The use of blue dye alone for sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with initially node-positive breast cancer.

INTRODUCTION: False-negative sentinel lymph node biopsy (SLNB) rates following neoadjuvant chemotherapy (NACT) in initially node-positive (cN1/2) breast cancer patients are high, but decrease when lymph nodes are clipped, ≥3 sentinel lymph nodes (SLN) are removed or dual-tracer localization (radioisotope and blue dye) is used. Radiotracer, however, is often unavailable and outcomes with blue dye alone are unknown. MATERIALS AND METHODS: Initially cT1-4, cN1/2 patients treated with NACT in 2013-2023 who underwent SLNB using blue dye alone were evaluated regarding SLN identification, axillary recurrence, disease-free and overall survival rates. RESULTS: Of 119 patients included, 19 remained cN1/2 after NACT. SLNB was performed using blue dye alone in 100 ycN0 cases (84%), with an identification rate of 96%. The SLN was negative in 70/119 cases (i.e. 59% avoided axillary dissection). The number of SLN detected was ≥3 in 55/70 cases (78%) (median 3.1; 1-6). Median age was 49 years (25-84). Most were T2 (n = 40, 57.1%), N1 (n = 64, 91.4%). Predominant subtypes were ERBB2 (52.9%) and triple-negative (20%). No axillary recurrence occurred over a median 36-month period. Five-year disease-free and overall survival were, respectively, 85.9% (95%CI: 74-99.8) and 96.3% (95%CI: 89.4-100). The ERBB2 subtype (1.99, 95%CI: 1.02-3.85, p = 0.04) and N1 lymph node status (2.58, 95%CI: 1.54-9.10, p = 0.03) were associated with a greater likelihood of undergoing SLNB alone without axillary dissection. CONCLUSIONS: SLNB with blue dye alone following NACT in initially cN1/2 patients avoided axillary dissection in almost 60% of cases, with no recurrences during the period evaluated. Longer follow-up studies are necessary.

Analysis of the distinct features of metastasis male breast cancer and its effect on overall survival based on the SEER database compared with female breast cancer.

Background: Male breast cancer (MBC) is a rare disease and differs from female breast cancer (FBC) in clinicopathological and immune tissue types. Given the limited research on MBC due to its rarity, an understanding of the shared and distinct features of MBC and FBC is vital for formulating efficacious treatment strategies. Methods: Data of patients diagnosed with metastatic breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database from 2012 to 2017 were analysed. Chi-square test was used to compare clinicopathological characteristics between male and female patients. Kaplan-Meier analysis was utilized to compare differences in overall survival (OS). Results: A total of 2,858 patients with MBC were studied, 134 of whom had distant metastasis. Compared with 8,698 patients with metastatic FBC, a higher proportion of metastatic MBC patients had tumors located in the center of the breast, received surgical treatment, and had bone + lung metastasis. Survival analysis revealed no difference in OS between metastatic MBC and FBC patients (P=0.27), but there was a significant difference in OS between metastatic and nonmetastatic MBC (P=0.004). Compared with metastatic FBC, MBC patients with bone metastasis alone, lung metastasis alone, liver metastasis alone, and bone + lung metastasis also had worse prognosis (P=0.021, 0.019, 0.024, 0.011, respectively). Conclusions: Metastatic MBC has unique clinicopathological disease features and patterns of metastasis. No significant difference between the survival of metastatic MBC and FBC patients was observed. Distant metastasis was an independent risk factor impacting the prognosis of MBC patients.

Sentinel lymph node biopsy following neoadjuvant chemotherapy: an evidence-based review and recommendations for current practice.

Sentinel lymph node biopsy (SLNB) at upfront surgery is the gold-standard surgical method for axillary lymph node staging in early stage breast cancer: the technique provides adequate information regarding axillary status, with similar oncological safety and lower morbidity compared to axillary dissection, despite the false negative rates. Neoadjuvant chemotherapy (NACT), traditionally used for locally advanced breast cancer, plays an important role in the treatment of early stage breast cancer, making downstaging possible in axillary lymph node and breast cancer, thus minimizing the impact of surgery and reducing morbidity, as well as enabling patients with residual disease to be selected for adjuvant treatment. In this respect, the role of SLNB has proved controversial, particularly in view of the lack of data from randomized clinical trials on this subject. Currently, the de-escalation of axillary surgery after NACT is mainly based on retrospectives studies and false negative rates. This paper reviews current evidence on the management of axillary surgery following NACT under different circumstances, with suggested recommendations in each scenario: clinically negative nodes at diagnosis and SLNB after NACT, clinically positive nodes at diagnosis and SLNB after NACT, positive SLNB following NACT and finally the possibility of omitting axillary surgery in good responders.

Oncological Outcomes of Nipple-Sparing Mastectomy in an Unselected Population Evaluated in a Single Center.

OBJECTIVE: Nipple-sparing mastectomy (NSM) has been traditionally used in selected cases with tumor-to-nipple distance > 2 cm and negative frozen section of the base of the nipple. Recommending NSM in unselected populations remains controversial. The present study evaluated the oncological outcomes of patients submitted to NSM in an unselected population seen at a single center. METHODS: This retrospective cohort study included unselected patients with invasive carcinoma or ductal carcinoma in situ (DCIS) who underwent NSM in 2010 to 2020. The endpoints were locoregional recurrence, disease-free survival (DFS), and overall survival (OS), irrespective of tumor size or tumor-to-nipple distance. RESULTS: Seventy-six patients (mean age 46.1 years) (58 invasive carcinomas/18 DCIS) were included. The most invasive carcinomas were hormone-positive (60%) (HER2 overexpression: 24%; triple-negative: 16%), while 39% of DCIS were high-grade. Invasive carcinomas were T2 in 66% of cases, with axillary metastases in 38%. Surgical margins were all negative. All patients with invasive carcinoma received systemic treatment and 38% underwent radiotherapy. After a mean of 34.8 months, 3 patients with invasive carcinoma (5.1%) and 1 with DCIS (5.5%) had local recurrence. Two patients had distant metastasis and died during follow-up. The 5-year OS and DFS rates for invasive carcinoma were 98% and 83%, respectively. CONCLUSION: In unselected cases, the 5-year oncological outcomes following NSM were found to be acceptable and comparable to previous reports. Further studies are required.

OBJETIVO: A mastectomia poupadora do complexo areolo-mamilar (MPM) tem sido tradicionalmente utilizada em casos selecionados com distância tumor-mamilo > 2 cm e biópsia de congelação da base do mamilo negativa. Recomendar MPM em populações não selecionadas continua controverso. Este estudo avaliou os resultados oncológicos de pacientes submetidas à MPM em uma população não selecionada atendida em um único centro. MéTODOS: Coorte retrospectivo incluindo pacientes não selecionadas com carcinoma invasivo ou carcinoma ductal in situ (CDIS) submetidas à MPM entre 2010 e 2020. Os desfechos incluíram: recorrência locorregional, sobrevida livre de doença (SLD) e sobrevida global (SG), independentemente do tamanho do tumor ou da distância tumor-mamilo. RESULTADOS: Setenta e seis pacientes (média: 46,1 anos de idade) (58 carcinomas invasivos/18 CDIS) foram incluídas. A maioria dos carcinomas invasivos era hormônio-positivo (60%) (superexpressão de HER2: 24%; triplo-negativo: 16%), enquanto 39% dos CDIS eram de alto grau histológico. Os carcinomas invasivos foram T2 em 66% dos casos, com metástases axilares em 38%. As margens cirúrgicas foram todas negativas. Todas as pacientes com carcinoma invasivo receberam tratamento sistêmico e 38% receberam radioterapia. Após um período médio de 34,8 meses, 3 pacientes com carcinoma invasivo (5,1%) e 1 com CDIS (5,5%) apresentaram recidiva local. Durante o acompanhamento, duas pacientes tiveram metástase à distância e vieram a óbito. As taxas de SG e SLD aos 5 anos para carcinoma invasivo foram de 98% e 83%, respectivamente. CONCLUSãO: Em casos não selecionados, os resultados oncológicos de 5 anos após MPM foram considerados aceitáveis e comparáveis a resultados anteriores. Estudos adicionais são necessários.

Management of early-stage triple-negative breast cancer: recommendations of a panel of experts from the Brazilian Society of Mastology.

BACKGROUND: Triple-negative breast cancer (TNBC) is a heterogenous subtype involving different patterns of behavior and clinical course, demanding a complex, individualized sequence of treatment. The knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology regarding TNBC were evaluated and a consensus regarding management and treatment was reached. METHODS: Affiliates completed a survey involving 44 objective questions. In addition, a specialist meeting was held with 27 experts and 3 ad hoc consultants. The panelists completed the survey before and after brainstorming. Answers achieving 70% of agreement were considered consensual. The chi-square test was used to compare answers between panelists and affiliates and the Kappa coefficient to calculate agreement. RESULTS: Consensus among the panelists increased from 26 (59.1%) to 32 questions (72.7%) following brainstorming (p = 0.17), including 7/10 questions on systemic treatment. Among the affiliates, consensus was achieved for 24 questions (54.5%), resulting in moderate agreement (κ = 0.445). Neoadjuvant chemotherapy should be indicated for almost all cases (except cT1a-b N0) and should include platinum agents. When indicated, immunotherapy is part of the standard of care. The panel reaffirmed the concept of no ink on tumor as indicative of adequate margins and the possibility of sentinel lymph node biopsy for cN1 patients who become cN0 following neoadjuvant therapy. Controversies remain on combining immunotherapy with capecitabine/olaparib in pertinent cases. CONCLUSION: Expert consensus was achieved for > 70% of the questions, with moderate agreement between panelists and affiliates. Educational interventions on systemic breast cancer treatment affected decision-making in 60% of the questions.

Oncological Outcomes of Nipple-Sparing Mastectomy in an Unselected Population Evaluated in a Single Center / Desfechos oncológicos da mastectomia poupadora do complexo areolo-mamilar em uma população não selecionada avaliada em um único centro

Abstract Objective Nipple-sparing mastectomy (NSM) has been traditionally used in selected cases with tumor-to-nipple distance > 2 cm and negative frozen section of the base of the nipple. Recommending NSM in unselected populations remains controversial. The present study evaluated the oncological outcomes of patients submitted to NSM in an unselected population seen at a single center. Methods This retrospective cohort study included unselected patients with invasive carcinoma or ductal carcinoma in situ (DCIS) who underwent NSM in 2010 to 2020. The endpoints were locoregional recurrence, disease-free survival (DFS), and overall survival (OS), irrespective of tumor size or tumor-to-nipple distance. Results Seventy-six patients (mean age 46.1 years) (58 invasive carcinomas/18 DCIS) were included. The most invasive carcinomas were hormone-positive (60%) (HER2 overexpression: 24%; triple-negative: 16%), while 39% of DCIS were high-grade. Invasive carcinomas were T2 in 66% of cases, with axillary metastases in 38%. Surgical margins were all negative. All patients with invasive carcinoma received systemic treatment and 38% underwent radiotherapy. After a mean of 34.8 months, 3 patients with invasive carcinoma (5.1%) and 1 with DCIS (5.5%) had local recurrence. Two patients had distant metastasis and died during follow-up. The 5-year OS and DFS rates for invasive carcinoma were 98% and 83%, respectively. Conclusion In unselected cases, the 5-year oncological outcomes following NSM were found to be acceptable and comparable to previous reports. Further studies are required.

Resumo Objetivo A mastectomia poupadora do complexo areolo-mamilar (MPM) tem sido tradicionalmente utilizada em casos selecionados com distância tumor-mamilo > 2 cm e biópsia de congelação da base do mamilo negativa. Recomendar MPM em populações não selecionadas continua controverso. Este estudo avaliou os resultados oncológicos de pacientes submetidas à MPM em uma população não selecionada atendida em um único centro. Métodos Coorte retrospectivo incluindo pacientes não selecionadas com carcinoma invasivo ou carcinoma ductal in situ (CDIS) submetidas à MPM entre 2010 e 2020. Os desfechos incluíram: recorrência locorregional, sobrevida livre de doença (SLD) e sobrevida global (SG), independentemente do tamanho do tumor ou da distância tumor-mamilo. Resultados Setenta e seis pacientes (média: 46,1 anos de idade) (58 carcinomas invasivos/18 CDIS) foram incluídas. A maioria dos carcinomas invasivos era hormônio-positivo (60%) (superexpressão de HER2: 24%; triplo-negativo: 16%), enquanto 39% dos CDIS eram de alto grau histológico. Os carcinomas invasivos foram T2 em 66% dos casos, com metástases axilares em 38%. As margens cirúrgicas foram todas negativas. Todas as pacientes com carcinoma invasivo receberam tratamento sistêmico e 38% receberam radioterapia. Após um período médio de 34,8 meses, 3 pacientes com carcinoma invasivo (5,1%) e 1 com CDIS (5,5%) apresentaram recidiva local. Durante o acompanhamento, duas pacientes tiveram metástase à distância e vieram a óbito. As taxas de SG e SLD aos 5 anos para carcinoma invasivo foram de 98% e 83%, respectivamente. Conclusão Em casos não selecionados, os resultados oncológicos de 5 anos após MPM foram considerados aceitáveis e comparáveis a resultados anteriores. Estudos adicionais são necessários.

Management of the positive sentinel lymph node following neoadjuvant chemotherapy: results of a survey conducted with breast surgeons.

Introduction: Despite the lack of randomised evidence, there is a current trend towards omitting axillary surgery in cases of positive sentinel lymph node (SLN) following neoadjuvant chemotherapy (NACT). This study evaluated practice patterns of Brazilian breast surgeons when managing positive SLN following NACT. Methods: This was a nationwide electronic survey of breast surgeons affiliated with the Brazilian Society of Mastology. Management approaches for positive SLN after NACT (axillary dissection (AD), regional nodal irradiation (RNI) or no additional treatment) were evaluated as a function of residual disease volume in the SLN (macro-metastasis, micro-metastasis or isolated tumour cells (ITC)). Results: Survey response rate was 49%, with 799/1,627 questionnaires returned. Most respondents were <50 years old (61%), lived in south-eastern Brazil (50%), in a major city (67%), worked in an academic institute (80%) and were board-certified (80%). AD recommendation rate decreased according to residual nodal disease volume: 91% of respondents recommended AD for cases of macro-metastasis, 64% for micro-metastasis and 38% for ITC (p < 0.00001). Furthermore, 35% would recommend no additional surgery for micro-metastasis, while 27% would recommend no treatment at all for ITC (p < 0.00001). Not working in an academic institute was associated with RNI for micro-metastasis (p = 0.02), but not for macro-metastasis or ITC. Being board-certified did not affect axillary management. Conclusion: Most respondents would recommend AD and/or RNI in residual nodal disease following NACT irrespective of disease volume. Nevertheless, a trend towards surgical de-escalation was found with low-volume disease (micro-metastasis and ITC). Ongoing randomised trials will clarify the impact of this trend.

Impact of COVID-19 Disease in Early Breast Cancer Management: A Summary of the Current Evidence.

PURPOSE: An expert panel on breast cancer and COVID-19 disease was convened to address the impact of the COVID-19 pandemic for early breast cancer (eBC) management. METHODS: To ensure that the most clinically relevant information was addressed, essential information was drawn from several of the latest national and international guidelines and another technical document. The expert panel met in five virtual closed sessions from November 2020 to May 2021 to consult on the relevant data from evidence-based results. The data gathered were discussed on an online platform. RESULTS: This article reports the expert panel's highlights of these meetings' discussions. In addition, it provides practical recommendations covering topics regarding diagnosis, treatment, and management of patients with eBC in clinical settings routinely encountered by health care professionals amid the COVID-19 pandemic. CONCLUSION: This article provided guidance on several topics regarding eBC management amid the COVID-19 pandemics to inform safer care practices.

The Attitudes of Brazilian Breast Surgeons on Axillary Management in Early Breast Cancer-10 Years after the ACOSOG Z0011 Trial First Publication.

PURPOSE: To evaluate the impact of the ACOSOG Z0011 trial on axillary breast cancer surgery management in Brazil following publication of that study (2010) and again in 2020. PATIENTS AND METHODS: A survey of members of the Brazilian Society of Mastology. RESULTS: Of 1627 breast surgeons, 799 (49.1%) completed and returned the questionnaire. For patients with the Z11 inclusion criteria, following detection of a positive sentinel lymph node (SLN), axillary dissection (AD) was recommended by 99.2% of respondents before publication of the study, 47.5% in 2010 and 18.5% in 2020 (p < 0.001). In breast-conserving surgery, if there were micro-metastases, 2.6% would perform AD, 30.3% axillary radiotherapy, and 67.1% no additional axillary treatment, while with macro-metastases, these proportions were 21.3%, 52.2%, and 26.5%, respectively. In cases of mastectomy and of nodal extracapsular extension, 43.4% and 36% of surgeons, respectively, recommended AD. For clinically negative axilla and suspicious findings at ultrasonography, 69% of the surgeons would apply the Z11 approach. Most applied the Z11 criteria in cases of younger patients (83.6%) and triple-negative and/or HER2 positive tumors (74%). AD was significantly more likely to be recommended by surgeons who did not work in academic institutes, who worked in locations other than capital cities, who were not board-certified, and who were ≥ 50 years old. CONCLUSIONS: This survey revealed substantial changes in axillary surgery management in cN0/pathologically positive SLN, particularly following publication of the updated Z11 results and other similar studies. A better education environment and long-term follow-up were factors associated with the incorporation of Z11-related changes in practice.

Trends in bilateral mastectomy for cases of unilateral breast cancer in a Brazilian institute over a 10-year period

Introduction: There has been a substantial increase worldwide in the number of women with unilateral breast cancer who undergo bilateral mastectomy. Possible contributing factors include the advent of nipple-sparing mastectomy (NSM) and an improvement in breast reconstruction techniques. This study evaluated the trend in bilateral mastectomy at the Ceará Cancer Institute in Brazil. Methods: Patients with unilateral breast cancer who underwent mastectomy and immediate breast reconstruction were evaluated retrospectively between 2009 and 2018. Clinical, pathological and surgical factors were analyzed to determine their possible effects on the type of surgery performed. Results: Of 121 patients, 77 (63.6%) were submitted to unilateral mastectomy, while 44 (36.4%) underwent bilateral mastectomy. Most were treated with NSM (n = 66; 54.5%), with this technique being significantly associated with bilateral mastectomy (p < 0.001). Bilateral mastectomy increased significantly over the period (p = 0.009; r2 = 0.592), but unilateral mastectomy did not (p = 0.417; r2 = 0.084). Age < 45 years (p = 0.007) and negative axilla (p = 0.003) were also associated with bilateral mastectomy, while axillary dissection was associated with unilateral mastectomy (p = 0.028). Multivariate analysis showed the 2016-2018 period to be an independent factor associated with bilateral mastectomy. Conclusions: These results corroborate the international literature. From 2010 onwards, there was a trend towards an increase in bilateral mastectomy with breast reconstruction. These data may contribute to multidisciplinary debates, facilitating the establishment of guidelines. Further studies are required to improve understanding of this phenomenon in Brazil.

Management of early breast cancer during the COVID-19 pandemic in Brazil.

PURPOSE: The COVID-19 pandemic has impacted early breast cancer (EBC) treatment worldwide. This study analyzed how Brazilian breast specialists are managing EBC. METHODS: An electronic survey was conducted with members of the Brazilian Society of Breast Cancer Specialists (SBM) between April 30 and May 11, 2020. Bivariate analysis was used to describe changes in how specialists managed EBC at the beginning and during the pandemic, according to breast cancer subtype and oncoplastic surgery. RESULTS: The response rate was 34.4% (503/1462 specialists). Most of the respondents (324; 64.4%) lived in a state capital city, were board-certified as breast specialists (395; 78.5%) and either worked in an academic institute or one associated with breast cancer treatment (390; 77.5%). The best response rate was from the southeast of the country (240; 47.7%) followed by the northeast (128; 25.4%). At the beginning of the pandemic, 43% changed their management approach. As the outbreak progressed, this proportion increased to 69.8% (p < 0.001). The southeast of the country (p = 0.005) and the state capital cities (p < 0.001) were associated with changes at the beginning of the pandemic, while being female (p = 0.001) was associated with changes during the pandemic. For hormone receptor-positive tumors with the best prognosis (Ki-67 < 20%), 47.9% and 17.7% of specialists would recommend neoadjuvant endocrine therapy for postmenopausal and premenopausal women, respectively. For tumors with poorer prognosis (Ki-67 > 30%), 34% and 10.9% would recommend it for postmenopausal and premenopausal women, respectively. Menopausal status significantly affected whether the specialists changed their approach (p < 0.00001). For tumors ≥ 1.0 cm, 42.9% of respondents would recommend neoadjuvant systemic therapy for triple-negative tumors and 39.6% for HER2 + tumors. Overall, 63.4% would recommend immediate total breast reconstruction, while only 3.4% would recommend autologous reconstruction. In breast-conserving surgery, 75% would recommend partial breast reconstruction; however, 54.1% would contraindicate mammoplasty. Furthermore, 84.9% of respondents would not recommend prophylactic mastectomy in cases of BRCA mutation. CONCLUSIONS: Important changes occurred in EBC treatment, particularly for hormone receptor-positive tumors, as the outbreak progressed in each region. Systematic monitoring could assure appropriate breast cancer treatment, mitigating the impact of the pandemic.