Preoperative chemotherapy decreases the need for re-excision of breast cancers between 2 and 4 cm diameter.

INTRODUCTION: It is accepted that preoperative chemotherapy can result in increased breast preservation for breast cancers greater than 4 cm. The benefits of preoperative chemotherapy are less clear, however, for patients who present with smaller tumors and are already candidates for breast-preserving surgery. The goal of this study is to assess the effect of preoperative chemotherapy on breast cancers between 2 and 4 cm diameter. METHODS: A retrospective chart review was conducted of patients diagnosed with new breast cancer at the Yale-New Haven Breast Center for the years 2002-2007. Patients were included in the study if their breast cancer was between 2 and 4 cm and their initial surgical treatment had been completed. Patients with distant metastases were excluded. RESULTS: There were 156 new cancers that met study requirements. Forty-seven patients underwent preoperative chemotherapy, and 109 patients had their surgery first, usually followed by chemotherapy. Initial surgery was lumpectomy for 31 out of 47 patients (66%) in the preoperative chemotherapy group compared with 62 out of 109 patients (57%) in the surgery group. For patients with lumpectomies, 2 out of 31 patients (6%) in the preoperative group had positive margins and required re-excision compared with 20 out of 62 patients (37%) in the surgery-first group (P<0.01). CONCLUSIONS: We conclude that, for tumors between 2 and 4 cm, preoperative chemotherapy is associated with a significantly decreased rate of re-excision following lumpectomy. This not only results in fewer mastectomies, but also avoids the morbidity and inferior cosmetic results associated with a re-excision lumpectomy.

What do breast surgeons do?

BACKGROUND: There are an increasing number of fellowship-trained breast surgeons and surgical oncologists who dedicate their clinical practice exclusively to breast disease. However, there are little published data regarding characteristics of a breast surgical practice. METHODS: All patient visits at a university-based breast surgery practice were reviewed for calendar years 2006 and 2007. RESULTS: There were 10,381 patient visits, of which 2,334 (22%) represented new patients. Of these, 11% were referred with a diagnosis of cancer. Out of the remainder, 29% had a needle biopsy (8% by the surgeon and 21% by radiology), 29% underwent surgery, and 13% were ultimately diagnosed with cancer. After completion of initial therapy, 6 months or 1 year follow-up was recommended for 59% of the patients. CONCLUSIONS: The specialty of breast surgery is unique in its nonoperative volume and extensive duration of follow-up. Strategies need to be designed to make this process more time-efficient for the surgeon.

Breast sentinel lymph node dissection before preoperative chemotherapy.

HYPOTHESIS: Timing of sentinel lymph node dissection (SLND), before or after preoperative chemotherapy (PC), for breast cancer is controversial. DESIGN: Single-institution experience with SLND before PC. SETTING: Data from prospectively collected Yale-New Haven Breast Center Database. PATIENTS: Fifty-five SLNDs were performed before PC for invasive breast cancer in clinically node-negative patients between October 1, 2003, and September 30, 2007. The results are compared with patients who underwent SLND and definitive breast and axillary surgery before chemotherapy (control group; n = 463 SLNDs). INTERVENTIONS: If sentinel nodes (SNs) were negative before PC, no axillary lymph node dissection (ALND) was performed. If SNs were positive, ALND was performed after PC at the time of definitive breast surgery. MAIN OUTCOME MEASURES: Sentinel node identification rate, false-negative rate, rate of positivity, and rate of residual disease in axilla. RESULTS: Of the 55 SLNDs performed before PC, 30 (55%) had a positive SN. The SN identification rate was 100% and the clinical false-negative rate was 0%. In the control group of those with a positive SN, 55% (56 of 101 patients) had no additional positive nodes, 25% (25 of 101) had 1 to 3 positive nodes, and 20% (20 of 101) had 4 or more positive nodes. In the group with a positive SN before PC, 69% (18 of 26 patients) had no additional positive nodes after PC, 27% (7 of 26) had 1 to 3 nodes, and 4% (1 of 26) had 4 or more nodes. Among the SN-positive patients, a pathologic complete response in the breast was found in 4 of 18 patients who had a tumor-free axilla after PC. CONCLUSIONS: Sentinel lymph node dissection before PC allows accurate staging of the axilla for prognosis and treatment decisions. Despite downstaging by PC, a significant percentage of patients had residual nodal disease in the axillary dissection.