer and the impact of the surgeon provider is warranted.

Local, regional, and systemic recurrence rates in patients undergoing skin-sparing mastectomy compared with conventional mastectomy.

BACKGROUND: Although the use of SSM is becoming more common, there are few data on long-term, local-regional, and distant recurrence rates after treatment. The purpose of this study was to examine the rates of local, regional, and systemic recurrence, and survival in breast cancer patients who underwent skin-sparing mastectomy (SSM) or conventional mastectomy (CM) at our institution. METHODS: Patients with stage 0 to III unilateral breast cancer who underwent total mastectomy at our center from 2000 to 2005 were included in this study. Kaplan-Meier curves were calculated, and the log-rank test was used to evaluate the differences between overall and disease-free survival rates in the 2 groups. RESULTS: Of 1810 patients, 799 (44.1%) underwent SSM and 1011 (55.9%) underwent CM. Patients who underwent CM were older (58.3 vs 49.3 years, P<.0001) and were more likely to have stage IIB or III disease (53.0% vs 31.8%, P<.0001). Significantly more patients in the CM group received neoadjuvant chemotherapy and adjuvant radiation therapy (P<.0001). At a median follow-up of 53 months, 119 patients (6.6%) had local, regional, or systemic recurrences. The local, regional, and systemic recurrence rates did not differ significantly between the SSM and CM groups. After adjusting for clinical TNM stage and age, disease-free survival rates between the SSM and CM groups did not differ significantly. CONCLUSIONS: SSM is an acceptable treatment option for patients who are candidates for immediate breast reconstruction. Local-regional recurrence rates are similar to those of patients undergoing CM. Cancer 2011. © 2010 American Cancer Society.

Incidence of breast cancer in Italy: mastectomies and quadrantectomies performed between 2000 and 2005.

OBJECTIVES: We aimed to determine the incidence of women's breast cancer in Italy without using statistical approximations. METHODS: We analyzed the national hospitalizations database at the Ministry of Health to calculate the number of major surgeries in Italian women (mastectomies and quadrantectomies) due to breast cancer between 2000 and 2005, overall and by age groups (<44, 45-64, 65-74 and >or= 75 years old). RESULTS: Over the six years examined, an overall number of 100,745 mastectomies and 168,147 quadrantectomies were performed. A total of 41,608 major surgeries due to breast cancer were performed in the year 2000 and this number rose to 47,200 in 2005, with a 13.4% increase over six years. CONCLUSION: by analyzing the hospitalizations database concerning major breast surgery, incidence of breast cancer in Italy was found to be 26.5% higher than the official estimations which have been computed using statistical models (namely 47,200 vs. 37,300 cases in year 2005).

Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy.

BACKGROUND: Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS: From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS: Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS: Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.

Does aggressive local therapy improve survival in metastatic breast cancer?

BACKGROUND: Women with metastatic breast cancer and an intact primary tumor are currently treated with systemic therapy. Local therapy of the primary tumor is considered irrelevant to the outcome, and is recommended only for palliation of symptoms. METHODS: We have examined the use of local therapy, and its impact on survival in patients presenting with stage IV breast cancer at initial diagnosis, who were reported to the National Cancer Data Base (NCDB) between 1990 and 1993. RESULTS: A total of 16,023 patients with stage IV disease were identified in the NCDB during this period, of whom 6861 (42.8%) received either no operation or a variety of diagnostic or palliative procedures, and 9162 (57.2%) underwent partial (3513) or total (5649) mastectomy. The presence of free surgical margins was associated with an improvement in 3-year survival in partial or total mastectomy groups (26% vs 35%, respectively). A multivariate proportional hazards model identified the number of metastatic sites, the type of metastatic burden, and the extent of resection of the primary tumor as significant independent prognostic covariates. Women treated with surgical resection with free margins, when compared with those not surgically treated, had superior prognosis, with a hazard ratio of 0.61 (95% confidence interval 0.58,0.65). CONCLUSIONS: These data suggest that the role of local therapy in women with stage IV breast cancer needs to be re-evaluated, and local therapy plus systemic therapy should be compared with systemic therapy alone in a randomized trial.

Prophylactic bilateral mastectomy: patterns of practice.

BACKGROUND: Many women who are at an elevated risk of developing breast carcinoma choose prophylactic mastectomy to decrease their risk. We conducted a population-based study to review the indications for, and patterns of practice of prophylactic mastectomy in Ontario, Canada, since 1991. METHODS: A medical chart review was conducted at 33 hospitals that were identified as having conducted at least one prophylactic mastectomy. All bilateral mastectomy patients with no diagnosis of invasive or in situ breast carcinoma were eligible. RESULTS: The number of prophylactic bilateral mastectomies performed varied from 6 to 19. The mean age of women undergoing prophylactic mastectomy was 43.5 years. Eighty percent of the women had prophylactic mastectomy performed because of a family history of breast carcinoma (89 of 99) or because of a known BRCA1 or BRCA2 mutation (10 of 99). Twenty percent of the women had no family history, but had the surgery for other benign breast conditions. Women with a family history of breast carcinoma were much more likely to have a total mastectomy (89%) than a subcutaneous mastectomy (11%). Sixty percent of the women had reconstructive surgery following mastectomy. CONCLUSIONS: Prophylactic mastectomy is not performed on a large scale. The introduction of genetic testing for BRCA1 and BRCA2 has the potential to change the patterns of practice for prophylactic mastectomy.

Outpatient mastectomy: clinical, payer, and geographic influences.

OBJECTIVE: To determine (1) the use of outpatient services for all surgical breast procedures for breast cancer and (2) the influence of payer and state on the use of outpatient services for complete mastectomy in light of state and federal length-of-stay managed care legislation. DATA SOURCES: Healthcare Cost and Utilization Project representing all discharges from hospitals and ambulatory surgery centers for five states (Colorado, Connecticut, Maryland, New Jersey, and New York) and seven years (1990-96). STUDY DESIGN: Longitudinal, cross-sectional analyses of all women undergoing inpatient and outpatient complete mastectomy (CMAS), subtotal mastectomy (STMAS), and lumpectomy (LUMP) for cancer were employed. Total age-adjusted rates and percentage of outpatient CMAS, STMAS, and LUMP were compared. Independent influence of state and HMO payer on likelihood of receiving an outpatient CMAS was determined from multivariate models, adjusting for clinical characteristics (age < 50 years, comorbidity, metastases, simple mastectomy, breast reconstruction) and hospital characteristics (teaching, ownership, urban). PRINCIPAL FINDINGS: In 1993, 1 to 2 percent of CMASs were outpatient in all states. By 1996, 8 percent of CMASs were outpatient in Connecticut, 13 percent were outpatient in Maryland, and 22 percent were outpatient in Colorado. In comparison, LUMPs were 78 to 88 percent outpatient, and by 1996, 43 to 72 percent of STMASs were outpatient. In 1996, women were 30 percent more likely to receive an outpatient CMAS in New York, 2.5 times more likely in Connecticut, 4.7 times more likely in Maryland, and 8.6 times more likely in Colorado compared to New Jersey. In addition, women with Medicare, Medicaid, or private commercial insurance were less likely to receive an outpatient CMAS compared to women with an HMO payer. CONCLUSIONS: LUMP is an outpatient procedure, and STMAS is becoming primarily outpatient. CMAS, while still primarily inpatient, is increasingly outpatient in some states. Although clinical characteristics remain important, the state in which a woman receives care and whether she has an HMO payer are strong determinants of whether she receives an outpatient CMAS.

Vigencia de la mastectomía para el tratamiento primario del cáncer de mama / Mastectomy operation for primary breast cancer treatment

Introducción: Estudio de las pacientes portadoras de carcinoma de mama que aún son sometidas a mastectomías. Material y métodos: Se evalúan 3108 carcinomas de mama tratados entre abril de 1993 y diciembre de 1999, los que fueron agrupados según recibieron tratamientos radicales (1834) o tratamientos conservadores (1029). En los restantes 237 casos se realizaron otros procedimientos. La edad media fue de 55 años. El seguimiento medio fue de 42 meses (rango 1-365). Resultados: Con respecto al motivo de consulta, se observó un aumento de los carcinomas diagnosticados a raíz de un control habitual (p < 0,05), como así también un incremento significativo de los estadios 0 y I (p < 0,05). Estudiando la progresión en el tiempo de las distintas técnicas empleadas, se observó una paulatina disminución de las mastectomías y un incremento de las cirugías conservadoras. La mastectomía radical clásica de Halsted y la resección del músculo pectoral menor ya han caído en desuso. En los últimos 4 años, el 30 por ciento de pacientes requirieron una mastectomía debido fundamentalmente al tamaño tumoral, la multicentricidad, el componente intraductal extensivo y edad avanzada. De éste subgrupo de pacientes, en el 41 por ciento se realizó reconstrucción mamaria. Conclusiones: A pesar de los buenos resultados obtenidos con la cirugía conservadora, existe hoy en día un 30 por ciento de carcinomas mamarios que requieren una mastectomía para poder obtener un correcto control locorregional

Surgical treatment of early-stage breast cancer in the Department of Defense Healthcare System.

BACKGROUND: The choice between breast-conserving surgery and modified radical mastectomy in the treatment of women with early stage breast cancer in the Department of Defense Healthcare System may be influenced by demographic factors. STUDY DESIGN: The Department of Defense Automated Central Tumor Registry (ACTUR) was queried for women diagnosed with American Joint Committee on Cancer Stage I or II invasive breast carcinoma from January 1, 1986, to December 31, 1996. Univariate analysis and multivariate analysis were applied to the study variables. Year of diagnosis, age at diagnosis, tumor size, type of hospital, geographic region, and local availability of radiation therapy were evaluated with respect to the type of surgical treatment performed. Surgical treatment was either breast conservation therapy (BCT) or modified radical mastectomy. RESULTS: After excluding women for whom the data were incomplete (n = 308), 7,815 women were identified who met study criteria. There was a progressive increase in the use of BCT to treat tumors of all sizes from 16% to 47% over the 11 years of the study (p < 0.0001). BCT was more frequently used for smaller tumors (< 2cm), with an odds ratio of 2.46 (2.20-2.76, 95% CI). In 1996, 54% of women with T1 (< 2 cm) tumors were treated with BCT. Women treated with BCT were nearly the same age as those undergoing modified radical mastectomy (55.5 years versus 56.8 years, p < 0.0001). BCT was used at a slightly greater rate in medical centers than in community hospitals (31% versus 28%, p < 0.0001). Use of BCT varied among geographic regions from a low of 24% in the southwestern USA to a peak of 36% in the Northeast and 40% in hospitals outside of the continental United States (p < 0.0001). Local availability of radiation therapy did not influence choice of treatment. CONCLUSIONS: The use of BCT to treat early stage invasive breast carcinoma in the Department of Defense Healthcare System is increasing. But BCT is used less often to treat larger tumors. Regional differences in the use of BCT persist, even after controlling for other factors. Patient age and type of hospital (community versus academic center) appear to exert little influence on the choice of treatment. Local availability of radiation therapy did not seem to influence the choice of treatment. Our data suggest that efforts to promote the use of BCT should target the central and southwestern USA. Use of BCT should also be emphasized for women with larger tumors (> 2 cm).

Geographic variation in postmastectomy breast reconstruction rates.

Data on postmastectomy breast reconstructive surgery were examined for 52,357 female breast cancers that were treated with mastectomy and diagnosed in geographic areas covered by the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The proportion of cancers that involved reconstruction varied in these geographic areas in each age group (under age 70 years) by a factor of about four or five, even after adjustment for stage at diagnosis, marital status, and poverty rate of county of residence at diagnosis. Studies are needed to explain the large differences in reconstruction rates by geographic area.