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RESUMO Introdução: O câncer de mama é a segunda neoplasia mais comum entre as mulheres. A constante evolução científica tem permitido abordagens cirúrgicas cada vez menos invasivas, diminuindo a morbidade relacionada ao tratamento sem prejuízo oncológico. O objetivo deste artigo é mostrar os resultados cirúrgicos e a versatilidade da mamoplastia redutora com a técnica de Pitanguy modificada, para otimização da reconstrução imediata associada à cirurgia oncológica. Métodos: Apresentamos os casos de três pacientes submetidas à técnica proposta. A marcação da mama com diagnóstico de câncer é planejada seguindo os princípios da mamoplastia redutora descrita por Pitanguy. Porém, o triângulo de ressecção inferolateral é transposto para a área supratumoral. Ele pode ser posicionado da junção dos quadrantes laterais (JQL) até o quadrante superolateral (QSL) da mama oncológica. Resultados: As três pacientes foram submetidas à técnica descrita associada à mamoplastia de simetrização contralateral com a técnica de Pitanguy. Todas realizaram radioterapia adjuvante, associada ou não à quimioterapia. Duas pacientes evoluíram sem intercorrências e uma apresentou pequena necrose de 1x1cm na junção inferior dos retalhos na mama com câncer, que foi tratada de maneira conservadora sem atrasar o tratamento adjuvante. Todas seguem satisfeitas com o resultado estético. Conclusão: A técnica descrita mostrou-se uma boa alternativa para tumores localizados entre a JQL e o QSL da mama oncológica, proporcionando ressecções mais amplas e dessa forma ampliando a indicação de cirurgia conservadora e reduzindo a necessidade de cirurgia radical, com melhores resultados estéticos sem prejuízo do desfecho oncológico. ABSTRACT Introduction: Breast cancer is the second most common cancer among women. Constant scientific evolution has allowed increasingly less invasive surgical approaches, reducing treatment-related morbidity without cancer damage. The objective of this article is to show the surgical results and the versatility of reduction mammoplasty with the modified Pitanguy technique to optimize the immediate reconstruction associated with cancer surgery. Methods: We present the cases of three patients who underwent the proposed technique. Marking of the breast diagnosed with cancer is planned following the principles of reduction mammoplasty described by Pitanguy. However, the inferolateral resection triangle is transposed into the supratumoral area. It can be placed from the junction of the lateral quadrants (JLQ) to the superolateral quadrant (SLQ) of the oncological breast. Results: the three patients underwent the described technique associated with contralateral symmetrization mammoplasty with the Pitanguy technique. All were submitted to adjuvant radiation therapy, associated or not with chemotherapy. Two patients progressed without incident and one had a small necrosis of 1x1 cm at the flaps lower junction in the breast with cancer, which was treated conservatively without delaying the adjuvant treatment. All were satisfied with the aesthetic result. Conclusion: The described technique proved to be a good alternative for tumors located between the JLQ and the SLQ of the oncological breast. It provides broader resections and thus expands the indication for conservative surgery and reduces the need for radical surgery, with better aesthetic results without impairment of the cancer outcome

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.

Age is a risk factor for breast cancer in females, and over 60% of female breast cancer deaths occur in those aged 65 and older. As the population in the United States continues to age, it is expected that there will be a commensurate increase in the number of women diagnosed with breast cancer, making understanding of effective treatment and management of breast cancer in the elderly essential. Here, we review the treatment and management of early breast cancer in the elderly. We report a case of invasive mucinous carcinoma in an 80-year-old female detected on routine clinical breast exam by her primary care physician. Mucinous carcinoma of the breast is a type of rare invasive neoplasm that generally carries an excellent prognosis. Following an ultrasound-guided core needle biopsy, a right breast needle localized segmental mastectomy was performed and the patient was prescribed an aromatase inhibitor for hormone-receptor positive tumor. After a follow-up of 8 years, the patient remains free of recurrence or metastasis and vibrantly living meaningful daily life.

We present a case of a 49-year Turkish woman who had synchronous renal leiomyoma and breast cancer. The patient was evaluated for a suspicious breast mass; and renal mass was detected incidentally by contrast-enhanced computed tomography (CT). Diagnostic tru-cut biopsy was performed for both masses. Breast mass biopsy was reported as invasive ductal carcinoma (IDC) while renal biopsy was described as benign mesenchymal tumour. According to the biopsy results, the renal mass was followed for six months. For breast cancer, segmental mastectomy and concomitant sentinel lymph node biopsy was performed. Histologically, the tumour was reported as IDC and low-grade cribriform ductal carcinoma in situ (less than 1%). Six months later, renal mass was excised by laparoscopic approach. Histopathological examination was consistent with renal leiomyoma. For both tumours, no recurrence within one year was found on follow-up. Key Words: Renal leiomyoma, Breast cancer, Laparoscopy.

Objective Few studies analyzed the safety of salvage nipple-sparing mastectomy (NSM) for local relapse treatment. We evaluated the outcomes of patients with indications for mastectomy who chose to undergo NSM for ipsilateral breast tumor recurrence (IBTR). Methods Between January 2001 and December 2018, we evaluated 24 women who underwent NSM for local relapse after conservative surgery. Results Thepatientswere followedupfor amean time of132months since thefirst surgery. After the NSM, 5 (20.8%) patients were diagnosed with local recurrence and only 1 (4.2%) patient died. The patients presented 4.8% (2) of partial and 2.4% (1) of total nipple necrosis. Conclusion In this long-term follow-up since the first surgery, we observed low rates of complication and good survival, although associated with high local recurrence in patients diagnosed with IBTR undergoing NSM as salvage surgery.We demonstrated that NSMmay be considered after IBTR for patients who did not want to undergo total mastectomy. Resumo Objetivo Há poucos estudos sobre a segurança de se realizar adenomastectomia (nipple-sparing mastectomy, NSM, em inglês) para tratamento de recidiva local. O objetivo deste estudo foi avaliar os resultados de pacientes com indicação para mastectomia que optaram por se submeter a NSM para o tratamento de recorrência local. Métodos Foram analisadas 24 pacientes submetidas a NSM para tratamento de recidiva local após tratamento conservador entre janeiro de 2001 e dezembro de 2018. Resultados As pacientes foramacompanhadas por um períodomédio de 132meses a partir da primeira cirurgia. Após a NSM, 5 (20,8%) pacientes foram diagnosticadas com recorrência local, e apenas 1 paciente foi a óbito. As pacientes apresentaram 4,8% de necrose parcial e 2,4% de necrose total do mamilo. Conclusão Em um longo período de acompanhamento desde a primeira cirurgia, foram observadas baixas taxas de complicação pós-operatória e boa sobrevida, porém, associadas comuma alta taxa de recorrência local em pacientes submetidas a NSM para tratamento de recidiva local após cirurgia conservadora. Neste estudo, demonstrou-se que a NSM pode ser considerada uma opção cirúrgica para pacientes que não querem se submeter a mastectomia total.

■ RESUMO Introdução: Como o câncer de mama é a doença maligna mais prevalente em todo o mundo, o tratamento conservador é de extrema importância. No entanto, em muitos casos, a mastectomia continua sendo o procedimento cirúrgico indicado e, como qualquer outra amputação, leva um fardo significativo para essas pacientes. No caso da mastectomia, a reconstrução imediata da mama é o tratamento padrão. A reconstrução aloplástica continua sendo o tipo mais amplamente realizado de reconstrução mamária imediata. Métodos: Neste artigo, os autores apresentam uma série de 105 casos de reconstrução aloplástica imediata em 5 anos de 2015 a 2019 no Centro Hospitalar e Universitário de Coimbra, Portugal. Inclui mastectomias curativas e redutoras de risco realizadas por ginecologistas oncológicos. As opções de reconstrução oferecidas pela equipe de reconstrução plástica incluíram tanto a reconstrução direta no implante quanto a reconstrução em dois estágios com o uso de expansores de tecido. Resultados: Dados sobre a doença oncológica, tipo de mastectomia, critérios de seleção das pacientes e resultados pós-operatórios imediato e tardio com diferentes técnicas de reconstrução imediata foram coletados, analisados e comparados com a literatura. Em nosso estudo, o índice de massa corporal foi o único preditor mais significativo de complicações e seu impacto foi estatisticamente significativo. Conclusão: Os resultados obtidos representam uma etapa essencial para a melhoria da qualidade da assistência à mulher em reconstrução mamária. ■ ABSTRACT Introduction: With breast cancer being the most prevalent malignancy worldwide, conservative treatment is of tremendous importance. Nevertheless, in many cases, mastectomy remains the indicated surgical procedure, and like any other amputation, it carries a significant burden on those patients. In the case of mastectomy, immediate breast reconstruction is the standard of care. Alloplastic reconstruction remains the most widely performed type of immediate breast reconstruction. Methods: In this article, the authors present a series of 105 cases of immediate alloplastic reconstruction in 5 years from 2015 to 2019 in Centro Hospitalar e Universitário de Coimbra, Portugal. It includes curative and risk-reducing mastectomies performed by oncologic gynecologists. The reconstruction options offered by the plastic reconstructive team included both direct-to-implant reconstruction and two-stage reconstruction with the use of tissue expanders. Results: Data regarding the oncologic disease, type of mastectomy, patient selection criteria and immediate and late postoperative outcomes with different techniques of immediate reconstruction were collected, analyzed, and compared to literature. In our study, body mass index was the single most significant predictor of complications and, its impact was statistically significant. Conclusion: The results obtained represent an essential step to improving care quality for women undergoing breast reconstruction.

Amaç: Primer meme neoplazilerinin %0,3-1’ini oluşturan nadir görülen fibroepitelyal meme tümörü ’dür. Klinik, radyolojik ve histopatolojik olarak fibroadenomlar ile karışırlar. Bu yazıda, filloides meme tümörü nedeni ile tedavi edilen hastalarımızın demografik özellikleri, klinikopatolojik bulguları, takip sonuçları ve uygulanan tedavi yöntemlerinin incelenmesi amaçlanmıştır.Gereç ve Yöntem: Ocak 2010-Temmuz 2019 tarihleri arasında tedavi edilen 24 filloides tümör hastasının verileri retrospektif olarak incelendi.Bulgular: Yaş ortalaması 44,1 (20-64) yıl idi. En sık başvuru semptomu hızlı büyüyen kitle idi. Hastalık 12 hastada sağ memede, 2 hastada bilateral idi. Biyopsi yöntemi olarak, 10 hastada tru-cut biyopsi, 13 hastada eksiyonel, 1 hastada insizyonel biyopsi kullanıldı. Eksizyonel biyopsi (n:6), segmental mastektomi(n:11) ve mastektomi (n:7) uygulanan cerrahi prosedürler idi. Ortalama tümör boyutu 64,6 mm(20-220) olarak saptandı. Histopatolojik olarak, 9 benign, 6 borderline ve 9 malign filloides tümör tanısı konuldu. Ortalama takip süresi 18 (6-82)ay idi. Takipte, malign filloides tümörlü 4 hastada lokal nüks, 1 hastada uzak metastaz tespit edildi. 3 hasta kemoterapi ve 2 hasta radyoterapi tedavisi aldı. Sonuç: Filloid tümörler nadir görülen, miks tip meme tümörleridir. Klinik, radyolojik ve histopatolojik olarak meme fibroadenomları ile karışabilmektedir. Uygun cerrahi tedavinin yapılabilmesi için tru-cut biyopsi ile ameliyat öncesi tanının konulması önemlidir. Aksi taktirde re-operasyon ve lokal nüks oranları artmaktadır., Purpose: Phyllodes tumoris a rare fibroepithelial breast tumor that constitutes 0.3-1% of primary breast neoplasms. They are confused with fibroadenomas, clinically, radiologically and histopathologically. In this article, it is aimed to examine the demographic characteristics, clinicopathological findings, follow-up results and treatment methods of our patients treated due tophyllodes tumor.Materials and Methods: The data of 24 phyllodes tumor patients treated between January 2010 and July 2019 were analyzed retrospectively.Results: The average age was 44.1 (20-64) years. The most common symptom was the fast growing mass. The disease was on the right breast in 12 patients and bilateral in 2 patients. As a biopsy method, true-cut biopsy was used in 10 patients, excisional biopsy in 13 patients, and incisional biopsy in 1 patient. Excisional biopsy (n: 6), segmental mastectomy (n: 11) and masectomy (n: 7) were surgical procedures applied. The mean tumor size was determined as 64.6 mm (20-220). Histopathologically, 9 benign, 6 borderline and 9 malignant phyllodes tumors were diagnosed. The mean follow-up was 18 (6-82) months. During follow-up, local recurrence was detected in 4 patients and distant metastasis in 1 patient. 3 patients received chemotherapy and 2 patients received radiotherapy.Conclusion: Phyllodes tumors are rare, mixed-type breast tumors. It can be mixed clinically, radiologically and histopathologically with breast fibroadenomas. It is important to make a preoperative diagnosis with tru-cut biopsy for proper surgical treatment. Otherwise, re-operation and local recurrence rates increase.

Purpose: Radiation recall dermatitis (RRD) is a rare complication that occurs after completion of radiation therapy (RT) and initiation of a precipitating agent, most commonly chemotherapeutic medications. Various theories attempt to explain the mechanism, including activation of the body’s inflammatory pathways through nonimmune activation. Likewise, radiation-induced organizing pneumonia (RIOP) is an infrequent but potentially life-threatening complication of RT that, while not fully understood, is suspected to be partly an autoimmune reaction. Patient: We present the case of a 71-year-old female with a history of type 2 diabetes mellitus, hypothyroidism, interstitial cystitis, and osteoarthritis who presented with clinical stage T1N0M0 ER+/PR–/HER2– invasive ductal carcinoma of the lower outer quadrant of the left breast, for which she underwent left segmental mastectomy and sentinel lymph node biopsy followed by completion axillary lymph node dissection. Her final pathologic stage was T1N1M0. Result: The patient developed RRD and later RIOP following receipt of radiation and chemotherapy, which resolved with steroid administration. Conclusions: The rarity of both RRD and RIOP occurring in a patient, as in our case, suggests a shared pathophysiology behind these two complications. As both reactions involve some degree of inflammation and respond to corticosteroids, it seems likely that the etiologies of RRD and RIOP lie within the inflammatory pathway. However, further investigation should evaluate the frequency, duration, and triggering of concomitant RRD and RIOP.

Introduction: Breast cancer is the second most common malignant neoplasm in women. Surgical intervention is one of the recommended treatments, which can lead to significant physical and sensorial sequelae. Objective: To analyze the musculoskeletal, cardiorespiratory, anthropometric and sensorial functions of women who underwent breast cancer surgery. Methods: An observational, cross-sectional study with women who underwent surgical resection of breast tumors at Amaral Carvalho, a reference hospital in the countryside of the São Paulo State, Jaú/SP, Brazil. Three assessments were obtained: pre-surgery (Ass1), one day after the surgery (Ass2) and 15 days after surgery (Ass3). Sociodemographic and gynecological data were collected, and anthropometric, cardiovascular, dermal sensitivity, range of motion (ROM) of the upper limbs, peripheral oxygen saturation (SpO2), inspiratory muscle strength (PImax), peak expiratory flow (PEF) and thoraco-abdominal mobility assessments were performed. Data were evaluated by repeated measures ANOVA and Wilcoxon statistical test with a Bonferroni correction (p < 0.05). Results: Eighteen women, with a mean age of 57.44 ± 9.35 years, mainly with the left side affected (61.1%) and lymphadenectomy performed in 50% of the cases. Differences were found in systolic and diastolic blood pressure, PEF and SpO2, axillary ROM index (Ass1>Ass2), PImax (Ass3>Ass2), perimetry (Ass2>Ass3), ROM in all axes of shoulder motion and wrist flexion (Ass2Ass2 and Ass1). Conclusion: The surgery for breast cancer excision resulted in hemodynamic and respiratory changes, especially on the first day after the procedure, returning to baseline values approximately 15 days later. Resumo Introdução: O câncer de mama é a segunda neoplasia maligna mais encontrada entre as mulheres, sendo a intervenção cirúrgica um dos tratamentos preconizados, o que pode acarretar sequelas físicas e sensoriais importantes. Objetivo: Analisar as funções musculoes-queléticas, cardiorrespiratórias, antropométricas e sensoriais de mulheres submetidas ao procedimento cirúrgico para neoplasia mamária. Métodos: Estudo observacional e transversal com mulheres que realizaram procedimento cirúrgico para ressecção de neoplasia mamária assistidas no interior paulista, Jaú/SP. Foram realizadas três avaliações: pré-cirurgia (AV1), um dia (AV2) e 15 dias após a cirurgia (AV3). Foram coletadas informações sociodemográficas e ginecológicas e realizadas avaliações antropométrica, cardiovascular, sensibilidade dérmica, amplitude de movimento (ADM) dos membros superiores, saturação periférica de oxigênio (SpO2), força muscular inspiratória (PImax), pico de fluxo expiratório (PFE) e mobilidade toracoabdominal. Os dados foram avaliados pelo teste estatístico ANOVA de medidas repetidas e Wilcoxon com correção de Bonferroni (p < 0,05). Resultados: Dezoito mulheres, de 57,44 ± 9,35 anos, tiveram o lado esquerdo mais acometido (61,1%) e a linfonodectomia foi realizada em 50% dos casos. Houve diferenças nas variáveis pressão arterial sistólica e diastólica, PFE e SpO2, índice de amplitude axilar (AV1>AV2), PImax (AV3>AV2), perimetria (AV2>AV3), ADM em todos os eixos de movimento do ombro e em flexão de punho (AV2AV2 e AV1). Conclusão: A cirurgia para exerese de neoplasia mamária acarretou alterações principalmente hemodinâmicas e respiratórias, sobremaneira no primeiro dia após a cirurgia, retornando aos valores basais aproxi-madamente 15 dias após o procedimento.

Introduction Fibroepithelial lesions of the breast (FEL) are heterogeneous lesions ranging from fibroadenomas (FA) to phyllodes tumors (PT). FEL with cellular stroma are diagnostic challenges on core needle biopsy (CNB) as it is difficult to distinguish cellular FA from PT. The purpose of this study was to determine the features of FEL on CNB that may be predictive of PT, the upstage rate to PT after excision, and the outcomes of those who did not undergo excision. Methods Overall, 305 patients with FEL on CNB between 2009 and 2019 were identified from a prospectively maintained institutional database. Presentation, imaging, and pathology were evaluated. Results Mean age at diagnosis was 43.8 years. Pathology on CNB included 97 cases of FEL favoring FA, 19 cases of FEL favoring PT, 3 cases of FEL versus pseudoangiomatous stromal hyperplasia, and 186 cases of FEL not otherwise specified. Following CNB, 96 (31.5%) patients were observed, 158 (51.8%) patients had an excisional biopsy, 48 (15.7%) patients underwent segmental mastectomy, and 3 (1.0%) patients underwent a mastectomy. The upgrade rate from FEL on CNB to PT upon excision was 25.8%. PT on final pathology was more commonly seen when the CNB identified stromal overgrowth, necrosis, and diagnosis of FEL favoring PT. On multivariable analysis, a final diagnosis of PT was associated with age >50 years, larger tumor size >2 cm, stromal overgrowth, and ≥1 mitoses/10 high power fields (HPF) on CNB. Patients who were observed had smaller tumors compared with those who underwent excision. Conclusion In this 10-year single-institution experience of FEL, the upstage rate to PT was 25.8%. Excision of FEL is recommended. Furthermore, the observation of lesions appeared to be safe in select cases, specifically in patients with smaller tumor size.

Resumen La enfermedad de Paget mamaria es una neoplasia infrecuente de la mama, muchas veces de difícil diagnóstico y mal pronóstico. El objetivo es revisar los aspectos fundamentales clínicos, diagnósticos, así como los avances más recientes en su tratamiento. Se realizó una búsqueda bibliográfica a través de PUBMED, GOOGLE SCHOLAR y UPTODATE, de los últimos 20 años. Fueron seleccionados e incluidos en la revisión 38 artículos. La enfermedad de Paget mamaria es una neoplasia maligna infrecuente del complejo areola pezón de características inflamatorias al examen físico, asociado en un 85% de los casos a un cáncer de mama subyacente, en el 50% de los casos no identificable al examen físico, de difícil diagnóstico, cuya sospecha clínica se confirma con imágenes, biopsia e inmunohistoquímica. El tratamiento es mastectomía versus cirugía conservadora y radioterapia. Un mal enfoque clínico, retrasa el diagnóstico y empeora la sobrevida. MÉD.UIS.2021;34(1): 45-53. Abstract Paget’s disease of the breast is an uncommon neoplasm of the breast, many times difficult to diagnose and of poor prognosis. The objective is to review the fundamental clinical and diagnostic aspects, as well as the most recent advances in its treatment. A bibliographic search of the last 20 years was carried out through PUBMED, GOOGLE SCHOLAR and UPTODATE. 38 articles were selected and included in the review. Mammary paget disease is a rare malignant neoplasm of the nipple areola complex with inflammatory features on physical examination, associated in 85% of cases with underlying breast cancer, in 50% of cases not recognizable on physical exam, difficult to diagnose, whose clinical suspicion is confirmed by imaging, biopsy and immunohistochemistry. Treatment is mastectomy versus conservative surgery and radiotherapy. A poor clinical approach delays the diagnosis and worsens survival rate. MÉD.UIS.2021;34(1): 45-53.

Background In addition to conventional breast‐conserving surgery (BCS), oncoplastic breast surgery (OBS) is an operation technique that strives simultaneously to increase oncological safety and patient's satisfaction. It is the combination of the best‐proven techniques in plastic surgery with surgery for breast cancer. In a growing number of indications, OBS overcomes the limit of conventional BCS by allowing larger resection volumes while avoiding deformities. The aim of our retrospective study (2012–2014) was to compare oncological outcomes of OBS versus BCS. Methods We compared two groups of patients with primary non‐metastatic breast tumours: group A (n = 291), where BCS was performed, versus group B (n = 52), where OBS was performed. Surgical interventions were performed in German and Swiss teaching hospital settings. The surgeon for group B had subspecialist training in OBS. We assessed outcome in term of re‐excision rates, resection margin and complications. Results Groups were homogenous (no significant differences in terms of age, tumour size, tumour type or grade). The resection margin was larger in group B (7 mm) than in group A (3 mm). Re‐excision rate of group B (8%) was significantly lower than in group A (31%). Complication rates were comparably low in groups A and B. Conclusion Despite the limits of retrospective design, our study confirms that OBS is safe and reduces the re‐excision rates and the need for further surgery. OBS has the potential to improve oncological care and should be more widely adopted., Oncoplastic breast surgery is oncologically safe, allows large resection volumes, achieving more frequently clear margins. The re‐excision rates are three times lower than with conventional surgery group. The need for additional surgery is drastically reduced.

BACKGROUND Few guidelines exist for an opioid prescription after breast surgical oncology (BSO) procedures. We sought to characterize opioid prescribing and use patterns by surgery type. METHODS Patients (n = 332) undergoing BSO procedure were surveyed one week postoperatively for opioid use. The surgeons were surveyed about pain management preferences surgery type. CPT codes were collected for 2017 to calculate the amount of opioids used by surgery type relative to surgeon preference. RESULTS Mean oral morphine equivalent (OME) preferred prescription for surgeons who did not tailor prescriptions by surgery type (n = 7, group A) was 177, whereas for those who did tailor (n = 10, group B) varied from 137 to 257 OME. There was a significant difference in opioid use by surgery type: 32 OME for segmental mastectomy (SM) ± sentinel lymph node dissection (SLND), 63 for SM + axillary lymph node dissection (ALND), 76 for total mastectomy (TM) ± SLND, 115 for TM + ALND (P

PAST and PRESENT TRENDS in the MANAGEMENT of the PATIENT WITH BREAST CANCER. Organizing for Collaborative Management: What are the Options? Management of Primary Breast Cancer: A Biologic and Therapeutic Review. Coping with Breast Cancer: What Health Professionals Can Do to Help. Payments for Breast Cancer During 1985: The Michigan Blue Cross/Blue Shield Experience. Legal Requirements of Informed Consent for Treatment of Breast Cancer: Telling It All. Epidemiology of Breast Cancer. DIAGNOSIS and DECISION MAKING. Evaluation of Breast Masses. Mammography: Changing Role and Concepts. Fine Needle Aspiration: The New Diagnostic Technique? Technique of Segmental Mastectomy: The National Surgical Adjuvant Breast Project (NSABP) Experience. The Changing Role of the Pathologist in the Diagnosis of Breast Lesions. MANAGEMENT of the PATIENT WITH BREAST CANCER. The Surgeon's Role in the Management of the Patient with Breast Cancer. The Treatment of Breast Cancer with Excision Followed by Radiation Therapy. Contemporary Chemotherapy. Breast Reconstruction. Management Dilemmas: The Contralateral Breast and the Role of Prophylactic Mastectomy. Dilemmas in Breast Cancer: Occult Carcinoma and Paget's Disease of the Breast. Breast Cancer Management in Pregnancy and Young Women. New Horizons in the Treatment of Breast Cancer. PSYCHOSOCIAL ISSUES and WELLNESS. Multidisciplinary Breast Care Center: Experience at The University of Michigan. Women's Experience of Choice: Confronting the Options for Treatment of Breast Cancer. Coping with Breast Cancer: Psychological Interventions and Skills. Rehabilitation. Diet and Exercise in the Management of the Patient with Breast Cancer. Nursing Management of the Patient with Breast Cancer. Social Work with the Breast Cancer Patient. Update on the Psychosocial Issues of Breast Cancer Treatments.

Paraneoplastic neurologic syndromes (PNS) are a group of disorders characterized by an autoimmune response against the nervous system due to cross-reactivity between malignant and normal neural tissue. The most commonly associated malignancies include small cell lung cancer, ovarian cancer, breast cancer, and lymphoma. Multiple PNS have been reported including paraneoplastic cerebellar degeneration, retinopathy, sensorimotor peripheral neuropathy, encephalopathy, opsoclonus-myoclonus syndrome, and stiff-person syndrome. We report a case of a 67-year-old woman with breast cancer who presented with a history of progressive oropharyngeal dysphagia as a paraneoplastic neurologic complication. She was diagnosed with invasive ductal carcinoma, nuclear grade 3 with moderate peritumoral lymphoid infiltrate. Hormone receptors were weakly positive for estrogen receptor (ER) (H score 15), weakly positive for progesterone receptor (PR) (H score 30), and negative for human epidermal growth factor receptor 2 (HER-2/NEU). The patient underwent a localized segmental mastectomy but declined any further adjuvant treatment. Three years after being diagnosed with invasive ductal carcinoma of the breast, she developed progressive oropharyngeal dysphagia that warranted percutaneous endoscopic gastrostomy (PEG) tube placement. Testing for onconeural antibodies was positive for voltage-gated calcium channel antibody. An extensive workup was negative for any alternative etiology that would explain her neurological symptoms. The patient declined further treatment and eventually succumbed to her illness.

PURPOSE: To evaluate the acceptability and impact of 3D printed breast models (3D-BM) on treatment-related decisional conflict (DC) of breast cancer patients. METHODS: Patients with breast cancer were accrued in a prospective IRB-approved trial. All patients underwent contrast-enhanced breast MRI (MRI). A personalized 3D-BM was derived from MRI. DC was evaluated pre and post 3D-BM review. 3D-BM acceptability was assessed post 3D-BM review. RESULTS: DC surveys before and after 3D-BM review and 3D-BM acceptability surveys were completed by 25 patients. 3D-BM were generated in 2 patients with bilateral breast cancer. The mean patient age was 48.8 years (28–72). Tumor stage was Tis (7), 1 (8), 2 (8) and 3 (4). Nodal staging was 0 (19), 1 (7), 3 (1). Tumors were unifocal (15), multifocal (8) or multicentric (4). Patients underwent mastectomy (13) and segmental mastectomy (14) with (20) or without (7) oncoplastic intervention. Neoadjuvant therapy was given to 7 patients. Patients rated the acceptability of the 3D-BM as good/excellent in understanding their condition (24/24), understanding disease size (25/25), 3D-BM detail (22/25), understanding their surgical options (24/25), encouraging to ask questions (23/25), 3D-BM size (24/25) and impartial to surgical options (17/24). There was significant reduction in overall DC post 3D-BM review, indicating patients became more assured of their treatment choice (p=0.002). Reduction post 3D-BM review was also observed in the uncertainty (p=0.012), feeling informed about options (p=.005), clarity about values (p=0.032) and effective (p=0.002) DCS subscales. CONCLUSIONS: 3D-BMs are an acceptable tool to decrease decisional conflict in breast cancer patients. CLINICAL RELEVANCE: Breast cancer patients may experience decisional conflict when considering their surgical options. 3D-BM are an acceptable, impartial tool that reduces decisional conflict in patients with breast cancer.

Purpose To perform a planned interim analysis of acute (within 12 months) and late (after 12 months) toxicities and cosmetic outcomes after proton accelerated partial breast irradiation (APBI). Methods and Materials A total of 100 patients with pTis or pT1-2 N0 (≤3cm) breast cancer status after segmental mastectomy were enrolled in a single-arm phase 2 study from 2010 to 2019. The clinically determined postlumpectomy target volume, including tumor bed surgical clips and operative-cavity soft-tissue changes seen on imaging plus a radial clinical expansion, was irradiated with passively scattered proton APBI (34 Gy in 10 fractions delivered twice daily with a minimum 6-hour interfraction interval). Patients were evaluated at protocol-specific time intervals for recurrence, physician reports of cosmetic outcomes and toxicities, and patient reports of cosmetic outcomes and satisfaction with the treatment or experience. Results Median follow-up was 24 months (interquartile range [IQR], 12-43 months). Local control and overall survival were 100% at 12 and 24 months. There were no acute or late toxicities of grade 3 or higher; no patients experienced fat necrosis, fibrosis, infection, or breast shrinkage. Excellent or good cosmesis at 12 months was reported by 91% of patients and 94% of physicians; at the most recent follow-up, these were 94% and 87%, respectively. The most commonly reported late cosmetic effect was telangiectasis (17%). The total patient satisfaction rate for treatment and results at 12 and 24 months was 96% and 100%, respectively. Patients’ mean time away from work was 5 days (IQR, 2-5 days), and the median out-of-pocket cost was $700 (IQR, $100-$1600). The mean left-sided heart dose was 2 cGy (range, 0.2-75 cGy), and the mean ipsilateral lung dose was 19 cGy (range, 0.2-164 cGy). Conclusions Proton APBI is a maturing treatment option with high local control, favorable intermediate-term cosmesis, high treatment satisfaction, low treatment burden, and exceptional heart and lung sparing.

Effective intraoperative tumor margin assessment is needed to reduce re-excision rates in breast-conserving surgery (BCS). Mapping the attenuation coefficient in optical coherence tomography (OCT) throughout a sample to create an image (attenuation imaging) is one promising approach. For the first time, three-dimensional OCT attenuation imaging of human breast tissue microarchitecture using a wide-field (up to ~45 × 45 × 3.5 mm) imaging system is demonstrated. Representative results from three mastectomy and one BCS specimen (from 31 specimens) are presented with co-registered postoperative histology. Attenuation imaging is shown to provide substantially improved contrast over OCT, delineating nuanced features within tumors (including necrosis and variations in tumor cell density and growth patterns) and benign features (such as sclerosing adenosis). Additionally, quantitative micro-elastography (QME) images presented alongside OCT and attenuation images show that these techniques provide complementary contrast, suggesting that multimodal imaging could increase tissue identification accuracy and potentially improve tumor margin assessment.

Introduction: Breast cancer is the most common malignant tumour and the second cause of death among women in Poland following lung cancer. Its therapy includes a number of procedures, including surgical treatment, the choice of which depends, among others, on the histological form of the cancer and disease severity. In recent years, radical surgical techniques have been replaced by conserving ones, and in the context of routine resection of the axillary lymph nodes (lymphadenectomy), biopsy was introduced, i.e. sentinel lymph node biopsy (SNB). Also, wide access to reconstructive treatments carried out with various techniques, using patients’ own tissues or artificial materials (breast implants) have been applied. Study aim: The aim of the work is to present the current state of knowledge on the principles of breast cancer treatment and its undesirable consequences, as well as the selection of physiotherapeutic methods depending on the type of upper limb dysfunction as a result of the performed surgery. Research materials: The research materials consist of patients treated using various surgical and oncological methods as well as physiotherapeutic procedures at the Holy Cross Oncology Centre in Kielce, from 2014 to 2016. The written consent of the Clinic Chief and patients for the publication of their image was obtained. The authors of the work do not indicate any conflict of interest. Research Methods: The research methodology was based on the presentation of selected patients treated using various oncological and surgical methods for breast cancer treatment, as well as characterization of the physiotherapeutic methods necessary in restoring expected functional upper limb status in these patients. Conclusions: Modern methods used in breast cancer treatment should be conditioned by good cooperation of an entire team of specialists from various clinical areas and physiotherapists. The purpose of this procedure is to cure the patient, minimize the occurrence of complications and adverse side effects, and restore functional capacity. An integral part of such breast cancer treatment patients is, among others, their effective rehabilitation.

Purpose We evaluated the effect of positive superficial and/or deep margin status on local recurrence (LR) in invasive breast cancer treated with breast-conserving surgery (BCS) followed by radiotherapy. Materials and Methods In total, 3,403 stage 1 and 2 invasive breast cancer patients treated with BCS followed by radiotherapy from January 2000 to December 2008 were included in this study. These patients were divided into three groups according to margin status: clear resection margin status for all sections (group 1, n=3,195); positive margin status in superficial and/or deep sections (group 2, n=121); and positive peripheral parenchymal margin regardless of superficial and/or deep margin involvement (group 3, n=87). The LR-free survival between these three groups was compared and the prognostic role of margin status was analyzed. Results Across all groups, age, tumor size, nodal status, and human epidermal growth factor receptor 2 status did not significantly differ. High grade, positive extensive intraductal component, hormone receptor positivity, hormone therapy received, and chemotherapy not received were more prevalent in groups 2 and 3 than in group 1. Five-year LR rates in groups 1, 2, and 3 were 1.9%, 1.7%, and 7.7%, respectively. Multivariate analysis revealed that group 3 was a significant predictor for LR (hazard ratio [HR], 4.78; p < 0.001), but that positive superficial and/or deep margin was not (HR, 0.66; p=0.57). Conclusion Superficial and/or deep margin involvement following BCS is not an important predictor for LR.

Rhabdomyosarcoma (RMS) is an uncommon type of soft-tissue malignancy which mainly influences children. RMS rarely occurs in breast and little of the clinical behavior and treatment strategies were reported. Here, we describe a case of adult female patient with breast RMS. A 34-years-old Chinese woman visited to our hospital complaining palpable mass in her left breast. Seven months ago, the patient was diagnosed as lymphocytic mastitis and received surgical excision in the left breast. Five months later, she noticed a palpable mass again in the left breast. Ultrasonography suspected a malignant lesion and a diagnosis of RMS was made after segmental mastectomy and immunohistochemical staining. Therapy consisted of mastectomy and following neoadjuvant chemotherapy. The patient has remained disease free 30 months post-operatively. We should consider RMS when we see a breast mass. Tissue biopsy and immunohistochemical staining are recommended for diagnosis of RMS in young women. Oncologists should take immediate and active treatment on RMS.

Similar to mastectomy, breast conserving surgery (BCS) is currently the reference standard of surgical treatment of sporadic breast cancer in patients. However, its oncologic safety for BRCA mutation carriers has remained controversial. Thus, we conducted a systematic review to critically evaluate the best evidence from reported studies. A comprehensive search was performed of the Medline, EMBASE, CINAHL, and Cochrane databases using a predefined strategy. The retrieved studies were independently screened and rated for relevance. Data were extracted for qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol for systematic reviews. No randomized controlled trial has directly compared BCS and mastectomy for BRCA mutation carriers. Of the 18 studies included in our review, the pooled analysis of overall survival at 5, 10, and 15 years were comparable between BCS and mastectomy (88.7%, 89.0% and 83.6% with BCS and 83%, 86.0%, and 83.2% with mastectomy, respectively). However, the pooled ipsilateral breast cancer recurrence rates at 5, 10, and 15 years were higher in the BCS group (8.2%, 15.5%, and 23%, respectively) than in the mastectomy group (3.4%, 4.9%, and 6.4%, respectively). BCS was associated with a greater rate of ipsilateral breast cancer recurrence in BRCA mutation carriers. However, it was not associated with adverse short- and long-term survival outcomes. BCS should be offered as an option to BRCA mutation carriers with proper preoperative counseling.

WOS: 000463175700012, PubMed ID: 31080959, Erector spinae plane (ESP) block is a recently described regional anaesthesia/analgesia technique. Although there is stil no consensus on its mechanism, the published case series seem to promise a new block for both chronic and acute pain. In this case report, the use of ESP block in 47-year-old female patient scheduled for bilateral segmental mastectomy surgery is presented. ESP was formerly reported for rib fracture, bariatric surgery, open abdominal surgery and breast implant surgery. To the best of our knowledge, no article has been published for ESP block in breast cancer surgery including axillary dissection.

Background: In addition to conventional breast‐conserving surgery (BCS), oncoplastic breast surgery (OBS) is an operation technique that strives simultaneously to increase oncological safety and patient's satisfaction. It is the combination of the best‐proven techniques in plastic surgery with surgery for breast cancer. In a growing number of indications, OBS overcomes the limit of conventional BCS by allowing larger resection volumes while avoiding deformities. The aim of our retrospective study (2012–2014) was to compare oncological outcomes of OBS versus BCS. Methods: We compared two groups of patients with primary non‐metastatic breast tumours: group A (n = 291), where BCS was performed, versus group B (n = 52), where OBS was performed. Surgical interventions were performed in German and Swiss teaching hospital settings. The surgeon for group B had subspecialist training in OBS. We assessed outcome in term of re‐excision rates, resection margin and complications. Results: Groups were homogenous (no significant differences in terms of age, tumour size, tumour type or grade). The resection margin was larger in group B (7 mm) than in group A (3 mm). Re‐excision rate of group B (8%) was significantly lower than in group A (31%). Complication rates were comparably low in groups A and B. Conclusion: Despite the limits of retrospective design, our study confirms that OBS is safe and reduces the re‐excision rates and the need for further surgery. OBS has the potential to improve oncological care and should be more widely adopted. Refereed/Peer-reviewed Version of record

Purpose Breast-conserving surgery (BCS) is a surgical method designed to minimize intraoperative tissue injury. Although this technique is minimally invasive, it can cause significant postoperative pain and may be a risk factor for persistent pain. Erector spinae plane block (ESPB) is an easy interfascial plane block for analgesia in patients undergoing breast surgery. The primary outcome was the numeric rating scale scores measured separately on the breast and axilla. Secondary outcomes included correlation between pain score and skin sensitivity test. Methods Forty patients were divided into 2 groups (ESPB group and control group). Patients in the ESPB group received an ESPB 30 minutes before the induction of general anesthesia, whereas patients in the control group did not receive any regional analgesia during the perioperative period. Results Median pain scores of the breast were significantly lower in the ESPB group than that in the control group at 12, 24, and 48 hours after surgery. However, the median pain scores of the axilla were not significantly different between the groups, and the pain score was unrelated to skin sensitivity. Conclusion ESPB can effectively alleviate acute postoperative pain with an opioid-sparing analgesic technique in patients undergoing BCS, and a strong correlation is lacking between pain scores and skin sensitivity test.

Purpose To test clinical feasibility, safety, and toxicity of prone hypofractionated breast, chest wall, and nodal radiation therapy. Methods and materials Following either segmental or total mastectomy with axillary node dissection, patients were treated in an institutional review board–approved prospective trial of prone radiation therapy to the breast, chest wall, and supraclavicular and level III axillary lymph nodes. A dose of 40.5 Gy/15 fractions with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose, 48 Gy) was prescribed. In postmastectomy patients, the same treatment was prescribed, but without a tumor bed boost. The primary endpoint was incidence of >grade 2 acute skin toxicity. The secondary endpoints were feasibility of treatment using prone set-up, compliance with protocol-defined dosimetric constraints, and incidence of late toxicity. A dosimetric comparison was performed between protocol plans (prone) and nonprotocol plans (supine), targeting the same treatment volumes. Results Sixty-nine patients with stage IB-IIIA breast cancer enrolled in this trial. Surgery was segmental mastectomy (n = 45), mastectomy (n = 23), and bilateral mastectomy (n = 1), resulting in 70 cases. None experienced >grade 2 acute skin toxicity according to the Common Terminology Criteria for Adverse Events, v 3.0, meeting our primary endpoint. Ninety-six percent of patients could be treated with this technique prone. However, 17 plans (24%) exceeded protocol constraints to the brachial plexus. Maximum long-term toxicity was 1 grade 2 arm lymphedema, 1 grade 3 breast retraction, and no occurrence of brachial plexopathy. Dosimetric comparison of protocol with nonprotocol plans demonstrated significantly decreased lung and heart doses in prone plans. Conclusions Prone hypofractionated breast, chest wall, and nodal radiation therapy is safe and well tolerated in this study. Although the initial pattern of local and regional control is encouraging, longer follow-up is warranted for efficacy and late toxicity assessment, particularly to the brachial plexus.

Oncoplastic breast conserving surgery (BCS) has emerged as a third option between conventional BCS and mastectomy. Oncoplastic BCS includes two fundamentally different approaches: volume replacement and volume displacement. The former involves partial mastectomy and immediate reconstruction of the breast with the transposition of autologous tissue from elsewhere, while the latter involves partial mastectomy and using the remaining breast tissue to fill the defect resulting from extirpation of the tumor. There are several benefits associated with oncoplastic BCS. First, it allows partial mastectomy without cosmetic penalties, and can achieve better cosmetic outcomes than total mastectomy with immediate breast reconstruction. Second, it avoids the need for total mastectomy in an increasing number of patients without compromising local control. Third, partial breast reconstruction is less extensive and has fewer complications than conventional procedures. Partial mastectomy and partial breast reconstruction can be carried out either simultaneously as a one-stage procedure, or using a two-stage approach. Although patients prefer a one-stage procedure, it requires intraoperative confirmation of complete tumor excision using frozen-section analysis. Moreover, oncoplastic BCS requires combined skills, knowledge, and understanding of both oncological and plastic surgeries, which may be optimally achieved by an oncoplastic surgeon.

Objective: The purpose of this study was to investigate effects of hand grip strength on the muscle activation of shoulder joint in breast cancer patients. Design: Cross-sectional study. Methods: Ten breast cancer patients who agreed to active participation were included. These patients were operated with either conservative surgery or segmental mastectomy, and then were treated with radiation therapy and chemotherapy. The activity of the upper trapezius, lower trapezius, supraspinatus and serratus anterior muscle were measured using surface electrodes during 4 hand gripping tasks (lowered their arms in standing position, 0%, 30%, and 50% of maximum voluntary contraction) in the scapular abduction plane. Results: The results were analyzed using a one-way repeated measures ANOVA. There was a significant difference in the lower trapezius and supraspinatus muscles according to grip strength, lower trapezius and supraspinatus muscles showed significantly difference according to grip strength (p

Wire localization is currently the most widely used localization strategy for excision of nonpalpable breast lesions. Its disadvantages include patient discomfort, wire-related complications such as wire displacement/fracture, and operating room delays related to difficulties during wire placement. We have implemented the technique of intraoperative ultrasound-guided excision using hydrogel-encapsulated (HydroMARK) biopsy clips for lesion localization. We hypothesize that this method is as effective as wire localization for breast conserving therapy. This is a retrospective review of 220 consecutive patients who underwent segmental mastectomy or excisional biopsy using wire localization or hydrogel-encapsulated clip localization from January 2014 to July 2015. Data were collected and analyzed. Statistical analyses for differences between groups were performed using t tests and Mann-Whitney rank-sum analyses. A total of 107 excisions were performed using hydrogel-encapsulated clip localization, and 113 excisions were performed using the traditional wire localization technique; 68 % of our patients underwent excision for malignant pathology. Wire placement took a mean of 46 minutes (range 20–180 min), compared with 5 minutes for ultrasound localization (p

We present a case of a 63 year-old Caucasian female who developed a right breast skin lesion discrete from the nipple that was subsequently diagnosed as Paget's Disease of the breast (PDB). Imaging did not reveal an underlying breast cancer or involvement of the nipple. The patient underwent a segmental mastectomy preserving the nipple and final pathology demonstrated residual Paget's disease of the skin and did not reveal any additional underlying breast carcinoma. To our knowledge, this case represents the first reported diagnosed case of isolated PDB without nipple involvement.

Breast surgeries for cancer and tumors were first described approximately 3,000 years ago, and since that time the standard of management has changed dramatically. From Egyptian papyri to Hippocratic theory, from Galen's dissections to Halsted's radical mastectomy, and from sentinel lymph node mapping to the development of nipple-sparing mastectomies, this review starts at the beginning and highlights breakthroughs and innovation in technique and medicine that have fundamentally changed the way breast cancer is managed. The progression depicted in this review acts as a proxy to the management of other complex diseases. Breast cancer was initially managed with operative extirpation alone, but now requires a multidisciplinary team across various surgical, medical, psychological, and social specialties in order to produce the best outcomes for our patients.

Intraoperative margin assessment for breast cancer patients undergoing segmental mastectomy (SM) enables identification of positive margins, with immediate excision of additional tissue to obtain negative margins. The aim of this study was to determine the ability of digital breast tomosynthesis (DBT) to detect positive margins compared with an institution’s standard extensive processing (SEP). SM specimens underwent intraoperative SEP with two-dimensional (2D) imaging of the intact and sliced specimen, with review by a breast radiologist and gross assessment by a breast pathologist. Findings guided the surgeon to excise additional tissue. DBT images of intact specimens were prospectively obtained and retrospectively reviewed by a breast radiologist. A positive margin was defined as tumor at ink. Ninety-eight patients underwent 99 SMs. With SEP, 14 (14%) SM specimens had 19 positive margins. SEP did not detect 3 of the 19 positive margins, for a sensitivity of 84%, specificity of 78%, positive predictive value (PPV) of 11%, and negative predictive value (NPV) of 99%. Moreover, DBT did not detect 5 of the 19 positive margins, for a sensitivity of 74% (p > 0.05), specificity of 91% (p

Ultrasound is an easily accessible and cost-effective imaging method that is not associated with radiation exposure. Ultrasound-guided wire localization is a reliable method for resecting non-palpable breast lesions. Preoperative ultrasound-guided wire localization has the advantage of a shorter operative time, and the breast lesions may be accurately excised with less tissue injury. We herein report an unusual case of an ectopic breast localization wire in the pleural cavity in a 47-year-old female patient with a history of right-sided breast cancer, who received left segmental mastectomy due to a newly identified left-sided breast lesion. The wire was identified with intraoperative X-ray and computed tomography imaging and was successfully removed under thoracoscopic guidance. The patient recovered uneventfully. To the best of our knowledge, this is the first report on localization wire-related complications in the English literature.

BACKGROUND Although breast conservation therapy (BCT) is standard for breast cancer treatment, patients with tumors measuring >5 cm have been excluded from clinical trials. Nevertheless, only a few small retrospective series to date have compared BCT with mastectomy for tumors measuring >5 cm. The current study was performed to determine whether survival is equivalent for BCT versus mastectomy using a large national data set. METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked cases were identified for patients aged ≥66 years undergoing breast conservation for invasive, noninflammatory, nonmetastatic breast cancer between 1992 and 2009. Propensity score-based adjustment was used to account for demographics and tumor and treatment factors. RESULTS A total of 5685 patients with tumors measuring >5.0 cm underwent breast surgery, with 15.6% receiving BCT. Mean ages of the patients and tumor sizes were similar. Predictors of BCT included neoadjuvant chemotherapy and postoperative radiotherapy use, higher income, breast cancer as a first malignancy, and a higher Charlson Comorbidity Index. Predictors of mastectomy included younger age, nonductal histology, higher grade, numbers of lymph nodes examined and found to be positive, American Joint Committee on Cancer stage III disease, postoperative chemotherapy use, and residential region of the country. Adjusted overall and breast cancer-specific survival were not different between patients treated with BCT and mastectomy (hazard ratio, 0.934; 95% confidence interval, 0.791-1.103 [P = .419] for overall survival; and subdistribution hazard ratio, 1.042; 95% confidence interval, 0.793-1.369 [P = .769] for breast cancer-specific survival), with each improving over time. The median follow-up was 7.0 years. CONCLUSIONS For Medicare patients with tumors measuring >5 cm, survival is similar between those treated with BCT and mastectomy as for patients with smaller primary tumors. Despite exclusion from randomized trials, BCT may remain an option for patients with larger tumors when deemed clinically and cosmetically amenable to surgical resection. Cancer 2016;122:42–49. © 2015 American Cancer Society.

Purpose: Neoadjuvant chemotherapy (NAC) frequently results in shrinkage of the primary tumor. It is not easy to perform breast-conserving surgery (BCS) after NAC, based on tumor extent alone. We identified the clinicopathological factors associated with positive margins on frozen or permanent sections in patients undergoing BCS after NAC. Methods: The records of 151 patients who had BCS after NAC between 2005 and 2010 were reviewed. All patients underwent subsequent imaging work-up including breast magnetic resonance imaging, ultrasound, and breast mammography at the midpoint and/or the end of NAC. Positive resection margins on frozen or permanent sections were considered to be due to the presence of either invasive carcinoma or in situ carcinoma. The relationship between the microscopic margin status and clinicopathological factors was analyzed when positive margins were detected. Results: Of 151 patients, 39 (25.8%) were diagnosed with a pathological complete response, while 135 patients (89.4%) had a negative margin on both frozen and permanent sections and 16 (10.6%) had a positive margin on frozen or permanent sections. Of the 16 patients, 14 finally obtained negative margins after additional excision and two (1.3%) had positive margins due to in situ carcinoma. Multivariate analysis revealed that clinical multifocality after NAC (p= 0.006), and hormonal receptor (HR) positivity (p= 0.028) were significantly associated with positive margins on frozen or permanent sections, but were not associated with tumor size after NAC, specimen volume, or human epidermal growth factor receptor 2 positivity. Conclusion: We propose that HR positivity and clinical multifocality after NAC are predisposing factors for positive margins in patients undergoing BCS after NAC. It is necessary to obtain safe resection margins to avoid positive margins in these patients.

The purpose of this study was to compare outcomes of radioactive seed localization (RSL) versus wire localization using surgical margin size, reexcision and reoperation rates, specimen size, radiology resource utilization, and cosmesis as measures.Patients who underwent RSL before segmental mastectomy from April 1, 2011, to March 1, 2012, for biopsy-proven cancer were selected. Each was matched using tumor size, type, and surgeon to a wire localization control case, resulting in 232 cases. Width of the closest surgical margin, reexcision rate, and reoperation rate were compared as were the ratios of tumor volume to initial surgical specimen volume and tumor volume to all surgically excised volume (including reexcisions and reoperations). Cosmetic outcome was analyzed by comparison of Harvard scores and specimen volume with breast volume. Radiology resource utilization was compared before and after RSL implementation.No significant differences between methods were found in closest surgical margin (RSL mean, 0.45 cm; wire localization mean, 0.45 cm; p=0.972), reexcision rate (RSL mean, 21.1%; wire localization mean, 26.3%; p=0.360), reoperation rate (RSL, 11.4%; wire localization, 12.7%; p=0.841), ratio of the tumor volume to initial surgical specimen volume (RSL mean, 0.027; wire localization mean, 0.028; p=0.886), ratio of the tumor volume to total volume resected (RSL mean, 0.024; wire localization mean, 0.024; p=0.997), or in clinical or computed cosmesis scores (clinical p=0.5; calculated p=0.060). There was a 34% increase in scheduled biopsy slot utilization, 50% savings in time spent scheduling, and a 4.1-day average decrease in biopsy wait time after RSL institution.RSL is an acceptable alternative to wire localization and offers significant improvements in workflow.

A 32 year old female diagnosed with schizophrenia was treated with sulpiride, trihexyphenidyl and alprazolam for 6 years. A physical examination revealed bilateral nipple retraction and a non-tender mass in the left breast, with little nipple discharge. Tests revealed high levels of carbohydrate antigen 125, serum prolactin and testosterone levels, and ultrasound revealed a number of masses in the bilateral breasts; the largest mass (2.2×1.3 cm) was located in the left breast. A rich blood flow signal was identified around the nodule. The ducts in the bilateral breasts exhibited cystic ectasia. Multiple enlarged lymph nodes were found in the bilateral axillae. Mammography revealed thickened breast tissue without an evident mass, and calcification. A segmental mastectomy was performed and subsequent histological examination revealed multiple dilated ducts, the largest of which contained eosinophilic material. The pathological diagnosis was of breast duct dilatation. Bacterial culture and drug sensitivity analysis of the secretions from the cystic cavity revealed no bacterial growth, and an acid fast bacillus stain was negative. Extravasation of the surgical wound occurred 1 month later, and Staphylococcus epidermidis was observed using a bacterial culture. This was treated with moxifloxacin for 1 week. It was suggested that the patient should switch to a prolactin sparing antipsychotic in view of the hyperprolactinemia, however, the patient refused. After a clinical follow-up of 16 months, the wound had healed well and no palpable mass was found in the breast.

Two consecutive surveys for breast surgeons in Korea were conducted to comprehend the practice patterns and perceptions on margin status after breast-conserving surgery. The surveys were conducted online in 2014 (initial) and 2016 (follow-up). A total of 126 and 88 responses were obtained in the initial and follow-up survey, respectively. More than 80% of the respondents replied to routinely apply frozen section biopsy for intraoperative margin assessment in both surveys. Re-excision recommendations of the margin for invasive cancer significantly changed from a close margin to a positive margin over time (p=0.033). Most of the respondents (73.8%) defined a negative margin as "no ink on tumor" in invasive cancer, whereas more diverse responses were observed in ductal carcinoma in situ cases. The influence of guideline establishment for negative margins has been identified. A high uptake rate of intraoperative frozen section biopsy was noted and routine use needs reconsideration.

Purpose To report the results of a correlation analysis of skin dose assessed by in vivo dosimetry and the incidence of acute toxicity. This is a phase 2 trial evaluating the feasibility of intraoperative radiotherapy (IORT) as a boost for breast cancer patients. Materials and methods Eligible patients were treated with IORT of 20 Gy followed by whole breast irradiation (WBI) of 46 Gy. A total of 55 patients with a minimum follow-up of 1 month after WBI were evaluated. Optically stimulated luminescence dosimeter (OSLD) detected radiation dose delivered to the skin during IORT. Acute toxicity was recorded according to the Common Terminology Criteria for Adverse Events v4.0. Clinical parameters were correlated with seroma formation and maximum skin dose. Results Median follow-up after IORT was 25.9 weeks (range, 12.7 to 50.3 weeks). Prior to WBI, only one patient developed acute toxicity. Following WBI, 30 patients experienced grade 1 skin toxicity and three patients had grade 2 skin toxicity. Skin dose during IORT exceeded 5 Gy in two patients: with grade 2 complications around the surgical scar in one patient who received 8.42 Gy. Breast volume on preoperative images (p = 0.001), ratio of applicator diameter and breast volume (p = 0.002), and distance between skin and tumor (p = 0.003) showed significant correlations with maximum skin dose. Conclusions IORT as a boost was well-tolerated among Korean women without severe acute complication. In vivo dosimetry with OSLD can help ensure safe delivery of IORT as a boost.

In-operating room specimen radiography (ORSR) has not been studied among women undergoing radioactive seed localization (RSL) for breast cancer surgery and had the potential to decrease operative time and perhaps improve intraoperative margin management.One hundred consecutive RSL segmental mastectomies among 98 patients using ORSR were compared to 100 consecutive segmental mastectomies among 98 patients utilizing conventional radiography (CSR) prior to the initiation of ORSR from December 2013 to January 2015 after radioactive seed localization. Final pathologic margins were considered to be 10 mm for all cases of no residual disease after biopsy or neoadjuvant therapy, but such patients were excluded from analyses involving tumor size. All patients' specimens were subjected to intraoperative pathologic consultation in addition to ORSR or CSR.The median age of the cohort was 65 years (range 36-97), and the median tumor size was 1 cm. There were no differences between the ORSR and CSR groups in age, tumor size, percentage of cases with only DCIS, and percentage of cases with microcalcifications. The ORSR group had a statistically significant lower BMI. Mean operative time from cut-to-close was not significantly different (ORSR 77 min, SD 24.8 vs CSR 76 min, SD 24.8, p = 0.75). There was no statistical difference in mean closest final pathologic margin (4.99 mm, SD 3.3 vs 4.88 mm, SD 3.5, p = 0.9). The percentage undergoing intraoperative margin re-excision (ORSR 40%, CR 47%, p = 0.31) and the mean total number of margins excised intraoperatively (ORSR 0.9, CR 1.0 p = 0.65) were similar. The rate of any margin2 mm was 14% vs 12% for ORSR and CR, respectively (p = 0.64). The mean specimen volume for ORSR was 76cm3 (SD 101.8) vs 90cm3 (SD 61.2) for CSR; this difference was not statistically significant (p = 0.25). The mean ratio of segmental mastectomy volume to maximum tumor diameter was less for ORSR (82.7cm2 vs 139.4cm2, p = 0.014).ORSR for RSL breast surgery, in the setting of routine intraoperative pathology consultation, does not significantly impact operative time, the rate or number of additional intraoperative margins excised, the number of reoperations for margins, or the width of final pathological margins. ORSR was associated with a decrease in the volume of segmental mastectomies relative to the tumor diameter.

CASE STUDY DE, a 31-year-old premenopausal woman with a nonsignificant medical history, noticed a right breast mass after playing basketball in September 2011. She initially attributed the mass to slight trauma, but after 2 weeks, she realized the mass was increasing in size. Her primary care physician ordered a bilateral screening mammogram and ultrasound. Mammography revealed no evidence of malignancy in the left breast. In the right breast, at the 7 o'clock position, a loose cluster of faint calcifications spanned a 2.2-cm area. Ultrasound confirmed an irregular hypoechoic mass in the right breast measuring 3.5 × 2.7 × 2.8 cm. Ultrasound of the right axilla identified two enlarged right axillary lymph nodes. Ultrasound core-needle biopsy of the suspicious right breast mass confirmed invasive ductal carcinoma, nuclear grade 2, Ki67 index of 55%, estrogen receptor-positive (H score of 180), progesterone receptor-positive (H score of 135), HER2-positive (3+ on immunohistochemistry). Utilizing the TNM (tumor, node, metastasis) staging system, she was clinically staged with a stage IIB (cT2, cN1, M0) invasive breast tumor. The computerized axial tomography (CT) scan of the chest, abdomen, and pelvis demonstrated the known right breast mass and two enlarged right axillary lymph nodes; however, no metastatic disease was noted. Nuclear bone scan revealed no bone metastases. Her medical oncologist recommended she receive neoadjuvant chemotherapy. The patient was treated with 6 cycles of neoadjuvant docetaxel at 75 mg/m², carboplatin at an AUC (area under the curve) of 6, and trastuzumab (Herceptin) at 6 mg/kg (TCH), which she tolerated well. She then underwent a right segmental mastectomy with axillary lymph node dissection and was found to have a residual 1.0-cm invasive ductal carcinoma, representing a 60% tumor volume reduction. None of 13 axillary lymph nodes were positive for disease. Pathologic staging confirmed a stage IA (ypT1, ypN0, M0) tumor. DE completed 33 fractions of radiation therapy to the right breast. She initiated endocrine therapy with tamoxifen at 20 mg daily and received 1 year of maintenance trastuzumab (6 mg/kg). Due to vaginal discharge and weight gain, endocrine therapy was switched from tamoxifen to toremifene (Fareston), which she tolerated relatively well. She continued routine follow-up, with no evidence of disease. In September 2014, DE presented to her primary care physician complaining of left hip pain. Magnetic resonance imaging (MRI) of the left hip revealed T2 hyperintense masses within the right anterior superior iliac crest, right sacrum, and left iliac body consistent with skeletal metastases. She was referred back to her medical oncologist, and per National Comprehensive Cancer Network (NCCN) guidelines, a biopsy of the suspicious lesion was obtained. The bone biopsy of the lytic lesion was consistent with metastatic breast cancer, which was estrogen receptor-positive, progesterone receptor-positive, and HER2-positive (3+ on immunohistochemistry). Restaging CT scan of the chest, abdomen, and pelvis revealed new 4- to 6-mm pulmonary nodules, hilar and mediastinal lymphadenopathy, new liver lesions, and bone lesions. Nuclear bone scan confirmed multiple bone metastases of the right and left iliac bones and sternum. Complete blood cell count with differential and complete metabolic panel were within normal ranges. The CA 27-29 tumor marker for breast cancer was elevated at 495 U/mL (normal range, < 37 U/mL). DE was understandably devastated by the new diagnosis. She questioned how the treatment plan was to be established. Her medical oncologist struck a somewhat optimistic tone. He explained that metastatic breast cancer was not yet considered to be curable, but periods of disease stability and chronicity were possible. He explained that the HER2 positivity was perhaps the most important factor in delineating her treatment options. He told her that current treatment options were numerous and increasing in number.

Purpose The ability to accurately predict the likelihood of achieving breast conservation surgery (BCS) after neoadjuvant chemotherapy (NCT) is important in deciding whether NCT or surgery should be the first-line treatment in patients with operable breast cancers. Materials and Methods We reviewed the data of 513 women, who had stage II or III breast cancer and received NCT and surgery from a single institution. The ability of various clinicopathologic factors to predict the achievement of BCS and tumor size reduction to ≤ 3 cm was assessed. Nomograms were built and validated in an independent cohort. Results BCS was performed in 50.1% of patients, with 42.2% of tumors reduced to ≤ 3 cm after NCT. A multivariate logistic regression analysis showed that smaller initial tumor size, longer distance between the lesion and the nipple, absence of suspicious calcifications on mammography, and a single tumor were associated with BCS rather than mastectomy (p < 0.05). Negative estrogen receptor, smaller initial tumor size, higher Ki-67 level, and absence of in situ component were associated with residual tumor size ≤ 3 cm (p < 0.05). Two nomograms were developed using these factors. The areas under the receiver operating characteristic curves for nomograms predicting BCS and residual tumor ≤ 3 cm were 0.800 and 0.777, respectively. The calibration plots showed good agreement between the predicted and actual probabilities. Conclusion We have established a model with novel factors that predicts BCS and residual tumor size after NCT. This model can help in making treatment decisions for patients who are candidates for NCT.

Case Discussion A 70-year-old female patient presents to the breast clinic for annual screening. She has no family history of breast cancer. Her physical examination is normal, however an area of 0.5cm in size located in the lower inner quadrant of the right breast has microcalcifications and the adjacent area of approximately 2cm shows structural distortion on mammography (BIRADS 5). The core biopsy reveales high grade, solid ductal carcinoma in situ that contains areas of comedo necrosis and invasive ductal carcinoma in one border. The estrogen receptor (ER) (+), progesterone receptor (PR) (-), Her 2 (-) and Ki-67 is reported as 12% . The patient undergoes segmental mastectomy with wire guide and sentinel lymph node biopsy (SLNB). A 1% isosulfane blue and gamma probe is used for the detection of SLN. One SLN that was not macroscopically suspicious is sent to the pathology department peroperatively, without a request for frozen section evaluation. The paraffin section examination shows a grade 3, ER (+), PR (-) and HER- neu2n (-) invazive tumor with a 2 cm integrity diameter. Lymphovascular invasion (LVI) is positive, and comedo necrosis that surrounds the invasive tumor and forms 15% of the tumor volume are determined, as well as a nuclear grade 3 ductal carcinoma in situ containing microcalcifica tions. The nearest margins to DCIS are 0.3cm at the medial and 0.2cm at the lateral borders, with negative surgical margins. The pathologic evaluation of the aferomentioned single lymph node shows an 8mm metastasis with 0.2 X 0.2 cm extracapsular extension by hematoxylin and eosin (H&E). Is Completion Axillary Dissection Necessary For This Patient?

Introducción: El enfrentamiento del cáncer de mama evolucionó en el último cuarto de siglo desde el autoexamen a la mamografía como herramienta de sospecha y desde el tratamiento con cirugía radical a la cirugía conservadora más radioterapia. El objetivo de esta revisión fue evaluar la evolución de la presentación y manejo local del cáncer de mama en un centro de radio-oncología. Materiales y Método: Se analizaron 1.204 pacientes con cáncer de mama que recibieron irradiación post-operatoria en dos períodos de cuatro años. El primer período incluyó 223 pacientes y coincide con la introducción de mamografía y cirugía conservadora. El segundo incluyó 981 pacientes manejadas según el estándar actual. Las variables analizadas fueron: forma de sospecha, tiempo entre sospecha y confirmación diagnóstica, tipo de cirugía, histología y tamaño tumoral. Los datos fueron obtenidos de fichas clínicas y analizados con STATA 12. Resultados: Al comparar el segundo período con el primero se evidenció un aumento absoluto del 39,8% de la sospecha por mamografía, disminución a la mitad del tiempo entre sospecha y diagnóstico histológico, reducción de la proporción de tumores mayores a 2 cm de 61 a 45%, triplicación en la proporción de carcinoma ductal in situ de 6 a 18% y aumento absoluto de 28% del uso de cirugía conservadora. Todas estas diferencias fueron estadísticamente significativas (p < 0,01). Conclusión: En el grupo analizado la introducción de mamografía y manejo conservador se asoció a un aumento de sospecha y diagnóstico precoz del cáncer de mama.