Breast parenchymal density: does it affect oncological and surgical outcomes in conventional lumpectomy and oncoplastic surgery?

INTRODUCTION: Mammographic breast density (MBD) has been investigated as a risk factor for many years and has been determined to increase the risk of breast cancer in many studies. Research has shown that the correlation between MBD with breast cancer as both a risk factor and a prognostic factor is not limited to difficulty in diagnosis and patient age. This study was aimed to investigate the effect of MBD on the surgical effectiveness of different techniques applied for breast-conserving surgery (BCS). METHODS: We investigated the data of 460 patients who were prospectively registered in the database of the center between 2007-2017 and who were treated with level II Oncoplastic surgery (OPS) and conventional lumpectomy due to invasive breast cancer. RESULTS: BCS was applied to 223 (48.5%) patients, and OPS was applied to 237 (51.5%) patients. 213 (46.3%) patients had fatty breast density, and 247 (53.7%) had dense breasts. Mean surgical margin was 11.01 mm in the OPS group and 9.17 mm in the BCS group, with a statistically larger surgical margin in the OPS group (p=0.011). Regarding the surgical margin, mean distances were 10.59 mm infatty breasts and 9.70 mm in dense breasts. DISCUSSION AND CONCLUSIONS: In the present study, increased MBD was found to be associated with closer surgical margins and increased reoperation rates, albeit with a reduced risk for late complications. We think that level II OPS can eliminate this handicap in terms of surgical margin and reoperation in dense breasts. KEY WORDS: Breast Cancer, Breast Conserving Surgery, Breast Density, Oncoplastic Surgery.

The effect of CEA/Albumin ratio in gastric cancer patient on prognostic factors.

AIM: Gastric cancer is an important disease worldwide with high mortality and morbidity rates. Novel targeted treatment approaches and recent improvements in immunotherapy have significantly improved survival. New indicators that can help determine the prognosis of stomach cancer have been of interest to researchers. We evaluated and recorded the patients' final preoperative CEA/albumin ratios and investigated the effect of this ratio on lymph node involvement, pathological tumor stage, and overall survival. MATERIAL AND METHOD: We retrospectively evaluated data from electronic files of patients who were operated for stomach cancer in our center between January 2012 and December 2017. The study included 195 patients who were followed up regularly and whose complete medical data were available. RESULTS: The effect of CEA/Albumin ratio on the number of Metastatic Lymph Nodes was analyzed using Linear Regression and was found to be statistically significant (p = 0.001). One unit increase in CEA/Albumin ratio increases the number of Metastatic Lymph Nodes by 0.223 (Confidence Interval: 0.097-0.380) units, and this variable alone explains 5.7% of the change in the number of Metastatic Lymph Nodes. CONCLUSION: Neoadjuvant treatment decisions can be made by estimating the T and N stages by using CEA/albumin ratio in cases where conventional radiological methods are insufficient. KEY WORDS: Albumin, Carcinoembryonic antigen, Gastric cancer, Lymph node, Prognosis.

Luminal A Breast Cancer: How Feasible is Omitting Axillary Dissection Without Neoadjuvant Therapy.

Background: Luminal A breast cancer has a good prognosis and the criteria for adjuvant and neoadjuvant chemotherapy (NAC) are not clear. The aim of this study was to present our results of upfront surgery and long-term survival in luminal A tumors as well as the rates of protection from axillary dissection. Material and Methods. 271 Luminal A breast cancer patients who had operated at our center were evaluated retrospectively. In patients with 2 or less sentinel lymph node (SLN) positivity who did not receive neoadjuvant therapy and underwent breast-conserving surgery, axillary lymph node dissection was omitted (OAD). Axillary lymph node dissection (ALND) was performed in patients with positive SLN who did not meet these criteria (axillary dissection after sentinel/ADAS). Results: While Sentinel Lymph Node Biopsy (SLNB) was performed in 212 (77.9%) patients, SLNB + Axillary Dissection (AD) was performed in 58 (21.3%), and direct axillary dissection was performed in 1 (0.8%) patient. OAD was applied to 18 (23.6%) of the positive patients. Discussion/Conclusions. ALND rates are still strikingly high in luminal A breast cancer treatment, despite the disease's milder clinical course. In order to avoid complications of axillary dissection, patients should be considered for NAC as much as possible. Novel neoadjuvant or other therapy options are also required.

The Comparative Frequency of Breast Cancer-Related Lymphedema Determined by Bioimpedance Spectroscopy and Circumferential Measurements.

Objective: The survival of patients with breast cancer has prolonged due to early diagnosis and modern methods of treatment and lymphedema has become the most important morbidity secondary to the treatment of the disease. Early detection and timely intervention have potential to reduce advanced breast cancer-related lymphedema. The aims of this study were to comparatively determine the frequency of subclinical/clinical lymphedema by using prospective monitoring with bioimpedance spectroscopy (BIS) and circumferential measurements in a group of patients who underwent breast cancer surgery. Materials and Methods: Patients having breast cancer surgery were recruited between October 2018 and December 2019. Demographical and surgical properties were recorded. Extremity volumes by circumferential and BIS measurements were performed after surgery (baseline) and monitorizations were carried out at third and sixth months, in order to determine the frequency of subclinical/clinical lymphedema. L-Dex value of >6.5 was recently taken attention as subclinical lymphedema and values >7 were considered as clinical lymphedema. The presence of subclinical and clinic lymphedema was assessed by inter-limb volume difference (>5% and >10 respectively) based on the serial circumferential measurements in both affected and non-affected extremities. The functional status and quality of Life (QoL) were determined by quick-DASH and LYMQOL-Arm questionnaires respectively. The relationship between volume measurements, functional status and QoL scores were determined. Results: Eighty-two female patients with a mean age of 49.6 years were included to the study. 30 (36.5%) and 21 (25.6%) of patients were determined as having subclinical/clinical lymphedema by BIS, while 18 (21.9%) and 19 (23.1%) of patients had subclinical/clinical lymphedema by circumferentialmeasurements at third-and-sixth months respectively. The functional and QoL scores were not correlated with circumferential volume measurements and BIS scores. There was a moderate-high correlation with BIS and circumferential measurements. Conclusion: In conclusion 36.5% and 25.6% of our study group had subclinical and clinical lymphedema by BIS respectively during the 6 months surveillance period. Periodic monitoring of women with BIS allows early detection for lymphedema in more patients than in circumferential volume measurements, which may have implications for timely and necessary management.

Oncoplastic Level II Surgical Techniques for Breast Cancer Treatment: Long-Term Outcomes.

Background: Problems in patients who could not get adequate surgical margins (SM) and good cosmetic results with breast-conserving surgery (BCS) have been overcome with the introduction of oncoplastic surgery (OPS) methods. The purpose of this study was the documentation of level II techniques and the presentation of long-term survival results. Methods: The data on patients who had been prospectively registered in the database between 2007 and 2017 and who had been treated with level II OPS due to invasive breast cancer were examined. Results: A total of 1,074 patients were included in the study. The most commonly applied level II oncoplastic techniques were performed in the upper outer quadrantectomy with racquet incision in 334 (31%) patients, inferior pedicle flaps in 294 (27.3%), and vertical mammoplasty in 140 (13%). Reexcision was performed in 96 patients (8.9%). Total breast conservation rate was 96%. Five-year disease-free survival (DFS) was 88%, local recurrence-free survival (LRFS) 93.6%, and overall survival (OS) 96%. Ten-year DFS was 72%, LRFS 85.4%, and OS 90.2%. Conclusion: Level II OPS techniques have low reoperation and complication rates and a high rate of breast protection. The success of these techniques has been demonstrated in terms of long-term local control. Awareness of the fact that many patients who undergo OPS will not lose their breasts should be created, and regular training programs for OPS techniques should be conducted especially in developing countries. By revealing these results, it is hoped that the OPS and breast conservation rates will increase.

The Effects of Modified Lymphoscintigraphy Techniques on Sentinel Lymph Node Biopsy Success During the COVID-19 Pandemic Period.

BACKGROUND AND OBJECTIVE: Sampling of the sentinel lymph node (SLN) in breast cancer provides accurate information about the condition of the axilla in 95% of cases. Technically in detecting SLN; radioactive substance, dyers or both are used. During the COVID-19 (Coronavirus disease 2019) pandemic, delayed images were not taken in lymphoscintigraphy to reduce the risk of transmission by shortening the waiting time in our center. In this study, the effects of early and delayed lymphoscintigraphic images and only early images on our clinical practice were evaluated. METHODS: We investigated the data of 147 patients in this study who underwent SLNB due to early-stage breast cancer at our institute during the COVID-19 pandemic period (PP) (March/April/May 2020) and within 3 months before the pandemic were evaluated. RESULTS: Patients were divided into two groups, before pandemic (BP) and PP. BP consisted of patients whose early and delayed images were taken in lymphoscintigraphy whereas PP consisted of those with early images only. There were 74 patients in the BP group and 73 patients in the PP group. Early phase increased uptake was not observed in 23 patients, and increased uptake was obtained from 22 of these patients with delayed imaging in BP period. In PP, increased uptake was not observed in 12 patients. SLN was not detected in 2 patients in the BP group and 7 in the PP group. It was found that the sensitivity, NPV and accuracy of the SLNB procedure performed after taking delayed images was higher. CONCLUSIONS: In the present study, we believe that if technically possible, delayed images taken during the lymphoscintigraphy can assist the surgeon in terms of SLN detection and the number of SLNs removed.

Efficacy and Safety of Glandular Flap Techniques in Surgical Treatment of Large Ductal Carcinoma in situ.

BACKGROUND: It is well known that full segmentary resection can be performed using oncoplastic surgery (OPS) techniques, and the anatomic resection of the ductal system is possible. Therefore, the efficacy and safety of OPS should be investigated in the treatment of ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: Patients who were diagnosed as pure DCIS and underwent surgical treatment and follow-up were retrospectively evaluated. Patients who underwent OPS and conventional breast-conserving surgery (BCS) were included in the study. The number of patients who required an intervention after the surgery and had a relapse during the follow-up period was determined in both groups. RESULTS: There were 45 patients in the OPS group and 138 patients in the BCS group. The mean tumor size was larger in patients in the OPS group (36 ± 12 mm vs. 24 ± 8 mm, p = 0.02). Six (12.7%) patients were reoperated in the OPS group. Of these, 4 were re-excisions and 2 were mastectomies. In this group, breast conservation was possible in 45 (95.7%) patients. Thirty-nine (27%) patients were reoperated in the BCS group. Of these, 23 were re-excisions, and 16 were mastectomies. In this group, breast conservation was possible in 126 (88.7%) patients (p = 0.02). There was no significant difference between the groups in terms of 5-year cumulative local recurrence rates. While the 5-year local recurrence-free survival rate was 93.3% in the OPS group, it was 90.8% in the BCS group. CONCLUSION: This study provided evidence that OPS can be used safely in the surgical treatment of DCIS by reducing re-excision and completion mastectomy rates compared to BCS.

Can preoperative axillary ultrasound and biopsy of suspicious lymph nodes be an alternative to sentinel lymph node biopsy in clinical node negative early breast cancer?

AIM: The aim of this study was to assess the efficacy of preoperative axillary ultrasonography (AUS) and preoperative axillary fine-needle aspiration biopsy (FNAB) from suspicious lymph nodes in clinically node-negative breast cancer to compare with radiologically positive and sentinel lymph node biopsy (SLNB) positive involvement. METHOD: Clinically node-negative early-stage breast cancer patients were included in the study. These patients underwent preoperative AUS examination, suspicious lymph nodes were evaluated with FNAB. AUS-FNAB results were compared with those of SLNB or axillary dissection. RESULTS: Of 181 patients undergoing AUS, 32 were reported to have axillary metastasis, 25 suspicious, and 124 benign nodes. The suspicious group underwent FNAB examination and metastasis was found in 9 of them. The sensitivity of AUS-FNAB was found to be 64.06%, specificity 100%, positive predictive value 100%, and negative predictive value (NPV) 83.5%. The false negativity rate (FN) of this method was 16,4%. Lymphovascular invasion and tumour size were found statistically significant factors for false negativity. CONCLUSION: It was concluded that axillary AUS-FNAB with its high NPV, low FN rate, may be a clinical alternative to SLNB for early-stage breast cancer patients.

Is it mastalgia or myofascial pain? A clinical confusion.

OBJECTIVES: This study aims to investigate the frequency of myofascial pain syndrome (MPS) and its characteristics in mastalgia patients. PATIENTS AND METHODS: The localization of pain, age, education, menopausal status, hormone replacement and employment status, and existence of comorbid diseases were reviewed on consecutive 131 female mastalgia patients (mean age 43.3±9.4 years; range, 18 to 75 years) in this prospective study conducted between June and December 2019. A total breast pain index (IBP) was obtained and mastalgia was classified according to these scores as mild, moderate, and severe. Patients were divided into four diagnostic groups of MPS, cyclic mastalgia, fibrocystic breast disease, and mastitis. RESULTS: The total IBP was significantly higher in MPS group (129.2±49.5) than in cyclic mastalgia group (98.3±11.9) (p<0.05). However, it was significantly higher in mastitis group (230.7±17.6) compared to MPS group (p<0.05). The fibrocystic disease group was similar to MPS group in terms of total IBP (p>0.05). Considering the localization of pain according to the quadrants where the pain was felt, 57.1% of the patients who felt pain in the upper quadrants were from MPS group (p=0.001) and 45.3% of the patients who felt pain in the lower quadrants were from cyclic mastalgia group (p=0.001). Myofascial pain was observed particularly in upper quadrants and almost all was unilateral; however, cyclic mastalgia was observed bilaterally in the majority, particularly in lower quadrants. CONCLUSION: Myofascial pain syndrome should be kept in mind as an extramammary disorder in the differential diagnosis of particularly unilateral upper quadrant mastalgia. It may be for the benefit of patients complaining of mastalgia with no primary breast disorder to be consulted with a physiatrist.

Unplanned breast-conserving surgery after systemic therapy in locally advanced breast cancer: The results of level II oncoplastic techniques.

BACKGROUND: In patients with breast cancer for whom neoadjuvant chemotherapy (NAC) is planned, it is recommended to mark the primary tumour before treatment (planned surgery). However, surgeons may have to perform breast-conserving surgery on patients whose tumours are not marked (unplanned surgery). This study focused on the results obtained with planned and unplanned level II oncoplastic surgery (OPS) techniques applied to patients after NAC. METHODS: Patient groups who underwent planned, unplanned OPS and mastectomy after NAC were compared. Surgical margin status, re-operation and re-excision requirements, ipsilateral breast tumour recurrence (IBTR) and axillary recurrence rates recorded. Long-term local recurrence-free survival (LRFS), disease-free survival and overall survival were evaluated. RESULTS: There was no significant difference between the planned and unplanned OPS groups in terms of surgical margin status, re-excision requirement, and mastectomy rates. During an average follow-up period of 43 months, 5.3% and 4% of the patients in the planned OPS group developed IBTR and axillary recurrence, respectively, whereas these rates were 6.6% and 5.3% in the unplanned OPS group. In the mastectomy group, the rates of IBTR and axillary recurrence were found to be 4.1% and 3.8%, respectively. There was no significant difference between the three groups in terms of IBTR (P: .06) and axillary recurrence (P: .08) rates. CONCLUSION: Breast conserving surgery can be applied using level II OPS techniques with the post-NAC radiological examination and marking even if primary tumour marking is not done in the pre-NAC period.

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.

Feasibility of level II oncoplastic techniques in the surgical management of locally advanced breast cancer after neoadjuvant treatment.

BACKGROUND: The study aimed to identify the short- and long-term oncological results and complications of level-II oncoplastic surgery (OPS) techniques applied after neoadjuvant chemotherapy (NAC) for locally advanced breast cancer. METHODS: Patients undergoing OPS because of breast cancer (non-NAC) and those undergoing OPS after systemic treatment (NAC) were evaluated. Surgical margin (SM) status, reoperation and re-excision requirements, axillary intervention results, ipsilateral tumour recurrence, axillary recurrence rates and early postoperative complications were recorded. Long-term locoregional recurrence-free survival (LRFS) and overall survival (OS) rates of the patients were analysed. RESULTS: There were 1043 patients (893 patients in the non-NAC group and 150 in the NAC group) in the study. There were no significant differences in SM status, re-excision and mastectomy rates between the groups. The 5-year (LRFS) rate was 90.1% in the NAC group and 93.2% in the non-NAC group (P: .09). OS was shorter in the NAC group. Five-year OS rate was 96% in the non-NAC group and 92% in the NAC group (P: .01). There was no significant difference between the groups in terms of delayed wound healing, minor wound infection, fat necrosis, seroma/hematoma, partial nipple necrosisor T-junction necrosis. CONCLUSION: It should be noted that the responses to NAC increased with targeted therapies, and breast-conserving became possible in a substantial number of patients who were not eligible for breast-conserving surgery at the first presentation. Notably, oncoplastic surgery increased breast conservation rates without compromising oncological results.

Impact of obstructive sleep apnea-related symptoms on surgical wound complications in breast cancer patients: pilot study in a tertiary health center in Turkey.

PURPOSE: Wound healing is an important factor influencing morbidity following surgical procedures. The association of obstructive sleep apnea (OSA) with numerous postoperative complications has been previously reported. In this study, we report the impact of OSA-related symptoms on wound complications in breast cancer patients in the postoperative period. METHODS: Breast cancer patients were enrolled for a prospective observational study. Outcome measures included sociodemographic data, self-reported sleep-wake questionnaires (Berlin questionnaire, STOP-BANG, and Epworth sleepiness scale [ESS]) as well as type of surgery, smoking status, duration of anesthesia, the need for postoperative opioid drugs, and complications for surgical wounds. Patients' general preoperative health status was quantified by using American Society of Anesthesiologists (ASA) scores. RESULTS: A total of 132 women were included in the study, of whom 61% (n = 81) underwent mastectomy, and 39% (n = 51) had breast conserving surgery. Mean ESS score of the study group was 7.7 ± 0.5. Multivariant analysis identified, either being at medium high risk by STOP-BANG questionnaire (OR:1.77, p: 0.04) or being at high risk by Berlin questionnaire (OR:1.96, p: 0.04) as well as high BMI (OR:2.76 95% CI:1.73-4.65, p: 0.02), smoking history (OR:3.04 95% CI: 2.25-3.86, p: 0.01) and type of surgery (OR:2.64 95% CI: 1.63-2.89, p: 0.03) were independent factors for wound healing. CONCLUSIONS: The study results suggest that patients with high risk for OSA have a tendency to develop postoperative wound complications after breast cancer surgery. This study lays groundwork for further scrutiny using more robust methodology.

Relationship of Preoperative Serum Uric Acid Level with Survival in Colorectal Cancer.

OBJECTIVE: To investigate the prognostic significance of uric acid level in colorectal cancer in addition to conventional factors in terms of  survival. STUDY DESIGN: Observational Study. PLACE AND DURATION OF STUDY: At the University of Health Sciences, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey, between January 2012 and December 2019.   Methodology: A total of selected 332 patients, who underwent surgery for colorectal cancer between 2012 and 2019, were retrospectively reviewed. Patients with a history of neoadjuvant therapy due to rectal cancer, GUT disease, renal failure, stage 4 disease, emergency surgery and severe preoperative infection, were excluded from the study. Peripheral blood samples were collected about a week before the operation. Serum uric acid (SUA) values were measured and recorded.   Results: The patients comprised 198 males and 134 females with a mean age  62.2 ±11.7 years (14-91) years in total. Conventional surgery was performed in 228 patients, and laparoscopy in 104 patients. Uric acid level, number of pathological lymph nodes, number of pathological lymph nodes/total number of lymph nodes (LNO), perineural invasion, type of surgery and disease stage were found to be factors affecting the prognosis (p <0.05). Uric acid cut off value of 5.3 or higher was found to be statistically significant in terms of survival. CONCLUSION: Serum uric acid (SUA) value measured preoperatively was found to be a prognostic factor for colorectal cancer. Key Words: Serum uric acid (SUA), Colon cancer, Rectal cancer, Prognostic factor.

Serum AMDL DR-70 levels: a new concept in the diagnosis and follow-up of colorectal carcinoma.

Aim: The purpose of this study was to determine the diagnostic potential of DR-70 assay in patients with colorectal cancer and to investigate the relationship between serum DR-70 levels and the biological characteristic of the tumor. Patients & methods: The experimental group included patients who were diagnosed with colorectal adenocarcinoma after biopsy specimen. The control group of this study consisted of patients whose total colonoscopy was reported as normal. Results: Serum levels of DR-70 was found to be significantly higher in patients with colorectal cancer than healthy participants (p = 0.001). Receiver operating curve analyses indicated a cut-off value of 1.69 µg/ml for serum DR-70 levels. Stage of the disease, grade of the tumor, number of metastatic lymph nodes and microsatellite instability status were significantly related to serum DR-70 levels (p = 0.001, p = 0.001, p = 0.001 and p = 0.002, respectively). Conclusion: It can be concluded that serum levels of DR-70 can be regarded as an indicator for the diagnosis of colorectal cancer.