Detecting nonpalpable recurrent breast cancer: the role of routine mammographic screening of transverse rectus abdominis myocutaneous flap reconstructions.

PURPOSE: To perform a retrospective cohort study to determine the rates of recall and cancer detection and then to develop a decision analytic model to evaluate the effectiveness of routine screening of transverse rectus abdominis myocutaneous (TRAM) flap reconstructions. MATERIALS AND METHODS: This study was approved by the institutional review board, and the methods comply with HIPAA regulations. A retrospective search of the institutional mammographic results database was done to identify bilateral screening mammographic examinations obtained from January 1, 1999, through July 15, 2005. The search included the term TRAM; the recall and cancer detetion rates were then detected. Subsequently, a decision analytic model was constructed to evaluate a hypothetical cohort of women with TRAM flap reconstructions. RESULTS: Of 554 mammograms (265 TRAM flap reconstructions), 546 (98.6%) had negative results (Breast Imaging Reporting and Data System category 1 or 2). Eight (1.4%) had positive test results (Breast Imaging Reporting and Data System category 0, 3, 4, or 5). All suspicious lesions underwent biopsy and had benign pathologic results. No interval breast cancers were identified. The detection rate for nonpalpable recurrent breast cancer was 0% (exact 95% confidence interval: 0.0%, 1.4%). According to decision analysis, screening would help detect an estimated 12 additional recurrent cancers per 1000 women screened, providing an additional 1.6 days of life expectancy for the screened cohort. Under base-case conditions, screening of TRAM flap reconstructions is less effective than screening asymptomatic women in their 40s. Sensitivity analysis revealed that a benefit equivalent to that of screening asymptomatic women in their 40s was achievable under conditions related to estimates of screening effectiveness and cancer detection rate. CONCLUSION: Routine screening mammography of TRAM flap reconstructions has a very low detection rate for nonpalpable recurrent breast cancer. Decision analysis indicates that screening such women is less effective than screening asymptomatic women in their 40s for primary breast cancer.

External beam accelerated partial-breast irradiation using 32 gy in 8 twice-daily fractions: 5-year results of a prospective study.

PURPOSE: External beam accelerated partial breast irradiation (APBI) is an increasingly popular technique for treatment of patients with early stage breast cancer following breast-conserving surgery. Here we present 5-year results of a prospective trial. METHODS AND MATERIALS: From October 2003 through November 2005, 98 evaluable patients with stage I breast cancer were enrolled in the first dose step (32 Gy delivered in 8 twice-daily fractions) of a prospective, multi-institutional, dose escalation clinical trial of 3-dimensional conformal external beam APBI (3D-APBI). Median age was 61 years; median tumor size was 0.8 cm; 89% of tumors were estrogen receptor positive; 10% had a triple-negative phenotype; and 1% had a HER-2-positive subtype. Median follow-up was 71 months (range, 2-88 months; interquartile range, 64-75 months). RESULTS: Five patients developed ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial IBTR rate of 5% (95% confidence interval [CI], 1%-10%). Three of these cases occurred in patients with triple-negative disease and 2 in non-triple-negative patients, for 5-year actuarial IBTR rates of 33% (95% CI, 0%-57%) and 2% (95% CI, 0%-6%; P<.0001), respectively. On multivariable analysis, triple-negative phenotype was the only predictor of IBTR, with borderline statistical significance after adjusting for tumor grade (P=.0537). CONCLUSIONS: Overall outcomes were excellent, particularly for patients with estrogen receptor-positive disease. Patients in this study with triple-negative breast cancer had a significantly higher IBTR rate than patients with other receptor phenotypes when treated with 3D-APBI. Larger, prospective 3D-APBI clinical trials should continue to evaluate the effect of hormone receptor phenotype on IBTR rates.