A New Convenient Incision Model of the Nipple-Sparing Mastectomy: Lateralized Parabolic Multiplanar Incision.

BACKGROUND: In this study, a lateralized parabolic multiplanar incision was defined. It was aimed to reduce necrosis in the nipple-areola complex (NAC) and, in the long run, to prevent the scar from pulling the areola laterally by maintaining healthy skin tissue between the scar and the areola and preserving the natural round appearance of the areola. Moreover, we purposed the scar not to be visible from the anterior view. METHODS: The study included 243 patients who underwent nipple-sparing mastectomy and immediate implant-based breast reconstruction. The incision was made 4-5 cm away from the lateral border of the NAC. The incision was completed after passing the anterior axillary line by drawing a parabolic curve in superolateral axis. RESULTS: The mean follow-up period was 24.6 months, and the mean age of the patients was 42.3 years. Full-thickness necrosis of the NAC occurred in 3.6% of breasts. In long-term follow-ups, the incision scar measured an average length of 8.6 cm. None of the patients had lateral displacement of the NAC. The NAC preserved its round appearance, except for 12 breasts that had full-thickness NAC necrosis. Ten breasts had an unnatural breast appearance. CONCLUSION: The lateralized parabolic multiplanar incision is an ideal incision model for nipple-sparing mastectomy, as it allows for the exposure and reconstruction of all breast quadrants. We maintain areolar circulation; there are no visible scars when viewed anteriorly. Furthermore, it prevents lateral displacement of the NAC, ensuring that the natural round form of the NAC is not distorted. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Local steroid injection in severe idiopathic granulomatous mastitis as a new first-line treatment modality with promising therapeutic efficacy.

Background: Intralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM. Methods: Fifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone (n = 25) or combined LSI with systemic oral steroid treatment (OST) (n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg). Results: Patients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4-42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group (p < 0.008). Conclusion: Local steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

Assessment High-Risk Breast Cancer in Older Patients: A Comparative Analysis of PREDICT Scores and TAILORx Risk Categorization.

Objective: This study aimed to evaluate the relationship between PREDICT tool overall survival (OS) scores and high-risk patients according to TAILORx risk categorization in elderly hormone reseptor (HR) positive human epidermal growth factor negative early breast-cancer patients. Materials and Methods: We conducted a retrospective study, extracting data from medical records of 64 patients diagnosed with breast cancer. A retrospective analysis was performed on all patients who had Oncotype Dx Recurrence Scores across five medical centers between 2017 and 2022. PREDICT scores were defined as calculated 10-year OS rates via PREDICT tool. Results: The median age of the patients was 67, with a range between 65-75 years. Low-risk patients had a slightly higher two PREDICT scores compared to high-risk patients (78% vs. 73%), (81% vs. 77%), which were statistically significant. The progesterone receptor (PR) level was significantly lower in the high-risk group (3.5% vs. 80%). A unit decrease in the PREDICT scores was associated with a 11% increase in the odds of being in the high-risk group. However, these effects weren't statistically significant in the multivariate analysis. A unit decrease in the PR level was significantly associated with increased odds (by 5% in the multivariate analysis) of being in the high-risk group. Conclusion: Our study underscores the importance of using a combination of tools, including the PREDICT tool, PR levels, and TAILORx risk categorization, for a comprehensive risk assessment in these patients, especially in the older population. Accurate risk assessment is crucial for tailoring the treatment and optimizing outcomes in this vulnerable population. Future studies are warranted to further validate these findings in larger cohorts and to explore additional biomarkers and genomic signatures that may aid in the risk assessment and management of breast cancer in older patients.

Sentinel lymph node biopsy after nipple-sparing mastectomy in early postoperative period: Is it feasible?

Background: Axillary lymph node status is one of the most important prognostic factors for breast cancer. Sentinel lymph node biopsy (SLNB) after mastectomy is highly controversial. There is not enough data about SLNB in the early period after nipple-sparing mastectomy (NSM). This study investigated the feasibility of SLNB in the early postoperative period of NSM. Materials and Methods: Patients who were operated on for breast cancer in Acibadem Maslak Hospital between 2009 and 2018 were searched retrospectively. Results of SLNB as the second session in patients whose final pathology report revealed breast carcinoma after contralateral/bilateral prophylactic mastectomy and mastectomy for benign lesions were evaluated. Results: In the early period (median 14 days) after NSM, SLNB was performed by intradermal radioisotope injection in five patients with occult breast cancer in contralateral/bilateral prophylactic mastectomy and in one patient with preoperatively suspicious mass which yielded breast cancer at final pathology. In five (80%) patients, SLNB was performed, whereas in one patient axillary lymph node dissection (ALND) was performed due to the undetectability of SLN. In one patient, micrometastasis was observed, whereas no metastasis was observed in other patients including the one who underwent ALND. No complication due to SLNB was detected. No recurrence and distant metastasis were detected in a mean follow-up of 42.82 (19-70) months. While SLNB did not change the treatment of patients with contralateral occult carcinoma, other patients had hormonal therapy due to negative SLNB. Conclusion: SLNB in the early postoperative period of NSM can be performed by intradermal radioisotope injection. However, further studies are needed to determine the feasibility of SLNB in the early postoperative period of NSM.

Survival results according to Oncotype Dx recurrence score in patients with hormone receptor positive HER-2 negative early-stage breast cancer: first multicenter Oncotype Dx recurrence score survival data of Turkey.

Background: The Oncotype Dx recurrence score (ODx-RS) guides the adjuvant chemotherapy decision-making process for patients with early-stage hormone receptor-positive, HER-2 receptor-negative breast cancer. This study aimed to evaluate survival and its correlation with ODx-RS in pT1-2, N0-N1mic patients treated with adjuvant therapy based on tumor board decisions. Patients and methods: Estrogen-positive HER-2 negative early-stage breast cancer patients (pT1-2 N0, N1mic) with known ODx-RS, operated on between 2010 and 2014, were included in this study. The primary aim was to evaluate 5-year disease-free survival (DFS) rates according to ODX-RS. Results: A total of 203 eligible patients were included in the study, with a median age of 48 (range 26-75) and median follow-up of 84 (range 23-138) months. ROC curve analysis for all patients revealed a recurrence cut-off age of 45 years, prompting evaluation by grouping patients as ≤45 years vs. >45 years. No significant difference in five-year DFS rates was observed between the endocrine-only (ET) and chemo-endocrine (CE) groups. However, among the ET group, DFS was higher in patients over 45 years compared to those aged ≤45 years. When stratifying by ODx-RS as 0-17 and ≥18, DFS was significantly higher in the former group within the ET group. However, such differences were not seen in the CE group. In the ET group, an ODx-RS ≥18 and menopausal status were identified as independent factors affecting survival, with only an ODx-RS ≥18 impacting DFS in patients aged ≤45 years. The ROC curve analysis for this subgroup found the ODx-RS cut-off to be 18. Conclusion: This first multicenter Oncotype Dx survival analysis in Turkey demonstrates the importance of Oncotype Dx recurrence score and age in determining treatment strategies for early-stage breast cancer patients. As a different aproach to the literature, our findings suggest that the addition of chemotherapy to endocrine therapy in young patients (≤45 years) with Oncotype Dx recurrence scores of ≥18 improves DFS.

Implant selection in natural and stable direct-to-implant reconstruction with ten steps at nipple-sparing mastectomy.

Direct-to-implant reconstruction is one of the breast repair techniques after mastectomy. Implant selection is critical in the short- and long-term success of direct-to-implant reconstruction after nipple-sparing mastectomy. In this study we developed a 10-step algorithm that we use before and during surgery. We aimed to obtain natural and stable breast reconstruction with this algorithm. In addition, we also aimed to evaluate which implants were selected using this algorithm and their short- and long-term outcomes. This retrospective study included 218 patients aged 27 to 60 years who underwent mastectomy and direct-to-implant reconstruction between November 2018 and December 2021. The patients were assigned into 4 groups according to amount of breast tissue removed. We developed a 10-step algorithm and these included: breast base, amount of breast tissue removed, evaluation of mastectomy skin flap, breast projection, ptosis, unilateral/bilateral reconstruction, chest wall deformity, patient's request, comorbid conditions and stabilization and arrangement of novel sulcus. The evaluation was made when the patient's photographs were taken at least 1 year after the surgery. The highest number of patients was recorded in group 3; in addition, mean age was also highest in group 3. The lowest number of patients was recorded in group 4. The body mass index showed a progressive increase from group 1 to group 4. Medium height moderate profile prosthesis was used in 81.7% while medium height moderate plus profile prosthesis was used in 18.3% of breasts included. We used larger prosthesis up to 58.1% when compared to the tissue removed in group 1 while we used smaller prosthesis by 25.6% in group 4. In the anterior view, the medial and lateral arch of the lower pole of the breast was obtained in all patients. Obvious asymmetry developed in 4 patients. In lateral and oblique views, upper and lower pole natural breast images were obtained in all patients, except for 5 patients. There was no sulcus inferior displacement in any patient. Implant extrusion did not occur in any patient. This algorithm is an easy to use and effective method to obtain a stable and natural breast image in the long-term.

Adherence to adjuvant tamoxifen and associated factors in breast cancer survivors.

PURPOSE: Adjuvant endocrine therapy reduces the recurrence and mortality of early hormone receptor-positive breast cancer in both pre- and postmenopausal women. The aim of this study was to investigate adjuvant tamoxifen adherence and associated factors in breast cancer survivors. METHODS: This descriptive, prospective study was conducted in 2019-2020 with the participation of 531 women who survived breast cancer and were under follow-up at the Senology Institute of a hospital in Istanbul. Inclusion criteria were having completed treatment for early hormone receptor-positive breast cancer, being prescribed tamoxifen, and being 18 years or older. Data were collected using a patient information form and the Morisky Medication Adherence Scale-8 (MMAS-8). RESULTS: The mean age of the participants was 44.9 ± 6.5 years, and the mean duration of tamoxifen use was 834.4 ± 685.7 days. The women's mean MMAS-8 score was 6.86 ± 1.39. Medication adherence was significantly positively correlated with current age (p = 0.006) and age at diagnosis (p = 0.002). There was a statistically significant difference between tamoxifen adherence according to participants' employment status (p = 0.028), chronic disease status (p = 0.018), loss of libido (p = 0.012), treatment-related changes in mood changes (p = 0.004), and having negative effects affecting daily life (p < 0.001). CONCLUSION: Overall, breast cancer survivors in this study reported moderate adherence to tamoxifen. The women's individual characteristics and the adverse effects of treatment influenced medication adherence. Healthcare professionals can help increase adherence to this treatment, which reduces the risk of mortality, by explaining the importance of the medication, identifying and eliminating barriers to adherence, and informing women about evidence-based interventions to increase medication compliance.

Comparison of mammography and ultrasound findings in the follow-up of patients with breast cancer treated with segmental mastectomy followed by intraoperative electron radiotherapy versus external whole breast radiotherapy

PURPOSE: This study aims to describe imaging findings in patients treated with intraoperative electron radiotherapy and compare them with those detected in patients treated with external whole breast radiotherapy (WBRT). METHODS: The study population consisted of 25 patients who received intraoperative radiotherapy [IORT (21 Gy)] as single-dose radiotherapy and a control group of 25 patients who received WBRT at the same institution. Mammography and ultrasound (US) findings were divided into three groups: minor, intermediate, and advanced. On mammography, mass lesions were considered advanced, and asymmetries or architectural distortions were considered intermediate. Oil cysts, linear scars, and the increase in parenchymal density were considered minor findings. On US, irregular non-mass lesions were considered advanced, and circumscribed hypoechoic lesions or planar irregular scars with shadowing were considered intermediate. Oil cysts, fluid collections, or linear scars were considered minor findings. RESULTS: On mammography, skin thickening (P = 0.001), edema (P < 0.001), increased parenchymal density (P < 0.001), dystrophic calcifications (P = 0.045), and scar/distortion (P = 0.005) were significantly more common in the WBRT group. On US, irregular non-mass lesions, which made interpretation considerably difficult, were significantly more common in the IORT group (P = 0.004). Dominant US findings were fluid collections and postoperative linear or planar scars in the WBRT group. Minor findings were more common in low-density breasts, and major findings (intermediate and advanced) were more common in high-density breasts on both mammographies (P = 0.011) and US (P = 0.027) in the IORT group. CONCLUSION: Ill-defined non-mass lesions detected on US in the IORT group have not been defined previously. Radiologists should be aware of these lesions because they can be confusing, especially in early follow-up studies. This study has found that minor findings are seen more frequently in low-density breasts, while major findings are more common in high-density breasts in the IORT group. This has not been reported before, and further studies with more cases are needed to verify these results.

Favorable locoregional control in clinically node-negative hormone-receptor positive breast cancer with low 21-gene recurrence scores: a single-institution study with 10-year follow-up.

BACKGROUND: Recent studies have shown a lower likelihood of locoregional recurrences in patients with a low 21-gene recurrence score (RS). In this single-institution study, we investigated whether there are any associations between different cutoff values of 21-gene RS, histopathological factors, and outcome in patients with long-term follow-up. METHODS: The study included 61 patients who had early-stage (I-II) clinically node-negative hormone receptor-positive and HER2-negative breast cancer and were tested with the 21-gene RS assay between February 2010 and February 2013. Demographic, clinicopathological, treatment, and outcome characteristics were analyzed. RESULTS: The median age was 48 years (range, 29-72 years). Patients with high histologic grade (HG), Ki-67 ≥ 25%, or Ki-67 ≥ 30% were more likely to have intermediate/high RS (≥ 18). Based on the 21-gene RS assay, only 19 patients (31%) received adjuvant chemotherapy. At a median follow-up of 112 months, 3 patients developed locoregional recurrences (4.9%), which were treated with endocrine therapy alone. Among patients treated with endocrine treatment alone (n = 42), the following clinicopathological characteristics were not found to be significantly associated with 10-year locoregional recurrence free survival (LRRFS): age < 40 years, age < 50 years, high histological or nuclear grade, high Ki-67-scores (≥ 15%, ≥ 20%, ≥ 25%, ≥ 30%), presence of lymphovascular invasion, luminal-A type, multifocality, lymph node positivity, tumor size more than 2 cm, RS ≥ 18, and RS > 11. However, patients with RS ≥ 16 had significantly poorer 10-year LRRFS compared to those with RS < 16 (75% vs. 100%, respectively; p = 0.039). CONCLUSIONS: The results suggest that patients with clinically node-negative disease and RS ≥ 16 are more likely to benefit from adjuvant chemotherapies. However, those with RS < 16 have an excellent outcome and local control in long-term follow-up with endocrine treatment alone.

Do prognosis and clinicopathological features differ in young early-stage breast cancer?

Background: Breast cancer is the most frequently detected cancer and the leading cause of cancer-related death in women. Although it is mostly seen in older patients, breast cancer affects women aged 24 to >70 years, with poorer prognosis in young patients. Young age remains a controversial topic in the literature. This study aimed to identify subtype differences and the effect of age on early-stage breast cancer outcomes. Methods: A total of 300 consecutive patients underwent surgery between 2011 and 2015 for early-stage breast cancer. Of these, 248 were eligible for this study and were divided into three groups: group Y (aged ≤35 years), group M (aged >35 and ≤45 years), and group E (aged >45 years). The clinical and pathological features and data related to recurrence, metastasis, and death were recorded. Results: No statistical differences were found between groups regarding histopathological features except for higher histological grade and Ki-67 levels in group M. Additionally, group Y recorded no progression (recurrence or metastasis) or death. Disease-free survival was 117.8 months (95% CI 111.8-123.8) for group M, which was significantly shorter than that for group E (p < 0.001). Additionally, the hazard ratio (HR) for progression from group M to group E was 10.21 with significant difference (p = 0.003, 95% CI 2.26-46.08). However, the HR of group Y to group E was 0.04, without significance (p = 0.788, 95% CI 0.18-345 × 106). The overall 5-year survival was 100% in group Y, 98.8% in group M, and 99.3% in group E, without significance. Conclusion: A very young age cannot be considered an independent risk factor for poor prognosis. Rather than age, histological grade and Ki-67 index are more important factors in early-stage breast cancer.

Impact of preoperative PET/CT for axillary staging in patients with early breast cancer.

BACKGROUND: Preoperative evaluation of axillary lymph node status is very important for the choice of primary treatment in breast cancer. This study assessed predictive properties of positron emission tomography-computerized tomography for axillary lymph node metastasis. METHODS: Patients who were operated between 2014-2019 for early breast cancer and who had preoperative positron emission tomography-computerized tomography images were included. Positron emission tomography-computerized tomography results and histopathologic results were compared retrospectively. RESULTS: Medical records of 223 patients who were operated for early breast cancer and have had positron emission tomography-computerized tomography were evaluated. positron emission tomography-computerized tomography revealed that axillary lymph node status is positive in 97 patients and negative in 126 patients. In histopathological examination, tumor cells were found in 86 patients, of those 27 were negative while 59 were positive in positron emission tomography-computerized tomography. Furthermore, 137 patients were free from tumor cells, in which 99 were negative and 38 were positive in positron emission tomography-computerized tomography. Positive and negative predictive value of positron emission tomography-computerized tomography for metastatic axillary lymph nodes were found 60.8% and 78.5%, respectively. CONCLUSIONS: Clinically, positron emission tomography-computerized tomography has low negative predictivity for determination of axilla in early stage or operable breast cancer. Even though it is valuable for the systematic scanning, positron emission tomography-computerized tomography can be overlooked for axillary evolution. KEY WORDS: Axilla, Breast Cancer, Cancer Staging, PET-CT.

Has the COVID-19 Pandemic Affected Breast Cancer Stage and Surgical Volume?

BACKGROUND: This study investigates the effects of COVID-19 on the breast cancer stage and the volume of breast cancer surgery in a specialized breast institute. METHODS: Data of 332 patients who were diagnosed and treated for breast cancer between December 2019 and November 2020 were evaluated retrospectively according to periods of pandemic. RESULTS: A significant decrease in the number of operations, especially upfront surgeries rather than surgeries after neoadjuvant chemotherapy, was detected in the early period of the COVID-19 pandemic. It was found that patients with complaints were mostly admitted during this period (p = 0.024). No statistical significance was found for age, sex, side of the tumor, type of tumor, surgery to breast, and axilla. Following the early period of the pandemic, it was observed that patients with mostly luminal, early-stage, and less axillary nodal involvement (p < 0.05) were admitted, and as a result, it was founded that upfront surgeries increased, although no change in TNM staging was observed. However, it did affect the decision of initial treatment. Thus, the number of upfront surgeries was significantly higher than the NCT group (p = 0.027) following the early period. CONCLUSION: Surgical volume is significantly affected in the early period of the COVID-19 pandemic. To overcome overload due to delayed surgeries related to pandemics, some hospitals should be spared for oncological treatments. Following the early period, mostly luminal type, early-stage patients were admitted, probably because of increased self-awareness and short wave duration, but the breast cancer stage was not affected.

Detachment and embolization of totally implantable central venous access devices: diagnosis and management.

BACKGROUND: Detachment and embolization (DE) is a rare complication of totally implantable central venous access devices (TIVADs). This study aimed to analyze clinical findings, etiology, and treatment options in DE of TIVADs. METHODS: Patients who experienced DE between 2010-2019 were included. Indications, implantation techniques, time to diagnosis, patient complaints, diagnostic methods, rupture site, location of embolization, treatment methods, and chest X-rays prior to detachment were analyzed retrospectively. RESULTS: DE of TIVAD was detected in 12(1.2%) patients. Eleven patients had breast cancer and one had colon cancer. Mean age at implantation was 45.3 ± 9.6(31-61.3) years. Seven (58%) patients were asymptomatic, four (33.3%) had TIVAD malfunction, and one (8.3%) had pain and swelling at port site after injection. Mean time from implantation to diagnosis was 1149.92(16-2795) days. The etiologies comprised Pinch-off Syndrome (POS) in eight (66%) patients, detachment directly adjacent to the lock mechanism in three (25%) patients, and probable iatrogenic injury during explantation in one (9%) patient. The most common site of embolism was the superior vena cava (25%). While the embolized fragment was removed percutaneously in 11 patients, medical follow-up was treatment choice for one patient. CONCLUSIONS: DE is a rare complication with an incidence rate of 1.2% in this study. Since most patients were asymptomatic, chest radiography plays an important role in diagnosis. The most common cause was POS, and it can be prevented by inserting the catheter from lateral third of the clavicle during subclavian vein catheterization. The first-choice treatment was percutaneous femoral retrieval. However, if not technically possible, alternative treatment options are thoracotomy or follow-up with anticoagulant therapy.

Transmesocolic approach in laparoscopic complete mesocolic excision for right sided colon cancers.

Introduction: A mesocolic plane, central vascular ligation (CVL) and proper proximal-distal margins are the essential components of complete mesocolic excision (CME). In the transmesocolic approach, we identify the middle colic vessels and enter the lesser sac through the mesocolon for ascending colon and caecum tumors. Aim: To investigate the feasibility and identify the technical details of this technique. Material and methods: The clinical and pathological findings of 26 patients who had undergone laparoscopic right hemicolectomy with CME between 2010 and 2020 were collected retrospectively. All operation videos were recorded and reviewed by the authors with regard to the components of CME. In the transmesocolic approach, dissection starts with identification of the middle colic vessels directly. After division of the middle colic vessels, we enter the omental bursa and dissection continues from superior to inferior direction. Results: There were 26 patients in the study. The mean age was 59.3 ±16.1. There were 15 female and 11 male patients with a mean body mass index of 25.9 ±16.1 kg/m2. The mean operative time was 137.6 ±19.4 min. The mean length of hospital stay and the time to first flatus were 7.5 ±4.6 days and 2.3 ±1.5 days, respectively. None of the patients were re-admitted to the hospital in 30 days. There was no 30-day mortality in the patients. There were no major complications. Conclusions: The transmesocolic approach seems to be feasible and safe for CME in right sided colon cancers. However, more prospective randomized studies are needed to use the transmesocolic approach as a standard technique.

Comparison of PET-CT and MRI for evaluation of axillary lymph nodes in early breast cancer patients.

BACKGROUND: Evaluation of axillary lymph node in women with breast cancer is very important as it can change the initial treatment decision. None of the noninvasive methods used for assessment of axilla is accurate as sentinel lymph node biopsy (SLNB) yet. This study compared the diagnostic performance of 18-fluorodeoxyglucose positron emission tomography/ computed tomography (PET-CT) and Dynamic Contrast-Enhanced Magnetic Resonance Imaging (DCE-MRI) in preoperative axillary evaluation of women diagnosed with early breast cancer (EBC). METHODS: The records of 1246 patients operated for EBC between 2016-2019 were analyzed retrospectively. Pathological evaluations of axillary lymph nodes and the data of these two imaging modalities were analyzed. RESULTS: Forty patients operated for EBC had both DCE-MRI and PET-CT. Axillary metastasis were detected in 12 patients (27.5%). Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of DCE-MRI/ PET-CT for determining axillary lymph node metastases were 25/66.6%, 75/67.8%, 30/47%, 70/82.6%, and 60/67.5%, respectively. DISCUSSION: Any method has yet reached the performance of sentinel lymph node biopsy in the axillary mapping of patients with EBC. If a clinically EBC patient is suspected of axillary involvement in DCE-MRI or PET-CT (since have low PPV and sensitivity), a biopsy should be performed. KEY WORDS: Breast Cancer, Magnetic Resonance Imaging, Positron Emission Tomography, Staging.

The Effect of Primary Surgery in Patients with De Novo Stage IV Breast Cancer with Bone Metastasis Only (Protocol BOMET MF 14-01): A Multi-Center, Prospective Registry Study.

BACKGROUND: More evidence shows that primary surgery for de novo metastatic breast cancer (BC) prolongs overall survival (OS) in selected cases. The aim of this study was to evaluate the role of locoregional treatment (LRT) in BC patients with de novo stage IV bone only metastasis (BOM). METHODS: The prospective, multicenter registry study BOMET MF14-01 was initiated in May 2014. Patients with de novo stage IV BOM BC were divided into two groups: those receiving systemic treatment (ST group) and those receiving LRT (LRT group). Patients who received LRT were further divided into two groups: ST after LRT (LRT + ST group) and ST before LRT (ST + LRT group). RESULTS: We included 505 patients in this study; 240 (47.5%) patients in the ST group and 265 (52.5%) in the LRT group. One hundred and thirteen patients (26.3%) died in the 34-month median follow-up, 85 (35.4%) in the ST group and 28 (10.5%) in LRT group. Local progression was observed in 39 (16.2%) of the patients in the ST group and 18 (6.7%) in the LRT group (p = 0.001). Hazard of death was 60% lower in the LRT group compared with the ST group (HR 0.40, 95% CI 0.30-0.54, p < 0.0001). CONCLUSION: In this prospectively maintained registry study, we found that LRT prolonged survival and decreased locoregional recurrence in the median 3-year follow-up. Timing of primary breast surgery either at diagnosis or after ST provided a survival benefit similar to ST alone in de novo stage IV BOM BC patients.

The role of loco-regional treatment in long-term quality of life in de novo stage IV breast cancer patients: protocol MF07-01Q.

BACKGROUND/OBJECTIVE: Since more solid evidence has emerged supporting the effectiveness of loco-regional treatment (LRT), clinicians consider LRT a treatment option for selected de novo stage IV breast cancer (BC) patients. This is the first report on long-term quality of life (QoL) in a cohort of patients who were randomized to receive either LRT and then systemic treatment (ST) or ST alone in the protocol MF07-01. We aimed to evaluate QoL in patients living at least 3 years since randomization using scores from the SF-12 health survey. METHODS: SF-12 (V2) forms were completed during visits of patients who were living 36 months after the randomization. We first calculated PCS-12 (Physical Health Composite Scale) and MCS-12 (Mental Health Composite Scale) scores from de novo stage IV BC patients and compared them with the scores of patients diagnosed with stage I-III BC who lived more than 3 years. Further, PCS-12 and MCS-12 scores were compared between the LRT and ST groups with de novo stage IV BC. Additionally, general health, physical functioning, role functioning, bodily pain, vitality, mental health, and social functioning were evaluated and compared between the groups. Considering age-related changes in QoL, we also compared PCS-12 and MCS-12 scores of patients below or above 55 and 65 years of age. Responses to four additional questions (compare your physical health, mental health, daily activities, and energy currently vs. at diagnosis of BC) were recorded, considering cultural differences. RESULTS: There were 81 patients in this analysis; 68% of patients (n = 55) had LRT, and 32% (n = 26) received ST. General health was good or very good in 62% (n = 34) in the LRT group and 66% (n = 17) in the ST-only group (p = 0.63). Mean PCS-12 score was 40.8 + 1.6, and mean MCS-12 score was 43.4 + 2.0 (p = 0.34 and p = 0.54, respectively). PCS-12 and MCS-12 score difference was lower than that of the general Turkish population (PCS-12 = 49.3 + 12.8 and MCS-12 = 46.8 + 13.0) and stage I-III BC patients (PCS-12 = 51.1 ± 0.5, MCS-12 = 45.7 ± 0.6). PCS-12 and MCS-12 scores were similar between the LRT and ST-only groups in patients younger and older than 55 and 65, but QoL scores were much better in stage I-III BC patients younger than 65 when compared to the scores of those with de novo stage IV BC. Although treatment with or without LRT did not affect physical health, mental health, daily activities, and energy at 3 years vs. at diagnosis of BC in de novo stage IV BC patients (p > 0.05), these variables were significantly better in stage I-III BC patients (p < 0.001). CONCLUSION: The current MF07-01Q study demonstrates that patient who had LRT has similar physical and mental health outcomes compared to ST only in a cohort of patients who lived longer than 3 years. Trial registration This study is registered on clinicaltrials.gov with identifier number NCT00557986.

Nipple-Sparing Mastectomy and Immediate Implant-Based Reconstruction with or Without Skin Reduction in Patients with Large Ptotic Breasts: A Case-Matched Analysis.

BACKGROUND: Nipple-sparing mastectomy (NSM) and implant-based immediate breast reconstruction are becoming preferred options with improved outcomes. However, reconstruction in patients with large and ptotic breasts is challenging. When mastectomy and skin reduction are combined in a single-staged procedure, the vasculature of the skin is disturbed leading to increased complication rates. This paper aims to compare complication rates of NSM and immediate implant-based reconstruction with or without reduction to determine the safety of reduction in this patient group. METHODS: Breast cancer patients that underwent NSM and implant-based immediate breast reconstruction between November 2010 and 2018 were analyzed. All implants were placed submuscularly. Patients with skin reduction and nipple-areolar complex transposition were matched in a 1:1 fashion with patients without reduction. RESULTS: There were 50 patients (72 procedures) in each group. Demographics of the groups were similar as a part of matching process. Mean implant volume in the reduction group was higher (399.93 ± 97.54 vs. 360.21 ± 82.54, p = 0.009). Full thickness skin necrosis rate was higher in the reduction group [12/72 (%17) vs. 2/72 (3%), p = 0.009], and the most common site was over the suture line [6/12 (50%)]. Complications in the reduction group were more common in reconstructions with implant volumes greater than 500 cc (p = 0.008). CONCLUSIONS: When compared with no reduction, the skin necrosis rate of NSM and immediate implant-based reconstruction with skin reduction is higher. The described technique can only be considered in patients with moderate breast volumes, grade II-III ptosis, and when the planned implant volume is low (< 500 cc). LEVEL OF EVIDENCE: IV. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Clinical Factors Affecting the Therapeutic Efficacy of Evening Primrose Oil on Mastalgia.

BACKGROUND: Saturated fatty acid esters may cause mastalgia via hypersensitivity of breast epithelium to circulating hormones. Evening primrose oil (EPO) may restore the saturated/unsaturated fatty acid balance and decrease sensitivity to steroidal hormones or prolactin. Conflicting results exist regarding EPO treatment for mastalgia. The aim of this study was to determine the effectiveness of EPO and factors affecting its efficacy in treatment of mastalgia. METHODS: The study included 1015 patients, ages 14-82 (mean age 42.21 ± 10.8), admitted to Acibadem Breast Clinic between January 2015 and March 2018. The patients were divided into group I (n = 581) treated with EPO (1300 mg, twice a day) and group II (n = 434) treated with paracetamol (500 mg, twice a day). The visual analog scale was used to assess EPO's therapeutic efficacy, compared with paracetamol, measured at admittance, 2 weeks, and 6 weeks. Clinical factors affecting the efficacy of EPO were analyzed. RESULTS: The therapeutic efficacy of EPO on mastalgia was significantly higher than with paracetamol (p < 0.001). Factors significantly affecting the efficacy of EPO treatment were hormone replacement therapy (HRT), IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis (p < 0.01). Replacement of iron or thyroid hormone efficiently treated mastalgia in patients that did not respond to EPO treatment. Side effects (allergy, anxiety, blurred vision, constipation, and nausea) were rare and not statistically significant (p = 0.88). CONCLUSION: EPO can be used in the treatment of mastalgia without significant side effects. HRT, IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis significantly affect the efficacy of EPO on mastalgia.