Breast Cancer Presentation, Surgical Management and Mortality Across the Rural-Urban Continuum in the National Cancer Database.

OBJECTIVE: The purpose of this study was to examine differences in presentation, surgical management, and mortality among breast cancer patients in the National Cancer Database (NCDB) based on area of residence. METHODS: The NCDB was queried for women with a diagnosis of breast cancer from 1 January 2004-31 December 2015. The data were divided by metropolitan (large, medium, small) and non-metropolitan (urban, rural) status. RESULTS: Cancer stage increased with rurality (p < 0.0001). Residency in a large metropolitan area was associated with increased breast reconstruction rates (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.19-1.30) and reduced overall mortality (hazard ratio 0.92, 95% CI 0.89-0.95) compared with rural areas. There was no difference in mastectomy use among small metropolitan (OR 1.03, 95% CI 1.01-1.04), urban (OR 0.99, 95% CI 0.98-1), and rural areas (OR 1.05, 95% CI 1.01-1.07) compared with large metropolitan areas. CONCLUSIONS: Across the rural-urban continuum in the NCDB, stage of cancer presentation increased with rurality. Conversely, residency in a large metropolitan area was associated with higher reconstruction rates and a reduction in overall mortality. Future studies should evaluate factors contributing to advanced disease presentation and lower reconstruction rates among rural breast cancer patients.

Breast Cancer Recurrence in the Nipple-Areola Complex After Nipple-Sparing Mastectomy With Immediate Breast Reconstruction for Invasive Breast Cancer.

Importance: The main concern associated with nipple-sparing mastectomy (NSM) is the risk of local breast cancer recurrence at the retained nipple-areola complex (NAC) consequent to occult nipple involvement. Long-term follow-up data regarding the oncologic safety of modern therapeutic NSM in terms of cancer recurrence at the NAC and survival are limited. Objective: To assess the incidence, risk factors, treatment, and long-term outcomes associated with cancer recurrence at the NAC in a large series of patients with invasive breast cancer who underwent NSM and immediate breast reconstruction. Design, Setting, and Participants: In this retrospective cohort study at a single institution (Asan Medical Center) in Seoul, Republic of Korea, 962 breasts from 944 patients who underwent NSM and immediate breast reconstruction for invasive breast cancer were analyzed between March 3, 2003, and December 31, 2015. Patients who underwent neoadjuvant systemic therapy or palliative surgery were excluded. Data analysis was performed from June 4, 2018, to August 31, 2018. Main Outcomes and Measures: Univariate and multivariate Cox proportional hazards regression models were used to analyze the association between clinicopathologic variables and cancer recurrence at the NAC. To evaluate the association between cancer recurrence at the NAC and prognosis, distant metastasis-free survival, and overall survival were estimated using the Kaplan-Meier method and compared using the log-rank test. Results: Among the 944 study patients (median age at diagnosis, 43 years [range, 23-67 years]) during a median follow-up of 85 months (range, 14-185 months), 39 cases (4.1%) of cancer recurrence at the NAC were identified as the first event after NSM. The 5-year cumulative incidence of cancer recurrence at the NAC was 3.5% (n = 34). In multivariate analyses, multifocality or multicentricity (hazard ratio [HR], 3.309; 95% CI, 1.501-7.294; P = .003), negative hormone receptor or ERBB2 (formerly HER2 or HER2/neu)-positive subtype (HR, 3.051; 95% CI, 1.194-7.796; P = .02), high histologic grade (HR, 2.641; 95% CI, 1.132-6.160; P = .03), and extensive intraductal component (HR, 3.338; 95% CI, 1.262-8.824; P = .02) were independently associated with cancer recurrence at the NAC after NSM. All 39 recurrent cases involved wide local excision. Patients with and without cancer recurrence at the NAC as the first event did not differ significantly with regard to distant metastasis-free survival (P = .95) or overall survival (P = .21). The 10-year distant metastasis-free survival rates were 89.3% among patients with cancer recurrence at the NAC and 94.3% among patients without recurrence. The 10-year overall survival rates were 100% among patients with cancer recurrence at the NAC and 94.5% among those without recurrence. Conclusions and Relevance: Patients had a low incidence of cancer recurrence at the NAC after NSM and immediate breast reconstruction in this study. The findings suggest that multifocal or multicentric disease, hormone receptor-negative/ERBB2-positive subtype, high histologic grade, and positive extensive intraductal component should be considered before determining the NSM procedure.

Survival and Disease Recurrence Rates among Breast Cancer Patients following Mastectomy with or without Breast Reconstruction.

BACKGROUND: Concerns have been expressed about the oncologic safety of breast reconstruction following mastectomy for breast cancer. This study aimed to evaluate the association of breast reconstruction with breast cancer recurrence, and 5-year survival among breast cancer patients. METHODS: The authors analyzed data from The Johns Hopkins Hospital comprehensive cancer registry, comparing mastectomy-only to postmastectomy breast reconstruction in breast cancer patients to evaluate differences in breast cancer recurrence and 5-year survival. Kaplan-Meier curves were used to compare unadjusted estimates of survival or disease recurrence. Data were modeled through Cox proportional hazards regression, using as outcomes time to death from any cause or time to cancer recurrence. RESULTS: The authors analyzed data on 1517 women who underwent mastectomy for breast cancer at The Johns Hopkins hospital between 2003 and 2015. Of these, 504 (33.2 percent) underwent mastectomy only and 1013 (66.8 percent) underwent mastectomy plus immediate breast reconstruction. Women were followed up for a median of 5.1 years after diagnosis. There were 132 deaths and 100 breast cancer recurrences. A comparison of Kaplan-Meier survival estimates demonstrated a survival benefit among patients undergoing mastectomy plus reconstruction. After adjusting for various clinical and socioeconomic variables, there was still an overall survival benefit associated with breast reconstruction which, however, was not statistically significant (hazard ratio, 0.78; 95 percent CI, 0.53 to 1.13). Patients who underwent reconstruction had a similar rate of recurrence compared to mastectomy-only patients (hazard ratio, 1.08; 95 percent CI, 0.69 to 1.69). CONCLUSION: This study suggests that breast reconstruction does not have a negative impact on either overall survival or breast cancer recurrence rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long-Term Follow-up of Immediate Latissimus Dorsi Flap Reconstruction After Neoadjuvant Chemotherapy and Radiotherapy for Invasive Breast Cancer.

BACKGROUND: The treatment sequence involving a mastectomy and immediate breast reconstruction (IBR) via the latissimus dorsi flap technique after chemotherapy and radiotherapy is not common. Our experience of this alternative to the standard treatment at our institute is reported herein. PATIENTS AND METHODS: This was a single-center, retrospective study. We enrolled patients who received this so-called "inverse" sequence for invasive, nonmetastatic breast cancer between 2009 and 2016. RESULTS: Fifty-two patients, aged between 24 and 65 years, with a mean body mass index of 24.5 underwent this treatment. Most involved T2 (59.6%, n = 32), multifocal (55.8%, n = 29) tumors, and 57.7% (n = 30) of the patients presented with axillary lymph node involvement. All patients had received sequential chemotherapy and 50 Gy of radiation. Pathological complete response (pCR) was found in 51.3% (n = 20), of cases in the traditional inverse sequence group, using Chevalier and Sataloff classifications (T and N pCR). Postoperatively, 1 patient required surgical revision because of a hematoma, 42 (80.8%) presented with lymphocele, 3 had impaired would healing, and 2 had more than 5 cm of skin necrosis on the front flap. Median follow-up was 61.9 months and the median time between diagnosis and surgery was 9.7 months. Three patients presented with metastases, 2 with local recurrence, and 1 patient died of cancer. No contralateral or lymph node recurrence was discovered. CONCLUSION: This treatment sequence, the feasibility of which was shown in this study, is an alternative for patients who want an IBR to avoid the time spent without one breast. This practice requires upstream multidisciplinary cooperation for optimal patient screening.

Assessing the Quality of Microvascular Breast Reconstruction Performed in the Urban Safety-Net Setting: A Doubly Robust Regression Analysis.

BACKGROUND: Safety-net hospitals serve vulnerable populations; however, care delivery may be of lower quality. Microvascular immediate breast reconstruction, relative to other breast reconstruction subtypes, is sensitive to the performance of safety-net hospitals and an important quality marker. The authors' aim was to assess the quality of care associated with safety-net hospital setting. METHODS: The 2012 to 2014 National Inpatient Sample was used to identify patients who underwent microvascular immediate breast reconstruction after mastectomy. Primary outcomes of interest were rates of medical complications, surgical inpatient complications, and prolonged length of stay. A doubly-robust approach (i.e., propensity score and multivariate regression) was used to analyze the impact of patient and hospital-level characteristics on outcomes. RESULTS: A total of 858 patients constituted our analytic cohort following propensity matching. There were no significant differences in the odds of surgical and medical inpatient complications among safety-net hospital patients relative to their matched counterparts. Black (OR, 2.95; p < 0.001) and uninsured patients (OR, 2.623; p = 0.032) had higher odds of surgical inpatient complications. Safety-net hospitals (OR, 1.745; p = 0.005), large bedsize hospitals (OR, 2.170; p = 0.023), and Medicaid patients (OR, 1.973; p = 0.008) had higher odds of prolonged length of stay. CONCLUSIONS: Safety-net hospitals had comparable odds of adverse clinical outcomes but higher odds of prolonged length of stay, relative to non-safety-net hospitals. Institution-level deficiencies in staffing and clinical processes of care might underpin the latter. Ongoing financial support of these institutions will ensure delivery of needed breast cancer care to economically disadvantaged patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate Breast Reconstruction in De Novo Metastatic Breast Cancer: An Analysis of 563 Cases Based on the SEER Database.

BACKGROUND: Controversy exists regarding the appropriateness of immediate breast reconstruction (IBR) in patients with metastatic breast cancer (MBC). PATIENTS AND METHODS: By using the Surveillance, Epidemiology, and End Results (SEER) database, data of patients with de novo MBC undergoing mastectomy with or without IBR were assessed. The trend of IBR in de novo MBC was explored. Comparisons of the distribution of clinicopathologic characteristics were evaluated by chi-square and Fisher exact tests. The predictors of IBR in de novo MBC were evaluated by multivariate logistic regression. The survival outcomes were compared by Cox hazards models adjusting for known clinicopathologic variables in both the entire population and in the matched cohorts. RESULTS: Between 1998 and 2015, 5.2% of patients with de novo MBC undergoing mastectomy received IBR. The rate of IBR increased significantly, from 6.3% in 1998 to 16.8% in 2015. Patients undergoing IBR were younger and had smaller tumor size, fewer positive lymph nodes, lower proportion of hormone receptor-negative disease and lung metastasis, and better economic status. They were also more likely to receive radiotherapy and chemotherapy. Although IBR was an independent favorable prognostic factor for breast cancer-specific survival and overall survival in the whole population, there were no statistically significant differences between IBR and mastectomy for breast cancer-specific survival (P = .892) and overall survival (P = .708) in the well-matched analysis. CONCLUSION: IBR in selected de novo MBC could be an acceptable practice when balancing quality of life, underlying health care burden, and oncologic risks.

Long-term Follow-up of Autologous Fat Transfer vs Conventional Breast Reconstruction and Association With Cancer Relapse in Patients With Breast Cancer.

Importance: Autologous fat transfer (AFT or fat grafting) has become an invaluable tool for the correction of disfiguring deformities after breast cancer surgery. However, clinical and animal studies have shown conflicting results regarding its oncologic safety. Objective: To determine whether exposure to AFT vs conventional breast reconstruction is associated with increased rates of cancer relapse in patients with breast cancer. Design, Setting, and Participants: This matched cohort study involved retrospective medical record review to identify all patients in a local patient database receiving AFT between 2006 and 2014. Each AFT case was matched with a nonexposed control patient with similar baseline characteristics. The mean (SD) follow-up of patients receiving AFT was 9.3 (4.9) years including 5.0 (1.7) years following AFT. Control patients were followed up for a mean (SD) of 8.6 (1.8) years from the primary surgery. Patients were identified through the local patient database of the Tergooi Hospital in Hilversum, the Netherlands. A total of 287 patients with breast cancer (300 affected breasts) who received AFT for breast reconstruction after cancer were included in the intervention group. Each AFT case was matched with a respective control patient based on age, type of oncologic surgery, tumor invasiveness, and disease stage. In addition, individual AFT-control pairs were selected to have the same locoregional recurrence-free interval at baseline. Data were analyzed between 2016 and 2017. Exposures: Reconstruction with AFT vs conventional breast reconstruction or none. Main Outcomes and Measures: Primary end points were the cumulative incidences of oncologic events in AFT and control patients and their respective hazard ratios. Results: Of the 587 total patients, all were women and the mean age was 48.1 years for the patients undergoing AFT and 49.4 years for the control patients. Eight locoregional recurrences were observed in the treatment group (287 patients) and 11 among the control group (300 patients), leading to an unadjusted hazard ratio of 0.63 (95% CI, 0.25-1.60; P = .33). No increased locoregional recurrence rates were seen in relevant subgroups based on the type of oncological surgery, tumor invasiveness, or pathological stage. In addition, no increased risks with AFT were detected with respect to distant recurrences or breast cancer-specific mortality. Conclusions and Relevance: No significant differences in the locoregional recurrence rates between the AFT and control groups were observed after 5 years of follow-up. These findings confirm the results of previous studies; therefore, clinical evidence suggesting that AFT is associated with increased risk for cancer relapse is still lacking.

[Oncological safety and prognosis factors analysis of immediate breast reconstruction after nipple-areola-complex sparing mastectomy].

Objective: To explore the oncological safety of immediate breast reconstruction after nipple-areola complex(NAC) sparing mastectomy(NSM+ IBR) in patients with early stage breast cancer, and to analyze the prognostic factors of NSM+ IBR. Methods: From January 2004 to December 2015, the clinical data of 118 cases of stage Ⅰ-ⅡA breast cancer who had undergone NSM+ IBR in Tianjin Tumor Hospital were collected, comparing with 75 cases of Ⅰ-ⅡA breast cancer patients who had undergone immediate breast reconstruction after modified radical mastectomy (MRM+ IBR) at the same period. In addition to the prognosis of these two groups, the prognostic factors were also retrospectively analyzed. Results: The median follow-up were 53 months in the NSM+ IBR group and 51 months in the MRM+ IBR group, respectively. In the NSM+ IBR group, local recurrence, distant metastasis, death and NAC necrosis occurred in 4, 6, 9 and 4 cases during 3 years after operation, respectively. The local recurrence rate (LRR) was 3.4%, 3-year disease-free survival (DFS) rate was 91.5%, and the overall survival (OS) rate was 92.4%. In the MRM+ IBR group, local recurrence, distant metastasis, and death occurred in 1, 4, and 3 cases during 3 years after operation, respectively. The LRR was 1.3%, 3-year DFS was 93.3%, whereas the OS rate was 96.0%. No statistical difference was noted between the two groups (all P>0.05). That HER-2 positive and molecular type correlated with the 3-year DFS (P<0.05) independently and molecular type correlated with OS (P<0.05) independently in the NSM+ IBR group. Conclusions: NSM does not impair patients' prognosis and could ensure oncological safety of patients with early stage breast cancer. IBR could improve female patients' figure and ensure the quality of life. HER-2 status and molecular type are the independent prognostic factors of the 3-year DFS. Molecular type is the independent prognosis factor of OS.

Impact of Breast Reconstruction on Time to Definitive Surgical Treatment, Adjuvant Therapy, and Breast Cancer Outcomes.

BACKGROUND: Delays in surgery and adjuvant treatment for breast cancer are associated with decreased survival. However, the time between diagnosis and surgery is rising, partly attributed to the added complexity of immediate breast reconstruction (IBR). We sought to investigate time to treatment and survival outcomes in breast cancer patients undergoing IBR. METHODS: We performed a retrospective review of 2004-2014 California Cancer Registry data for stage 0-III breast cancer patients undergoing mastectomy. Time to surgery, adjuvant systemic therapy and radiation therapy, propensity score, and covariate-adjusted overall mortality hazard ratios (HRs) were assessed by IBR status. RESULTS: Of 56,782 patients, 13,738 (24.2%) underwent IBR, with a median follow-up of 68.8 months. Median time between diagnosis and surgery was increased for patients undergoing IBR compared with those without {49 days (interquartile range [IQR] 34-73) vs. 35 days (IQR 21-56), p < 0.001}. IBR did not affect the interval from surgery to adjuvant chemotherapy or radiation, but prolonged time to endocrine therapy by 5 days (p = 0.014). Significantly lower survival was observed when time to surgery exceeded 120 days (vs. 0-30 days; HR 1.14 [1.02-1.28], p = 0.023), and improved survival with IBR (vs. without; HR 0.67 [0.61-0.74], p < 0.001). The benefit associated with reconstruction persisted for all age groups except age 80 + years, while surgical delay > 120 days demonstrated significantly lower survival in women < 60 years of age. CONCLUSIONS: While IBR delays time to definitive surgery, its use did not substantially affect time to adjuvant treatment or survival outcomes. Further research is ongoing to mitigate the effects of potential selection bias in favor of IBR.

Surgical and oncological outcomes of free dermal fat graft for breast reconstruction after breast-conserving surgery.

BACKGROUND: Oncoplastic breast surgery originated in order to improve the esthetic result of breast-conserving surgery (BCS). Autologous free dermal fat graft (FDFG) is an emerging oncoplastic technique to improve the cosmetic outcome of breast-conserving surgery. OBJECTIVES: The aim of this study was to analyze our experience with FDFGs in breast reconstruction after breast-conserving surgery. Oncological outcomes, surgical complications and cosmetic results were considered. MATERIAL AND METHODS: This retrospective chart review study considered all consecutive oncoplastic breast treatment by means of FDFG reconstruction during the period between September 2011 and September 2012 in our Clinic of Surgery (University of Udine, Italy). The data collected included patient and tumor characteristics and outcomes (cosmetic and oncological). RESULTS: During the study period, 37 women were treated by breast cancer surgery and immediate breast reconstruction by FDFG. At a 3-year follow-up, we found no cases of recurrence among breast cancer patients treated by FDFG; at a 18-month follow-up, we found a prevalence of 75.0% of women extremely satisfied with their oncoplastic surgery and a high prevalence of excellent or good cosmetic outcomes (70.3%) according to objective and subjective cosmetic assessment. CONCLUSIONS: Immediate breast reconstruction by FDFG after BCS in a population selected for a low risk of breast cancer recurrence seems to be an oncologically safe option, with a good cosmetic outcome and a high prevalence of women satisfied with the treatment.

The Muscle-Sparing Latissimus Dorsi Flap for Breast Reconstruction: A Retrospective Review of 126 Consecutive Flaps.

Our experience in the use of muscle-sparing latissimus dorsi (MSLD) flaps for breast reconstruction is presented. The procedure was performed on 83 patients by the senior author over an 8-year period. Of the 83 patients reviewed, a total of 126 MSLD flaps were done for immediate (26) or delayed (100) breast reconstructions. Preoperative and postoperative photographs were taken of all patients, and complications as well as ancillary procedures were recorded. The MSLD flap is shown to be a versatile option for breast reconstruction in a variety of clinical settings, with minimal complications and satisfactory aesthetic results.

Unilateral Versus Bilateral Breast Reconstruction: Is Less Really More?

OBJECTIVE: Over the recent years, there has been an increase in prophylactic mastectomies with an associated increase in bilateral breast reconstruction. We aimed to compare outcomes in terms of patient satisfaction with unilateral versus bilateral breast reconstruction after deep inferior epigastric perforator (DIEP) flap and implant-based reconstruction. METHODS: Patients who underwent breast reconstruction by a single surgeon between July 2011 and July 2015 were surveyed using the independently validated BREAST-Q questionnaire. Mean satisfaction scores between patients undergoing unilateral versus bilateral breast reconstruction were compared and stratified based on the type of reconstruction [eg, DIEP flap, tissue expander to implant (TE/I)]. Groups were further categorized by age (patients <55 years and ≥55 years of age) and body mass index (<24.9 and >24.9). Complications were recorded. RESULTS: Of the 308 patients included, 118 (38%) had unilateral reconstruction (42 TE/I and 76 DIEP) and 190 (62%) had bilateral reconstruction (124 TE/I and 66 DIEP). A total of 95 patient surveys were included (31% response rate). Overall, patients receiving unilateral reconstruction demonstrated increased satisfaction with outcome (P = 0.028), psychosocial well-being (P = 0.043), and sexual well-being (P = 0.002). Complication rates were similar between unilateral and bilateral reconstruction. No significant differences for satisfaction were found in the TE/I group (N = 58; unilateral, 10; bilateral, 48).In the DIEP group (N = 37; unilateral, 20; bilateral, 17), those receiving unilateral reconstruction had higher satisfaction with outcome (P = 0.013) and sexual well-being (P = 0.014).Additionally, younger patients (<55 years) were more likely to undergo bilateral reconstruction (P = 0.018). Body mass index did not have a significant association with unilateral or bilateral reconstruction. CONCLUSIONS: Patients undergoing DIEP flap reconstruction showed higher satisfaction with unilateral reconstruction, whereas patients receiving TE/I reconstruction, either unilateral or bilateral, were equally satisified. Additionally, younger women were more likely to undergo bilateral reconstruction, which is consistent with current data trends. When considering surgical options, unilateral DIEP flap reconstruction may provide improved outcomes in terms of patient satisfaction when compared with bilateral reconstruction in select patients.

Surgical Outcomes for Mastectomy Patients Receiving Neoadjuvant Chemotherapy: A Propensity-Matched Analysis.

OBJECTIVE: To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching. BACKGROUND: Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence. METHODS: Data from American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were used to identify females with invasive breast cancer undergoing planned mastectomy. Surgical cases categorized as clean and undergoing no secondary procedures unrelated to mastectomy were included. A 1:1 matched propensity analysis was performed using neoadjuvant chemotherapy within 30 days of surgery as treatment. A total of 12 preoperative variables were used with additional procedure matching: bilateral mastectomy, nodal surgery, tissue, and/or implant. Outcomes examined were 4 wound occurrences, sepsis, and unplanned return to the operating room. RESULTS: We identified 31,130 patient procedures with 2488 (7.5%) receiving chemotherapy. We matched 2411 cases, with probability of treatment being 0.005 to 0.470 in both cohorts. Superficial wound complication was the most common wound event, 2.24% in neoadjuvant-treated versus 2.45% in those that were not (P = 0.627). The rate of return to the operating room was 5.7% in the neoadjuvant group versus 5.2% in those that were not (P = 0.445). The rate of sepsis was 0.37% in the neoadjuvant group versus 0.46% in those that were not (P = 0.654). CONCLUSIONS: This large, matched cohort study, controlled for preoperative risk factors and most importantly for the surgical procedure performed, demonstrates that breast cancer patients receiving neoadjuvant chemotherapy have no increased risk for surgical morbidity.

Mamoplastía excisional en el manejo del tumor Filodes / Excisional mammoplasty in the management of the tumor Filodes

Se presenta el siguiente estudio retrospectivo-descriptivo en un lapso de 16 años de pacientes que consultaron con diagnóstico de tumor Filodes al departamento de Cirugía del Hospital General San Juan de Dios. Todas las pacientes recibieron imagen y diagnóstico preoperatorio con Mamografía, Ultrasonido, biopsia aguja gruesa y algunos casos con biopsia incisional o excisional...

The present following descriptive retrospective study over a period of 16 years of patients admitted with a diagnosis of phylldes tumor to the departament of surgery of the Hospital General San Juan de Dios.All patients received preoperative image diagnostic with mammography ultrasound biopsy core needlebiopsy anxd cases with incision or excision biopsy...

Oncological results of oncoplastic breast-conserving surgery: Long term follow-up of a large series at a single institution: A matched-cohort analysis.

PURPOSE: Oncoplastic surgery is a well-established discipline that combines conserving treatment for breast cancer with immediate plastic reconstruction. Although widely practiced, the oncologic outcomes of this combined approach are reported only in small series. The aim of the present paper is to assess the safety of oncoplastic surgery for invasive primary breast cancer. METHODS: We compared 454 consecutive patients who underwent an oncoplastic approach between 2000 and 2008 for primary invasive breast tumors (study group) with twice the number of patients who received conservation alone in the same interval time (control group). Disease free survival and overall survival were estimated using the Kaplan-Meier method. The log-rank test was used to assess differences between groups. RESULTS: The median follow-up was 7.2 years. The overall survival is similar within the two groups, being 91.4% and 91.3% at 10-yr in the study group and in the control group respectively. The disease free survival is slightly lower in the oncoplastic group (69 vs.73.1% at 10-yr). The difference is not statistically significant. DISCUSSION: We have compared a large series of primary breast cancer patients that have undergone oncoplastic surgery (454) with a control group (908) and they were followed for a prolonged period of time. It provides the best available evidence to suggest that oncoplastic surgery is a safe and reliable treatment option for the managing of invasive breast cancer.

Bilateral Mastectomy versus Breast-Conserving Surgery for Early-Stage Breast Cancer: The Role of Breast Reconstruction.

BACKGROUND: Although breast-conserving surgery is oncologically safe for women with early-stage breast cancer, mastectomy rates are increasing. The objective of this study was to examine the role of breast reconstruction in the surgical management of unilateral early-stage breast cancer. METHODS: A retrospective cohort study of women diagnosed with unilateral early-stage breast cancer (1998 to 2011) identified in the National Cancer Data Base was conducted. Rates of breast-conserving surgery, unilateral and bilateral mastectomy with contralateral prophylactic procedures (per 1000 early-stage breast cancer cases) were measured in relation to breast reconstruction. The association between breast reconstruction and surgical treatment was evaluated using a multinomial logistic regression, controlling for patient and disease characteristics. RESULTS: A total of 1,856,702 patients were included. Mastectomy rates decreased from 459 to 360 per 1000 from 1998 to 2005 (p < 0.01), increasing to 403 per 1000 in 2011 (p < 0.01). The mastectomy rates rise after 2005 reflects a 14 percent annual increase in contralateral prophylactic mastectomies (p < 0.01), as unilateral mastectomy rates did not change significantly. Each percentage point of increase in reconstruction rates was associated with a 7 percent increase in the probability of contralateral prophylactic mastectomies, with the greatest variation explained by young age(32 percent), breast reconstruction (29 percent), and stage 0 (5 percent). CONCLUSIONS: Since 2005, an increasing proportion of early-stage breast cancer patients have chosen mastectomy instead of breast-conserving surgery. This trend reflects a shift toward bilateral mastectomy with contralateral prophylactic procedures that may be facilitated by breast reconstruction availability.

Translating the concept of intrinsic subtypes into an oncoplastic cohort of more than 1000 patients - predictors of recurrence and survival.

INTRODUCTION: A paradigm shift in breast cancer was introduced by Sørlie's concept of intrinsic subtypes [1]. We validated this concept - which was originally based on 84 individuals - in a large cohort study of 1035 patients with oncoplastic surgery and analyzed if early and late recurrences are linked to a specific intrinsic tumor subtype or resection margins. MATERIALS AND METHODS: 1035 patients with oncoplastic surgery (2004-2009) were analyzed with regard to treatment characteristics and patterns of early (<5 years) and late recurrence (>5 years) and survival related to the intrinsic subtypes. Data was retrieved from patient's charts, customized patients questionnaires and cancer registries. RESULTS: 944 patients with primary, unilateral breast cancer, median age 58 years, were eligible for analysis. At a median FU of 5.2 years, LRR was 4.0%, 5-year-OS 94.5% and DFS 90.9%. Intrinsic subtypes, but not T-size, nodal-status, resections margins nor histopathology, governed local control and survival. There was no signal for prevelance of unclear margins in any of intrinsic subgroups and no preference of any oncoplastic technique attributed to them. TNBC and Her2 non-luminal breast cancer had highest recurrence and lowest survival rates. Although sentinel involvement (SLN+) was prevailing in the Luminal-B-Her 2 negative subtype at 34.3%, this did not translate into a higher axillary dissection rate. CONCLUSION: This study confirmed the intrinsic subtype concept on a large clinical basis and describes the patterns of early and late recurrence in oncoplastic surgery, concluding that bigger risk may not be overcome by bigger surgery.

Does breast reconstruction after mastectomy for breast cancer affect overall survival? Long-term follow-up of a retrospective population-based cohort.

BACKGROUND: This study compared overall and breast cancer-specific survival using long-term follow-up data among women diagnosed with invasive breast cancer undergoing mastectomy or breast reconstruction. METHODS: Retrospective study using population-based data from Ontario Cancer Registry (1980 to 1990) including women receiving breast reconstruction within 5 years after mastectomy and controls of age- and cancer histology-matched women with mastectomy alone. We compared overall and breast cancer-specific survival using an extended Cox hazards model. Secondary analysis examined conditional survival across early, intermediate, and late follow-up. RESULTS: Seven hundred fifty-eight matched pairs formed the cohort, with a median follow-up of 23.4 years (interquartile range, 1.1 to 33.0 years). Fewer breast reconstruction patients died overall or from breast cancer compared with controls (overall survival, 44.5 percent versus 56.7 percent, p < 0.0001; breast cancer-specific survival, 31.8 percent versus 42.6 percent, p = 0.0002, respectively). Breast reconstruction was associated with a 17 percent reduced risk of death and a 19 percent reduced risk of breast cancer death, after adjustment (overall survival hazard ratio, 0.83; 95 percent CI, 0.72 to 0.96; breast cancer-specific survival hazard ratio, 0.81; 95 percent CI, 0.68 to 0.99). Among 885 women (58 percent) surviving 20 or more years, there was no difference in risk of death from breast cancer (hazard ratio, 0.59; 95 percent CI, 0.31 to 1.10). CONCLUSION: In a large cohort with invasive breast cancer followed over 20 years, there is no evidence that breast reconstruction is associated with worse survival outcomes compared with mastectomy alone. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Effect of implant vs. tissue reconstruction on cancer specific survival varies by axillary lymph node status in breast cancer patients.

BACKGROUND: To compare the breast cancer-specific survival (BCSS) between patients who underwent tissue or implant reconstruction after mastectomy. METHOD: We used the database from Surveillance, Epidemiology, and End Results (SEER) registries and compared the BCSS between patients who underwent tissue and implant reconstruction after mastectomy. Cox-regression models were fitted, adjusting for known clinicopathological features. The interaction between the reconstruction types (tissue/implant) and nodal status (N-stage) was investigated. RESULTS: A total of 6,426 patients with a median age of 50 years were included. With a median follow up of 100 months, the 10-year cumulative BCSS and non-BCSS were 85.1% and 95.4%, respectively. Patients who underwent tissue reconstruction had tumors with a higher T-stage, N-stage, and tumor grade and tended to be ER/PR-negative compared to those who received implant reconstruction. In univariate analysis, implant-reconstruction was associated with a 2.4% increase (P = 0.003) in the BCSS compared with tissue-reconstruction. After adjusting for significant risk factors of the BCSS (suggested by univariate analysis) and stratifying based on the N-stage, there was only an association between the reconstruction type and the BCSS for the N2-3 patients (10-year BCSS of implant vs. tissue-reconstruction: 68.7% and 59.0%, P = 0.004). The 10-year BCSS rates of implant vs. tissue-reconstruction were 91.7% and 91.8% in N0 patients (P>0.05) and 84.5% and 84.4% in N1 patients (P>0.05), respectively. CONCLUSIONS: The implant (vs. tissue) reconstruction after mastectomy was associated with an improved BCSS in N2-3 breast cancer patients but not in N0-1 patients. A well-designed, prospective study is needed to further confirm these findings.