Search

Background: This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS)., Methods: Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008-2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved., Results: Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33-0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68-4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03-1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07-12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69-7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01-3.40) were independently associated with positive resection margins after BCS., Conclusions: Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS., (© 2021. The Author(s).)

Purpose: To outline the current status of and provide insight into possible future research on the breast lesion excision system (BLES) as a diagnostic and therapeutic device., Methods: A systematic search of the literature was performed using PubMed, Embase, and the Cochrane databases to identify relevant studies published between January 2002 and April 2018. Studies were considered eligible for inclusion if they evaluated the diagnostic or therapeutic accuracy or safety of BLES., Results: Ultimately, 17 articles were included. The reported underestimation rates of atypical ductal hyperplasia and ductal carcinoma in situ (DCIS) ranged from 0 to 14.3% and from 0 to 22.2%, respectively. Complete excision rates for invasive ductal carcinoma and DCIS ranged from 5.3 to 76.3%. Bleeding was the most frequently reported complication (0-11.8%). Device-related complications may arise, with an empty basket being the most common (0.6-3.6%). Thermal damage of the specimen, caused by the use of a radiofrequency cutting wire, was reported in eight of the included studies. Most thermal artifacts were reported as superficial and small (0.1-1.9 mm)., Conclusions: The BLES, an automated, image-guided, single-pass biopsy system for breast lesions using radiofrequency is designed to excise and retrieve an intact tissue specimen. It is an efficient and safe breast biopsy method with acceptable complication rates, which may be used as an alternative to vacuum-assisted biopsies. The variable rate of complete excision raises questions about the possibility to use BLES as a therapeutic device for the excision of small lesions. Further research should focus on this aspect of BLES.

Introduction: Consensus about surgical treatment options for breast cancer in elderly patients remains elusive due to exclusion from clinical trials. Fear of complications due to increased age often is an important factor in the choice of treatment and might result in different treatment of the older patient., Methods: A total of 1258 female patients who underwent breast cancer surgery for primary diagnosed breast cancer in 2010-2014 were included. Incidence of postoperative complications (POCs) was compared between the younger (18-70 years, N = 1008) and older (≥71 years, N = 250) patients. Multivariate logistic regression was performed to identify the correlation between age and POCs., Results: POCs developed in 25.9% of the younger and 31.6% of the older patients (p = 0.042). In multivariable logistic regression analysis of the overall study population, age was no risk factor for POC (odds ratio 0.950, 95% confidence interval 0.640-1.410, p = 0.798). More extensive surgery (mastectomy and/or axillary lymph node dissection compared with single lumpectomy) and increased body mass index increased the odds of developing a POC. Analyses of the ≥71-year group separately revealed only type of surgery to be of influence., Conclusions: Fear of increased risk of complications in the older patient is unjustified. Neither increased age nor high American Society of Anesthesiologists classification are predictors for developing POC. Type of surgery is the most important determinant. Choosing mastectomy while breast-conserving surgery is suitable should be discouraged, particularly in the older patient.

Background: This study aimed to compare the type and extent of surgery in patients with screen-detected and interval cancers after blinded or nonblinded double-reading of screening mammograms., Methods: The study investigated a consecutive series of screens double-read in either a blinded (n = 44,491) or nonblinded (n = 42,996) fashion between 2009 and 2011. During a 2 year follow-up period, the radiology reports, surgical correspondence, and pathology reports of all the screen-detected and interval cancers were collected., Results: Screen-detected breast cancer was diagnosed for 325 women at blinded and 284 women at nonblinded double-reading. The majority of the women were treated by breast-conserving surgery (BCS) at both reading strategies (78.2 vs. 81.7 %; p = 0.51). Larger total resection volumes were observed at BCS for ductal carcinoma in situ (DCIS) treatment for patients after blinded double-reading (p = 0.005). The proportions of positive resection margins after BCS were comparable for patients with DCIS (p = 0.81) or invasive screen-detected cancers (p = 0.38) for the two reading strategies. A total of 158 interval cancers were diagnosed. The proportions of patients treated with BCS were comparable for the two reading strategies (p = 0.42). The total resection volume (p = 0.13) and the proportion of positive resection margins after BCS (p = 0.32) for invasive interval cancer were comparable for the two cohorts. The BCS rate was higher for women after nonblinded double-reading (p = 0.04)., Conclusions: Blinded and nonblinded double-reading yielded comparable surgical treatments for women with screen-detected or interval breast cancer except for larger total resection volumes at BCS for screen-detected DCIS and a higher BCS rate for interval cancers at nonblinded double-reading.

Background: Seroma is a frequent problem after mastectomy (ME) and axillary lymph node dissection (ALND). Seroma is associated with pain, discomfort, impaired mobilisation and repeated aspirations, often resulting in a surgical site infection (SSI). It has already been demonstrated that minimizing dead space through fixation of the skin flaps to the underlying muscles (quilting) lowers the incidence of seroma. The aim of this study was to evaluate the effect of quilting on the incidence of seroma, and SSI., Methods: Two consecutive groups with a total of 176 patients following ME and/or ALND were retrospectively compared. Endpoints were the incidence of seroma, and number and volume of aspirations and SSIs. Analysed risk factors were age, ME, lymph node dissection, neoadjuvant therapy, body mass index (BMI) and hypertension., Results: The quilted group (n = 89) scored significantly better on all endpoints compared with the conventional group (n = 87). The incidence of seroma decreased from 80.5 % to 22.5 % (p < 0.01), the mean number of aspirations from 4.86 to 2.40 (p = 0.015), the volume of aspirations from 1660 ml to 611 ml (p = 0.05) and the SSIs from 31.0 % to 11.2 % (p < 0.01). Increasing age and lymph node dissection were found to be risk factors for seroma; quilting was a protective factor., Conclusion: Quilting is an effective method for preventing seroma and its complications.

Background: The absolute number of involved axillary lymph nodes (LNs) is considered the most important prognostic factor in breast cancer. Over the last decade, several studies indicated that the lymph node ratio (LNR) might predict outcome better than the number of positive LNs. In this study we test the applicability of earlier published LNR cutoff values and study the prognostic value of the LNR on a nationwide level., Methods: A nationwide population-based study was performed, using data from the Netherlands Cancer Registry, including all women diagnosed with node-positive breast cancer between 1999 and 2005 (N = 25,315). Patients were divided into 3 LNR risk groups (low, ≤0.20; intermediate, 0.21-0.65; and high, >0.65). Kaplan-Meier survival analysis was performed. In order to evaluate whether LNR was associated with overall survival (OS), Cox proportional hazards modeling was used., Results: For the entire cohort, 5- and 10-year OS rates were 78 % and 62 %, respectively. The number of positive LNs correlated with OS (5-year OS 84 %, 72 %, and 55 % for patients with 1-3, 4-9, and 10 or more positive LNs, respectively, P < .001). LNR also correlated with OS (5-year OS 86 %, 75 %, and 54 % for low-, intermediate-, and high-risk groups, respectively, P < .001). In the multivariable analysis, the risk of death increased with increasing LNR (P < .001)., Conclusions: The LNR has an important prognostic value in node-positive patients, independent of traditional clinicopathological factors. LNR should be added as an independent prognostic variable to the current staging system.

Background: Sentinel lymph node biopsy (SLNB) has become standard of care as a staging procedure in patients with invasive breast cancer. A positive SLNB allows completion axillary lymph node dissection (cALND) to be performed. The axillary recurrence rate (ARR) after cALND in patients with positive SLNB is low. Recently, several studies have reported a similar low ARR when cALND is not performed. This review aims to determine the ARR when cALND is omitted in SLNB-positive patients., Methods: A literature search was performed in the PubMed database with the search terms "breast cancer," "sentinel lymph node biopsy," "axillary" and "recurrence." Articles with data regarding follow-up of patients with SLNB-positive breast cancer were identified. To be eligible, patients should not have received cALND and ARR should be reported., Results: Thirty articles were analyzed. This resulted in 7,151 patients with SLNB-positive breast cancer in whom a cALND was omitted (median follow-up of 45 months, range 1-142 months). Overall, 41 patients developed an axillary recurrence. 27 studies described 3,468 patients with micrometastases in the SLNB, of whom 10 (0.3 %) developed an axillary recurrence. ARR varied between 0 and 3.7 %. Sixteen studies described 3,268 patients with macrometastases, 24 (0.7 %) axillary recurrences were seen. ARR varied between 0 and 7.1 %. Details regarding type of surgery and adjuvant treatment were lacking in the majority of studies., Conclusions: ARR appears to be low in SLNB-positive patients even when a cALND is not performed. Withholding cALND may be safe in breast cancer selected patients such as those with isolated tumor cells or micrometastatic disease.

Background: In approximately 40% of the breast cancer patients with sentinel lymph node (SLN) metastases, additional nodal metastases are detected in the completion axillary lymph node dissection (cALND). The MSKCC nomogram can help to quantify a patient's individual risk for non-SLN metastases with fairly accurate predicted probability. The aim of this study was to compare the predictions of surgical oncologists for non-SLN metastases with nomogram results and to clarify the impact of nomogram results on clinical decision-making., Methods: Questionnaires, containing patient scenarios, were sent to surgical oncologists involved in breast cancer care. The surgeon was asked to predict the probability for non-SLN metastases for the first five scenarios. For the remaining scenarios, the patient's actuarial likelihood, calculated by the nomogram, was supplied. The surgeon was asked whether or not (s)he would perform a cALND. The type of hospital and the surgeon's experience were registered., Results: The concordance-index amounted to 0.78, indicating moderate concurrence between the surgical predictions and nomogram results. The intersurgeon variation was important. About 25% of the surgeons was influenced by nomogram information and decided in one or more patients to abandon the cALND. Neither the type of hospital nor experience influenced predicting abilities or the clinical decision-making process., Conclusion: Individual predictions of surgical oncologists for non-SLN metastases do not correlate well with the MSKCC nomogram. The distribution between intersurgeon predictions for one scenario is important. Therefore, the nomogram is superior to clinical estimations for predicting the likelihood for non-SLN metastases.

Background: In this multi-institutional prospective study, we evaluated whether we could identify risk factors predictive for non-sentinel lymph node (non-SN) metastases in breast cancer patients with a positive sentinel lymph node (SN)., Methods: In this multi-institutional study, 541 eligible breast cancer patients were included prospectively., Results: The occurrence of non-SN metastases was related to the size of the SN metastasis (P = .02), primary tumor size (P = .001), and lymphovascular invasion (P = .07). The adjusted odds ratio was 3.1 for SN micro-metastasis compared with SN isolated tumor cells, 4.0 for SN macro-metastasis versus SN isolated tumor cells, 3.1 for tumor size (>3.0 cm compared with 3.0 cm, and with vessel invasion., Conclusion: We identified three predictive factors for non-SN metastases in breast cancer patients with a positive SN: size of the SN metastasis; primary tumor size; and vessel invasion. We were not able to identify a specific group of patients with a positive SN in whom the risk for non-SN metastases was less than 5%.

Background: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies., Methods: Patients from four hospitals (A-D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals., Results: In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined., Conclusions: Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.

Background: According to Dutch guidelines, an axillary lymph node dissection (ALND) is recommended whenever a sentinel lymph node (SLN) contains metastatic disease. However, only in approximately 50% of patients with metastatic disease in the SLN are additional nodal metastases detected in the completion ALND. To identify the individual patient's risk for non-SLN metastases, a nomogram containing eight predictors was developed by the Breast Service of Memorial Sloan-Kettering Cancer Center (New York, NY). The aim of this study was to test the accuracy of the nomogram on a population of Dutch breast cancer patients., Methods: Patient, tumor, and SLN metastasis characteristics were collected for 222 consecutive patients who underwent a completion ALND. The data of the index and test populations were compared. A receiver operating characteristic curve was drawn, and the area under the curve was calculated to assess the discriminative power of the nomogram., Results: Even though our patient population differed in many respects from the source population, the area under the receiver operating characteristic curve amounted to .77, a value very much comparable to the one found in the source population., Conclusions: The nomogram provides a fairly accurate predicted probability for the likelihood of non-SLN metastases in a general population of breast cancer patients at a regional teaching hospital in The Netherlands. This suggests that the nomogram's originally calculated predictive accuracy may be valid for patient populations that differ considerably from the population in which it was developed.

Background: Sentinel lymph node biopsy (SLNB) carries the inherent risk of approximately 5% false-negative sampling. Undetected tumor-positive nodes of clinical importance are those that lead to axillary recurrence. This survey aims at clarifying the extent of this problem in current practice and literature., Methods: In a regional teaching hospital, 696 consecutive breast cancer patients underwent SLNB between January 1998 and July 2003, and data were entered in a prospective database. PubMed and the Cochrane library were searched for a systematic review of the literature. Thirteen studies dealt with the follow-up of a cohort of sentinel lymph node (SLN)-negative patients or presented a case report., Results: The SLN identification rate was 97.1%. The SLN was tumor free in 439 (65%) of the 676 patients. After a median follow-up of 26 months, axillary recurrence was detected in 2 of 439 patients 4 and 27 months after the SLNB. The incidence of clinically apparent false-negative SLNB is .46%. The systematic review resulted in 3184 SLNB-negative patients with a median follow-up of 25 months. Axillary recurrence occurred in eight patients after a median of 21 months. The axillary recurrence rate in the literature is .25%. One third of these patients present with synchronous systemic metastases., Conclusions: Axillary recurrences after a negative SLNB occur, but at a much lower rate than would be expected on the basis of historical figures and the false-negative SLN findings. The natural history of axillary relapse after negative SLNB resembles the locoregional recurrence of breast cancer.