Ductal carcinoma in-situ: an update for clinical practice

Introduction

Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment.

Methods

Literature review facilitated by Medline, PubMed, Embase and Cochrane databases.

Results

DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease.

Conclusion

Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.     

Recent trends and predictors in immediate breast reconstruction after mastectomy in the United States

Introduction

Immediate breast reconstruction after mastectomy has increased in frequency during the past decade, but the socioeconomic and patient factors have yet to be fully identified.

Methods

Data were analyzed from the Nationwide Inpatient Sample from 1999 to 2003 using International Classification of Disease-9 codes to identify patients undergoing immediate breast reconstruction. Regression analyses were used to examine predictive variables for immediate breast reconstruction after mastectomy.

Results

Between 1999 and 2003, 469,832 patients underwent mastectomy. Immediate breast reconstruction occurred in 110,878 patients, yielding a 5-year average rate of 23.6% (range of 22.2% to 25.3%). Independent predictors of immediate breast reconstruction after mastectomy include private insurance, hospital in an urban location, teaching hospital, white race, hospital region in the south, age between the 3rd and 6th decades, and low number of comorbidities.

Conclusions

Immediate breast reconstruction after mastectomy is still not commonly performed in the United States. Socioeconomic and geographic factors play a significant role in whether patients undergo immediate reconstruction.     

Correlates of the desire for improved cosmetic results after breast-conserving therapy and mastectomy in breast cancer patients

The aim of this survey was to evaluate correlates for the patient's desire for surgical improvement of the cosmetic outcome after the primary operation for breast cancer. A cross-sectional study was carried out in a single follow-up outpatient clinic using a questionnaire. Patients were asked to assess their degree of satisfaction with the cosmetic results of their primary surgery and to state if they would like to undergo a further breast surgery to improve the appearance. Patients’ characteristics were correlated with this desire. After breast-conserving surgery, 21.6% of the patients stated that they desired surgical improvement, in comparison with 29.8% of the patients who underwent mastectomy. In the latter group, the desire for improvement remained constant up to 5 years after the initial operation, whereas it declined in the group of patients after breast-conserving surgery. Furthermore, a younger age and the perception that the appearance negatively influences femininity, partnership or sexual life were associated with a desire for further surgery. Breast reconstruction after mastectomy can be discussed with the patients even after a long follow-up, especially when the appearance seems to influence partnership issues.     

Sclerotherapy for the treatment of postmastectomy seroma

BACKGROUND: Seroma is a common complication after mastectomy. We review our experience with sclerotherapy for postmastectomy seroma management. METHODS: Patients who underwent outpatient sclerotherapy for postmastectomy seroma were reviewed. Ninety-five percent ethyl alcohol or povidone iodine, which was administered by way of percutaneous catheter, was the initial sclerosant, and dwell time was 20 to 30 minutes. Povidone iodine solution was instilled 2 to 3 times daily. Catheters were removed when output reached <30 mL/d or when cavity size was <20 ml by sinogram. RESULTS: Sixteen patients (18 seromas) had sclerotherapy initiated at median of 34 days after surgery. Mean number of treatment days was 3 (median duration 16). Seven patients (44%) developed infection during treatment, which was associated with increased duration. Three seromas recurred and were successfully treated with single aspiration. COMMENTS: Sclerotherapy is a feasible treatment for chronic seroma after mastectomy. Longer treatment duration was associated with infection; antibiotic prophylaxis should be considered. Research is necessary to determine optimal regimens and superiority over other approaches.     

The ratio of positive to excised nodes identifies high-risk subsets and reduces inter-institutional differences in locoregional recurrence risk estimates in breast cancer patients with 1-3 positive nodes: an analysis of prospective data from British Columbia and the M. D. Anderson Cancer Center

PURPOSE: To examine the power of the nodal ratio (NR) of positive/excised nodes in predicting postmastectomy locoregional recurrence (LRR) in patients with 1-3 positive nodes (N+) and in identifying cohorts at similar risk across independent data sets. METHODS AND MATERIALS: Data from 82 patients with 1-3 N+ treated without postmastectomy radiotherapy (PMRT) in the British Columbia (BC) randomized trial were compared with data from 462 patients treated without PMRT in prospective chemotherapy trials at the M. D. Anderson Cancer Center (MDACC). Kaplan-Meier LRR curves were compared between centers using the absolute number of N+ and nodal ratios. RESULTS: The median number of excised nodes was 10 in BC and 16 in MDACC (p < 0.001). Examining LRR by number of N+, the 10-year LRR rate for patients with 1-3 N+ was higher in BC compared with MDACC (21.5% vs. 12.6%; p = 0.02). However, when examining LRR using NR, no differences were found between institutions. In patients with NR < or = 0.20, the 10-year LRR rate was 17.7% BC vs. 10.9% MDACC (p = 0.27). In patients with NR > or = 0.20, the 10-year LRR rate was 28.7% BC vs. 22.7% MDACC (p = 0.32). On Cox regression analysis, NR was a stronger prognostic factor compared with number of N +. CONCLUSIONS: In patients with 1-3 N+, evaluating nodal positivity using NR reduced inter-institutional differences in LRR estimates that may exist due to variations in numbers of nodes excised. Nodal ratio >0.20 was associated with LRR >20%, warranting PMRT consideration. Nodal ratio may be useful for extrapolating data from prospective trials to clinical practices in which axillary staging extent vary.     

真空辅助乳腺微创旋切术在乳腺良性疾病应用进展

真空辅助乳腺活检系统( VABB)由美国食品与药品监督管理局于 1995年批准应用于乳腺肿物的活检。该系统包括内外套针、旋切刀、传送装置、真空抽吸泵、控制器及相关软件等组成。 VABB可在多种影像学引导下(乳腺超声、 MRI、X线)对乳腺病灶切除活检。起初 VABB系统主要应用于乳腺病灶的活检,如早期乳腺癌的诊断。由于 VABB通过影像学引导下精确完整切除病灶,能够获得足够量的组织样本进行病理学检查,因此广泛应用于良性乳腺疾病的治疗,如良性乳腺肿瘤的切除、乳腺炎、乳腺整形手术等,成为乳腺微创手术的重要手段。     

Factors influencing survival in bilateral breast cancer

One Hundred And Four Patients With Bilateral Breast Cancers, Detected Clinically, Were Studied. Patients With Synchronous Lesions Experienced The Worst Survival. Lymph Node Metastases In The Second Mastectomy Had Obvious Adverse Effect On Survival. The Development Of Scirrhous Carcinoma In The Second Breast Did Not Alter Survival. A Maximum Of 21 Patients Might Have Been Adversely Affected By The Development Of A Second Cancer Because Of Lymph Node Metastases In The Second Breast Only. Survivorship Data Suggest The Adequacy Of Treatment Of Contralateral Breast Cancers When They Become Detectable By Clinical Means Alone.     

Barriers,beliefs and practice patterns for breast cancer reconstruction: A provincial survey

BackgroundThe purpose of this study was to characterize beliefs and practice patterns for breast cancer reconstruction among physicians who treat patients with breast cancer, in order to delineate current clinical practice. This survey was administered prior to Cancer Care Ontario guideline publication.MethodSurvey questions addressed four domains: survival, delayed or obscured recurrence detection, delayed adjuvant therapy, and aesthetics. The survey was administered to 1160 Ontario plastic and general surgeons and radiation and medical oncologists. Data were compared to published guidelines.ResultsThe overall response rate was 48%, with 57% of respondents treating breast cancer. Of those treating breast cancer, 75% are affiliated with an academic center. Immediate breast reconstruction (IBR) is not available to 28%. Autologous reconstruction is thought to interfere with recurrence detection by 23% (oncologists 30%, surgeons 19%, p = 0.04). For patients not expected to require radiation therapy, IBR is not supported by 30%. Autologous IBR is believed to delay delivery of adjuvant chemotherapy by 45% (oncologists 55%, surgeons 41%, p = 0.02). Up to 42% of respondents believe delays in adjuvant therapy delivery following IBR are due to insufficient health care resources (ie. coordinating an oncologic and reconstructive surgeon). Radiation therapy following reconstruction is believed to have negative aesthetic outcomes, and increase the need for revision surgery.ConclusionsUnfavourable beliefs about certain clinical actions do not align with recent provincial guideline recommendations. Insufficient healthcare resources are perceived to be a significant barrier to IBR and timely care.     

Comparison of analgesic effect of locally and systemically administered ketorolac in mastectomy patients

Background: Ketorolac is a parenteral nonsteroidal antiinflammatory drug (NSAID). Two features have limited its clinical utility: tendency to elicit kidney failure and inability to produce complete analgesia. Because most NSAIDs are weak acids (pKa 3–5) and become concentrated in acidic tissues, such as injured and inflamed tissues, we hypothesized that local administration may enhance its analgesic efficacy while lowering the potential for systemic complications. Methods: We conducted a randomized, placebo-controlled study of 60 group I–III (American Society of Anesthesiology criteria) mastectomy patients, 20 in each group. Near the end of surgery and every 6 h postoperatively, 20 ml of the study solution containing normal saline with or without 30 mg of ketorolac were administered simultaneously either via a Jackson-Pratt drain or intravenously in a double-blind fashion. The quality of pain control, the amount and character of the drain fluid, incidence of nausea and vomiting, length of stay in the postoperative care unit, and amount of morphine used for treatment of breakthrough pain were recorded. Results: Intraoperative administration of ketorolac resulted in better quality of pain control in the immediate postoperative period regardless of route of administration. The incidence of nausea was significantly higher in the placebo group, and drain output in the ketorolac groups did not exceed the output in the placebo group. Conclusion: Analgesic of the locally administered ketorolac is equally effective to the efficacy of ketorolac administered intravenously. Presented at the 48th Annual Meeting of the Society of Surgical Oncology, Boston, Massachusetts, March 23–26, 1995.     

Comparison of Single Incision Endoscopic Nipple-Sparing Mastectomy and Conventional Nipple-Sparing Mastectomy for Breast Cancer Based on Initial Experience

PurposeEndoscopic breast surgery for patients with breast cancer was introduced for its superior cosmetic outcomes; it was initially studied in the field of breast-conserving surgery and, more recently, in robotic-assisted nipple-sparing mastectomy (NSM). The main purpose of this study was to investigate the feasibility and safety of endoscopic NSM (E-NSM) in patients with breast cancer by comparing E-NSM and conventional NSM (C-NSM).MethodsBetween May 2017 and October 2020, we retrieved the records of 45 patients who underwent NSM with permanent silicone implants and divided them into the E-NSM group (20 patients) and the C-NSM group (25 patients), depending on the use of the endoscopic device. We also analyzed demographic information, pathology, operative time, and complications.ResultsNo significant differences were observed between the 2 groups based on demographic information, postoperative pathological data, mean length of hospital stay, and total number of complications. The mean preparation time for surgery was comparable between both groups. Compared to the C-NSM group, the E-NSM group had a significantly longer mean operative time and, subsequently, a significantly longer mean total operative time and number of complications.ConclusionThe results showed that E-NSM was feasible and safe with a more inconspicuous incision in patients with breast cancer.