Outcomes of delays in time to treatment in triple negative breast cancer.

BACKGROUND: Compared with other breast cancer subtypes, triple negative breast cancers (TNBC) are associated with higher recurrence rates and worse survival. Because of the aggressive nature of TNBC, outcomes may be more sensitive to delays in time to treatment. This study evaluates whether delays from diagnosis to initial treatment in TNBC impacts survival or locoregional recurrence (LRR). METHODS: Retrospective review of TNBC patients treated between January 2004 and January 2011 at an academic center was performed. Data collected included demographics, pathology, treatment, recurrence, and survival. Interval to treatment was defined as days from pathologic diagnosis to first local or systemic treatment. The t test, Cox regression, and Kaplan-Meier analyses were used to evaluate impact of time to treatment on overall survival and LRR. RESULTS: Median follow-up was 40 months for 301 TNBC patients. Mean interval to treatment was 46 ± 2 days. Higher initial stage yielded worse survival (p < .0001). Interval to treatment did not impact overall survival (p = .24), although there was a trend toward worse survival with delays of >90 days (p = .06). LRR was seen in 20 patients (7 %). Median time to recurrence was 15 months. Time to treatment was 38 ± 6 days for patients with LRR versus 44 ± 2 days without a recurrence (p = .37). Short delay in time to treatment did not impact LRR (p = .54). CONCLUSIONS: In TNBC, a short delay from pathologic diagnosis to initial treatment does not appear to adversely affect survival or LRR. Appropriate time to perform evaluations such as genetic testing, imaging, or additional consultation can be taken to guide optimal treatment options.

Volume of excision and cosmesis with routine cavity shave margins technique.

BACKGROUND: Cavity shave margin (CSM) removal is a surgical technique that reduces re-excision rates. One criticism of this technique has been that negative margins are obtained primarily as a result of higher volumes of tissue removed. This study evaluates the volume of tissue removed in a group that underwent CSM versus one that underwent standard partial mastectomy (SPM) and explores cosmetic outcomes. METHODS: Single-institution retrospective review identified 533 patients with a diagnosis of breast cancer who underwent PM. Matched pair analysis of 72 patients who had undergone PM with CSM versus 72 who had undergone SPM was performed. Volumes were calculated from dimensions in the pathology report. A subgroup was analyzed by a multidisciplinary panel for cosmetic outcome using the Harvard Breast Cosmesis Grading Scale. RESULTS: Mean tumor size in the CSM group was 1.52 versus 1.51 cm(3) in the SPM (P = 0.8073). Mean total volume of tissue excised with CSM was lower than that in the SPM group. Mean volume of excision with CSM was 80.66 and 165.1 cm(3) in the SPM group (P = 0.0005). Patients undergoing CSM required fewer re-excisions than the SPM group: 13 (18.1%) versus 25 (34.6%) (P = 0.03). Mean score for cosmesis was 2.3 in the CSM group and 3.0 for SPM (P = 0.0004). CONCLUSIONS: CSM decreases the need for re-excision. Total tissue volume excised is lower in patients who undergo CSM, and cosmetic results appear to be improved. This approach should be considered for all patients undergoing PM.

Impact of routine cavity shave margins on breast cancer re-excision rates.

PURPOSE: Breast-conserving therapy (BCT) is an accepted method of treating early breast cancer. We hypothesized that routine excision of additional cavity shave margins (CSM) at time of initial partial mastectomy reduces the need for additional surgery. METHODS: A single-institution retrospective review was performed of women, 18 years or older, with a new diagnosis of breast cancer who underwent partial mastectomy between 1 January 2004 and 1 October 2009. Five hundred thirty-three charts were reviewed. Of those, 69 patients underwent CSM at time of initial operation. These 69 patients were matched with patients who had undergone partial mastectomy without CSM by tumor size, presence of extensive intraductal component, and primary histology. RESULTS: The two groups were well matched for age, nuclear grade, associated lymphovascular invasion (LVI), receptor status, and multifocality. We found that 31.9% (44/138) required return to the operating room (OR) for re-excision of margins. Rate of return to the OR was 21.7% (15/69) in the CSM group and 42.0% (29/69) in the matched group (p = 0.011). Multivariate analysis found factors significantly associated with need for additional operation included lack of CSM (odds ratio 9.2, 95% CI 2.8-30.5, p = 0.0003), larger extent of intraductal component (odds ratio 7.0, 95% CI 1.8-27.0, p = 0.005), and lack of directed re-excision (odds ratio 6.4, 95% CI 1.7-25.1, p = 0.007). CONCLUSIONS: CSM at time of initial partial mastectomy decreases rate of re-excision by as much as ninefold. CSM should be considered at time of initial operation to reduce the need for subsequent reoperation.

Delays in time to treatment and survival impact in breast cancer.

BACKGROUND: Time interval from diagnosis of breast cancer to treatment has been promulgated as one factor that can be used to evaluate cancer care quality. It remains controversial, however, whether a delay to treatment impacts survival. The purpose of this study was to evaluate whether delays from diagnosis to initial treatment in breast cancer impacts survival. MATERIALS AND METHODS: A retrospective review of patients undergoing breast cancer treatment between August 2005 and December 2008 in a comprehensive, multidisciplinary breast oncology program was undertaken. Two hospital systems were included: a county hospital (CH) treating a primarily minority, indigent population and a university hospital (UH) treating a primarily Caucasian, insured population. Interval to treatment, calculated from date of diagnosis to surgery, chemotherapy, or radiation treatment, and overall survival was compared between the two groups. RESULTS: A total of 1337 patients were included; 634 patients were treated in the CH and 703 in the UH. Interval to treatment was longer in the CH compared with the UH (53.4 ± 2.0 vs 33.2 ± 1.2 days; mean ± standard error of the mean [SEM], P < .0001). Patients treated at the CH had overall worse survival (P = .02); however, this difference did not hold true when controlled for stage. Additionally, when time to treatment was analyzed as an individual variable for all patients, there was no impact on survival. CONCLUSIONS: Interval from diagnosis to treatment of breast cancer within the same cancer center was longer at the CH than the UH. There was, however, no effect on overall survival. Time to treatment may not be a meaningful indicator of cancer care quality.

Experience with seed localization for nonpalpable breast lesions in a public health care system.

BACKGROUND: Seed localization uses a radioactive source to identify nonpalpable breast lesions for excision; it is an emerging alternative to wire localization (WL). Previous single health system studies report decreased rates of re-excision and improved patient convenience with this technique. This study is the first to implement this procedure in a public health care delivery system composed of a primarily minority and low-income population. MATERIALS AND METHODS: A multidisciplinary team was formed to create a protocol for breast seed localization (BSL) and monitor the results. After 50 seed localizations were successfully completed, a retrospective matched-pair analysis with patients who had undergone WL during the same period was performed. RESULTS: Overall experience with the BSL protocol is reviewed, along with the occurrence of a seed loss. Processes necessary to reactivate the BSL protocol and prevent future losses are delineated. BSL is associated with decreased rates of re-excision and can be successfully implemented in a public health care system. CONCLUSIONS: BSL is an attractive alternative to WL in a high-volume, county-based population. It allows increased efficiency in the operating room and has a low rate of complications. Cautionary measures must be taken to ensure proper seed chain of custody to prevent seed loss.

Axillary staging by percutaneous biopsy: sensitivity of fine-needle aspiration versus core needle biopsy.

BACKGROUND: We sought to determine whether percutaneous core needle biopsy (CNB) of suspicious axillary lymph nodes in patients with breast cancer offers improved diagnostic accuracy compared with fine-needle aspiration (FNA). METHODS: Records of 400 patients were reviewed to identify patients undergoing ultrasound-guided biopsy followed by surgical axillary evaluation (sentinel lymph node biopsy or axillary lymph node dissection). Patients underwent diagnosis and treatment at a single high-volume county hospital. Data collected included demographics, treatment, biopsy, and surgical pathology. Percutaneous biopsy results were compared with results of sentinel lymph node biopsy or axillary lymph node dissection. RESULTS: Forty-seven patients met final study criteria. Twenty-two patients underwent FNA, and 25 underwent CNB. Sensitivity of FNA was 75% vs. 82% for CNB. Specificity for both was 100%. Additionally, a cost comparison of CNB versus FNA revealed CNB to be $404; FNA cost was $237. CONCLUSIONS: The current data do not support the routine use of CNB over FNA for preoperative axillary staging in breast cancer patients with clinically negative axillas. Additionally, the substantial increase in cost without a marked improvement in sensitivity may favor the performance of FNA.

Prediction of post-operative necrosis after mastectomy: a pilot study utilizing optical diffusion imaging spectroscopy.

INTRODUCTION: Flap necrosis and epidermolysis occurs in 18-30% of all mastectomies. Complications may be prevented by intra-operative detection of ischemia. Currently, no technique enables quantitative valuation of mastectomy skin perfusion. Optical Diffusion Imaging Spectroscopy (ViOptix T.Ox Tissue Oximeter) measures the ratio of oxyhemoglobin to deoxyhemoglobin over a 1 x 1 cm area to obtain a non-invasive measurement of perfusion (StO2). METHODS: This study evaluates the ability of ViOptix T.Ox Tissue Oximeter to predict mastectomy flap necrosis. StO2 measurements were taken at five points before and at completion of dissection in 10 patients. Data collected included: demographics, tumor size, flap length/thickness, co-morbidities, procedure length, and wound complications. RESULTS: One patient experienced mastectomy skin flap necrosis. Five patients underwent immediate reconstruction, including the patient with necrosis. Statistically significant factors contributing to necrosis included reduction in medial flap StO2 (p = 0.0189), reduction in inferior flap StO2 (p = 0.003), and flap length (p = 0.009). CONCLUSION: StO2 reductions may be utilized to identify impaired perfusion in mastectomy skin flaps.

Sentinel lymph node biopsy followed by delayed mastectomy and reconstruction.

BACKGROUND: The role of sentinel lymph node (SLN) biopsy with total mastectomy is evolving. In patients who desire mastectomy with immediate reconstruction, the final pathologic results of the SLN may create unique problems. Specifically, if the SLN is found to be positive on final pathology, the reconstructed patient would generally require a potentially difficult re-operation on the remaining axillary nodes. The purpose of this study was to review the results of patients who underwent an initial SNL biopsy followed by a planned mastectomy and reconstruction. METHODS: A chart review of patients who underwent staged SLN biopsy with subsequent definitive procedure between 1997 and 2001 was conducted. These were evaluated with regard to type of tumor, status of sentinel node, and design of subsequent operation. RESULTS: There were 40 patients who underwent an initial SLN biopsy followed by a staged mastectomy with reconstruction. Tumors included high-grade carcinoma in situ (n = 4), infiltrating ductal carcinoma (n = 28), invasive lobular carcinoma (n = 4), mucinous carcinoma (n = 1), adenoid cystic carcinoma (n = 1), and mixed ductal and lobular carcinoma (n = 2). Tissue biopsy was obtained by either open (n = 9) or needle (n = 31) technique. Twenty-five patients had a negative SLN biopsy and a delayed total mastectomy with immediate reconstruction. Positive SLNs were identified in 15 patients (37%). Eight patients had macroscopic nodal metastases and underwent a delayed modified radical mastectomy and immediate reconstruction. Seven patients had microscopic nodal metastases and 3 declined further axillary dissection. They proceeded with total mastectomy and immediate reconstruction. CONCLUSIONS: These data suggest that a substantial proportion of patients treated with SLN biopsy, simple mastectomy, and reconstruction will have positive sentinel lymph nodes. Thus, the ideal approach for patients who wish to have reconstruction should involve an initial SLN biopsy as a separate procedure. If the SLN is benign, the patient may undergo a total mastectomy with immediate reconstruction. However, a patient with a positive SLN may proceed to a modified radical mastectomy with immediate reconstruction. This treatment algorithm eliminates a potentially difficult reoperation on the axilla following reconstruction.

Identification of breast cancer DNA methylation markers optimized for fine-needle aspiration samples.

BACKGROUND: Random periareolar fine-needle aspiration (RP-FNA) is increasingly used in trials of breast cancer prevention for biomarker assessments. DNA methylation markers may have value as surrogate endpoint biomarkers, but this requires identification of biologically relevant markers suitable for paucicellular, lymphocyte-contaminated clinical samples. METHODS: Unbiased whole-genome 5-aza-2'-deoxycytidine (5AZA)-induced gene expression assays, followed by several phases of qualitative and quantitative methylation-specific PCR (MSP) testing, were used to identify novel breast cancer DNA methylation markers optimized for clinical FNA samples. RESULTS: The initial 5AZA experiment identified 453 genes whose expression was potentially regulated by promoter region methylation. Informatics filters excluded 273 genes unlikely to yield useful DNA methylation markers. MSP assays were designed for 271 of the remaining genes and, ultimately, 33 genes were identified that were differentially methylated in clinical breast cancer samples, as compared with benign RP-FNA samples, and never methylated in lymphocytes. A subset of these markers was validated by quantitative multiplex MSP in extended clinical sample sets. Using a novel permutation method for analysis of quantitative methylation data, PSAT1, GNE, CPNE8, and CXCL14 were found to correlate strongly with specific clinical and pathologic features of breast cancer. In general, our approach identified markers methylated in a smaller subpopulation of tumor cells than those identified in published methylation array studies. CONCLUSIONS: Clinically relevant DNA methylation markers were identified using a 5AZA-induced gene expression approach. IMPACT: These breast cancer-relevant, FNA-optimized DNA methylation markers may have value as surrogate endpoint biomarkers in RP-FNA studies.

Influence of surgical technique on mastectomy and reexcision rates in breast-conserving therapy for cancer.

Introduction. Breast conserving surgery (BCS) requires tumor excision with negative margins. Reexcision rates of 30-50% are reported. Ultrasound localization, intraoperative margin pathology, and specimen mammography have reduced reexcisions, but require new equipment. Cavity shave margin (CSM) is a technique, utilizing existing equipment, that potentially reduces reexcision. This study evaluates CSM reexcision impact. Methods. 522 cancers treated with BCS were reviewed. Patients underwent standard partial mastectomy (SPM) or CSM. Data collected included demographics, pathology, and treatments. Results. 455 SPMs were compared to 67 CSMs. Analysis revealed no differences in pathology, intraductal component, or neoadjuvant chemotherapy. Overall reexcision rate = 43%. Most reexcisions were performed for DCIS at margin. SPMs underwent 213 reexcisions (46.8%), versus 16/67 (23.9%) CSMs (P = 0.0003). Total mastectomy as definitive procedure was performed after more SPMs (P = 0.009). Multivariate analysis revealed CSM, % DCIS, tumor size, and race to influence reexcisions. Conclusions. CSM is a technique that reduces reexcisions and mastectomy rates.

Predictors for nonsentinel node involvement in breast cancer patients with micrometastases in the sentinel lymph node.

Sentinel lymph node (SLN) biopsy in breast cancer allows for a more thorough pathologic assessment with serial sectioning and cytokeratin staining. This has resulted in increased detection of micrometastatic disease (tumor size < 2 mm) in the SLN. Unfortunately, the value of completion axillary dissection after finding micrometastatic disease in the SLN remains poorly defined. Over a 2-year period, a prospective database of 305 patients who underwent SLN biopsy for breast cancer at Baylor University Medical Center was reviewed. Eighty-four (27.5%) of the patients had evidence of metastatic disease in the SLN. Twenty-four of the 41 patients identified as having micrometastatic disease in the SLN underwent completion axillary lymph node dissection. In these patients, all nonsentinel nodes were further studied by serial sectioning and immunohistochemistry. The median age of these 24 patients was 52 years (range, 34-83). Their primary tumor stages were T1a and T1b (n = 5), T1c (n = 15), and T2 (n = 4). A total of 328 nonsentinel lymph nodes were examined, including 225 from patients with infiltrating ductal carcinoma (n = 17) and 103 from patients with infiltrating lobular carcinoma (n = 7). In the patients with infiltrating ductal carcinoma, no additional nodal metastases were identified, while in those with infiltrating lobular carcinoma, additional nodal disease was found in 5 lymph nodes (2 of 12 patients, 17%). Primary tumor characteristics were not predictive of additional nodal disease. These data suggest that patients with micro-metastasis in the SLN from infiltrating lobular carcinoma have a significant risk of harboring additional nodal disease and should undergo completion axillary dissection. However, those with micrometastatic disease from infiltrating ductal carcinoma have a very low incidence of additional metastasis and may not need completion axillary dissection.