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BACKGROUND: The aim of this study was to assess the oncological efficacy of breast conserving surgery (BCS) after neoadjuvant chemotherapy in patients with local advanced breast cancer. PATIENTS AND METHODS: A retrospective cohort study was conducted with locally advanced breast cancer invasive (Stage IIb to III) treated at ICESP, an oncologic referral center between 2008 and 2016. Endpoints were disease free survival (DFS), local disease free survival (LDFS) and overall survival (OS). Multivariable analyses were performed using Cox proportional hazards models. RESULTS: 530 patients were included, 26% (138) were stage IIB, 41.9% (222) IIIA, 29.6% (157) IIIB and 2.5% (13) IIIA. 88.8% (470) were invasive ductal carcinoma. The mean age was 51.5(23-95). 95.5% and 4.5% were submitted Neoadjuvant Chemotherapy and Hormone therapy, respectively. The BCS were performed in 24.5% (130) patients versus 75.5% (400) of mastectomies. The mean follow up was 36.4(0.16-80.2) months. There were no differences in local disease free-survival 59 (95%CI 58-61) versus 60 (95%CI 57-60); p=0.4 and overall survival 56.2 (95%CI 52-60) versus 59.3(95%CI 53-65); p= 0.24 for mastectomy and BCS. The disease free survival was lower at mastectomy group 51.4 (95%CI 49-53) versus 56,8 (95%CI 53-59); p=0.01. Logistic regression models were significant only for cancer stage both patterns, although the results were better for masses, particularly when kinetic assessments were included (LR 12.8; p = 0.005) CONCLUSION: In our population, the BCS does not affect the overall and local disease-free survival rates, which seems to be safe to perform in patients who desire to conserve the breast after neoadjuvant treatment. Citation Format: Boufelli G, Mota BS, Franca FC, Doria MT, Maesaka JY, Ricci MD, Piato JRM, Rocha FBC, Giribela AHG, Gonçalves R, Masili-Oku S, Mano MS, Chala LF, Thompson BM, Baracat EC, Filassi JR. Does conservative surgery treatment for locally advanced breast cancer safe after neoadjuvant treatment? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-11.

Introduction: Development of the nipple-sparing mastectomy (NSM) technique has constituted a significant advance in the surgical treatment of selected cases of breast cancer. The most important aspect of areolar complex preservation is the exclusion of carcinoma involving the nipple. The retroareolar surgical margin is usually sampled and subjected to an intraoperative evaluation by frozen section examination in order to avoid a second procedure. However, this method is not standardized resulting in variable rates of false-negative results. Here, a new technique is proposed for the intraoperative study of the retroareolar margin. This ex vivo study was conducted by performing a simulated NSM procedure for patients undergoing total mastectomy to assess the impact of these measures on the accuracy of retroareolar frozen section examination. Materials and Methods: Between September 2012 and April 2014, we studied 158 mastectomy specimens from patients undergoing total mastectomy for breast cancer at the Cancer Institute of the State of São Paulo. Inclusion criteria were stage Tis-T3 tumors, multifocal and multicentric breast carcinoma, unicentric carcinoma not suitable to quadrantectomy. Patients submitted to neoadjuvant chemotherapy were also included. To obtain the entire sample area, the terminal retroareolar milk duct bunch was isolated. Fragments approximately 1.5 cm in length were excised and sectioned in parallel at the base of the nipple using a cold bistoury. Three transverse histological sections (4 μm each) at 200 μm intervals that included the entire isolated fragments were subjected to frozen section examination. The sections were stained with hematoxylin-eosin (H&E) and were evaluated. The remainder of each fragment was embedded in paraffin and 4 μm sections were subsequently stained with H&E and examined. Results: A total of 158 mastectomy specimens involving mammary carcinoma of no special type were examined. These included 15 (9.5%) in situ stage tumors, 36 (22.8%) stage I tumors, 71 (44.9%) stage II tumors, and 36 (22.8%) stage IIIA tumors. Paraffin examinations identified 25 retroareolar fragments compromised by carcinoma, resulting in 16.1% prevalence. Of the frozen sections examined, 2/158 (1.3%) had false-negative results and 5/158 (3.1%) had false-positive results. For the former two cases, the corresponding paraffin examinations detected low-grade carcinoma in situ and a residual cell cluster with a diameter less than 1 mm. The latter was found in a mastectomy specimen from a patient that underwent neoadjuvant chemotherapy. For the three cases involving false-positive results, the corresponding paraffin examinations revealed no atypical ductal hyperplasia present, one sclerosing intraductal papilloma and one nipple syringomatous adenoma. Statistical analysis revealed that the frozen section examinations performed had a sensitivity rate of 92.0% and a specificity rate of 96.2%. In addition, the positive predictive value (PPV) was 82.1%, the negative predictive value (NPV) was 98.4%, and the accuracy was 95.4%. Conclusion: The frozen section examination technique described here detected nipple involvement in breast cancer with greater accuracy than the frozen section usually performed by most surgeons. Citation Format: Piato JR, Aguiar FN, Mota BS, Dória MT, Alves-Jales RD, Messias AP, Goncalves R, Mano MS, Soares JM, Ricci MD, Filassi JR, Baracat EC. Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-13-09.

Sentinel node (SN) biopsy is a reliable method for improved staging of breast cancer, offering an alternative to routine axillary dissection. Perhaps preoperative chemotherapy could increase the rate of false-negative SN because of induced lymphatic changes. The aim of the study was to evaluate the utility of lymphoscintigraphy and of hand-held probe detection in the SN approach after chemotherapy, correlating it with histologic analysis of the axilla.Eighty-three patients (mean age, 53 years; TNM stage I) were studied prospectively. They were separated into two groups: group 1 (G1), 37 patients with preoperative chemotherapy and group 2 (G2), 46 patients without chemotherapy. Mean tumor size was 2 cm in both groups. Lymphoscintigraphy was performed 3 to 4 hours after peritumoral injection of Tc-99m dextran-70 in a 0.2-ml volume and activity of 14.8 MBq (0.4 mCi), performed under ultrasound or mammographic control. On the following day, each patient underwent tumor resection with axillary dissection, included the SN.The SN was detected by scintigraphy in 78 patients (94%). The failure of SN to predict the axillary histologic status was significantly higher (P = 0.01) in G1 than in G2 (7 and 1 false-negative result, respectively).Preoperative chemotherapy seems to impair axillary evaluation by SN biopsy and should be used cautiously in this subset of patients.

Background: A precise preoperative evaluation of the tumor is essential to improve breast cancer surgical management. Currently, mammography associated with ultrasound and clinical exam are the standard techniques for evaluating extension and tumor localization. However, approximately one third of the lesions in patients eligible for conservative surgical treatment are misevaluated by these methods. Breast magnetic resonance imaging (MRI) has a high sensitivity (95-100%) in detecting invasive neoplasms, and is able to detect occult tumors, multifocal and/or multicentric disease, and contralateral breast cancer more accurately than mammography and ultrasound. Until now, there are only three randomized trials assessing the role of preoperative MRI. These trials have different designs and contradictory results. Trial design: BREAST-MRI is a randomized, open label, unblinded trial designed to compare the accuracy of breast MRI in the preoperative planning of surgical treatment of breast cancer to standard protocol (clinical exam of the breast, mammography and/or breast ultrasound) and the impact of breast MRI on breast cancer outcome. Patients are randomized on a 1:1 basis, stratified for mammary density, into two groups: 1)MRI group: patients are submitted to MRI and standard protocol 2)Control group: standard protocol. First phase: patient recruitment and data collection up until surgery. Second phase: follow-up for five years or until death. Eligibility criteria: women aged 18 years or older with breast cancer stages I to III candidates for conservative surgery (CC). Specific aims: The aim of this study is to evaluate the ability of MRI in selecting patients for conservative treatment of breast cancer. Primary outcomes are: false positive rates, false negative rates, positive predictive value and negative predictive value of MRI in breast cancer CC. Secondary outcomes are: rates of positive margins on pathological examination; reoperation rates; number of conversions to mastectomy; accuracy of MRI according to mammographic density, immunohistochemical subtype and histopathology of the tumor; rates of multicentricity, multifocality and bilateralality of tumors; disease-free survival after 3 and 5 years; and cost-effectiveness of breast MRI. Statistical methods: The calculated total case number for this trial is 372, assuming a recurrence rate of 10% for CC and 1% for mastectomies. The Shapiro-Whilks test will be used to verify if distribution of the quantitative variables follows normal distribution. The baseline population will be analyzed using the t-Student test, or the Mann-Whitney test when appropriate. To test the existence of a possible association between outcomes and the categorized characteristics, chi-square and Fisher's exact test will be performed. Disease progression will be reassessed at 3 and 5 years follow-up, in order to produce a log-rank Kaplan-Meier curve of survival. Present accrual and target accrual: In June 2017, randomizations are at approximately 90% of the target sample size. Citation Format: Dória MT, Mota BS, Reis YN, Ricci MD, Piato JRM, Ferreira VCCS, Shimizu C, Barros N, Filassi JR, Baracat EC. Brazilian randomized study - Impact of preoperative magnetic resonance in the evaluation for breast cancer conservative surgery (BREAST-MRI trial) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-02-01.

Introduction. The implementation of Nipple-Sparing Mastectomy (NSM) as a treatment option for selected cases of breast cancer has risen great interest among breast surgeons. The preservation of the nipple-areola complex (NAC) can lead to extremely favorable psychological effects in breast cancer patients treated with this type of procedure. However, to ensure the oncologic safety of this technique it is of utmost importance to evaluate the likelihood of NAC involvement pre-operatively. In this study we evaluate the contribution of Breast Magnetic Resonance Imaging (MRI) in predicting the involvement in the NAC in breast cancer patients. Materials and Methods: We studied 170 mastectomy specimens from 165 breast cancer patients (five patients had bilateral disease) affected by Ductal Carcinoma in situ (DCIS)(n=19) or Invasive Ductal Carcinoma (n=151), stages I, II or IIIA. Every patient was pre-operatively studied using a 1.5 Tesla, 4-channel in vivo dedicated surface breast coil MRI. The parameters we investigated were: type of index lesion enhancement pattern (nodular or non-nodular), size of the index lesion, enhancement between the index lesion and the NAC, enhancement of the nipple, thickening of the areola, nipple retraction and size of the nipple in comparison with the contra-lateral nipple. The retro-areolar area and papilla were evaluated in histological sections of 4μm to identify DCIS and Invasive Ductal or Lobular carcinomas. One radiologist, blinded to the result of the histological evaluation of the papillae, performed the evaluation of the MRIs. Results. In univariate analysis, type of lesion enhancement in MRI, enhancement between index lesion and the papilla, distance between the index lesion and the papilla, enhancement of the papilla and nipple retraction had a statistically significant correlation with neoplastic involvement of the NAC (p Conclusion. We can conclude that the probability of the NAC being cancer-free is around 90% when there is no enhancement between the index lesion and the nipple, and there is no retraction of the nipple in the pre-operative MRI study of the breast. Citation Format: Piato JR, Chala LF, Alves-Jales RD, Dória MT, Mota BS, Messias AP, Goncalves R, Mano MS, Soares JM, de Barros N, Filassi JR, Baracat EC. Magnetic resonance imaging to predict nipple involvement in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-04.