Titanium clip placement to allow accurate tumour bed localisation following breast conserving surgery – Audit on behalf of the IMPORT Trial Management Group

Introduction

Accurate tumour bed (TB) localisation is a key requirement for the UK IMPORT (Intensity Modulated Partial Organ Radiotherapy) trial. We audited the value of titanium clips for TB localisation following breast conserving surgery (BCS) in breast radiotherapy (RT) planning.

Patients and methods

At surgery, paired clips were positioned around the TB as follows: 1. Medial, lateral, superior and inferior: half-way between skin and fascia; 2. Posterior: at the pectoral fascia; 3. Anterior: close to the suture line. Thirty consecutive patients with clips inserted were audited at the time of RT planning. Audit standards were set as follows: (i) 5/6 pairs of clips identified on RT planning computed tomography (CT) scan – 100%; (ii) possible clip migration: <10%; (iii) TB localisation improved with clips: >50%. Inter- and intra-observer variability in clinician outlining of the TB was studied in a subset of 12 randomly selected patients to see if this impacted on positioning of radiotherapy field borders.

Results

Five or six pairs of clips were identified in all 30 cases. The TB could be successfully identified using CT seroma alone in only 8/30 (27%) patients. Clips were essential for the TB localisation of the other 22/30 (73%) patients. There was no evidence of clip migration. TB localisation led to modified RT field borders in 18/30 (60%) patients. Five of these patients had highly visible seromas, so the addition of clips modified field borders in 13/30 (43%) patients. Both inter- and intra-observer variability was reasonable and did not impact on positioning of radiotherapy field borders.

Conclusion

Titanium clips provide an accurate and reliable method of TB localisation following BCS. We anticipate that the audit results will lead to clips being adopted as best practice by the Association of Breast Surgeons (ABS) at BASO (British Association of Surgical Oncology).     

Association of breast tumour bed seroma with post-operative complications and late normal tissue toxicity: Results from the Cambridge Breast IMRT trial

Aims

There are two main surgical techniques for managing the tumour bed after breast cancer excision. Firstly, closing the defect by suturing the cavity walls together and secondly leaving the tumour bed open thus allowing seroma fluid to collect. There is debate regarding which technique is preferable, as it has been reported that a post-operative seroma increase post-operative infection rates and late normal tissue side effects.

Methods

Data from 648 patients who participated in the Cambridge Breast IMRT trial were used. Seromas were identified on axial CT images at the time of radiotherapy planning and graded as not visible/subtle or easily visible. An association was sought between the presence of seroma and the development of post-operative infection, post-operative haematoma and 2 and 5 years normal tissue toxicity (assessed using serial photographs, clinical assessment and self assessment questionnaire).

Results

The presence of easily visible seroma was associated with increased risk of post-operative infection (OR = 1.80; p = 0.004) and post-operative haematoma (OR = 2.1; p = 0.02). Breast seroma was an independent risk factor for whole breast induration and tumour bed induration at 2 and 5 years. The presence of breast seroma was also associated with inferior overall cosmesis at 5 years. There was no significant association between the presence of seroma and the development of either breast shrinkage or breast pain.

Conclusion

The presence of seroma at the time of radiotherapy planning is associated with increased rates of post-operative infection and haematoma. It is also an independent risk factor for late normal tissue toxicity. This study suggests that full thickness surgical closure may be desirable for patients undergoing breast conservation and radiotherapy.     

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim

The aim of this study was to evaluate the safety of breast conserving surgery in patients with breast tumours satisfactorily downstaged after neoadjuvant therapy.

Methods

A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group.

Results

The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient.

Conclusion

Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy.     

Ultrasonography-Guided Surgical Clip Placement for Tumor Localization in Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer

Purpose

We investigated the feasibility of using surgical clips as markers for tumor localization and their effect on the imaging evaluation of treatment responses after neoadjuvant chemotherapy (NAC).

Methods

A total of 16 breast cancers confirmed by needle biopsy in 15 patients were included in this study from October 2012 to June 2014. Under ultrasonography (US)-guidance, the surgical clips were placed prior to NAC. Additional mammography, breast US, and breast magnetic resonance examinations were performed within 10 days before surgery. The time period from marker insertion to operation date was documented. Images acquired via the three modalities were evalu-ated for the following parameters: location of clip, clip migration (>1 cm), the presence of complications from clip placement, and the effect of clips on the assessment of treatment.

Results

The mean time period was 128.6±34.4 days (median, 132.0 days) from the date of clip insertion to the date of surgery. The mean number of inserted clips was 2.3±0.7 (median, 2.0). Clip migration was not visualized by imaging in any patient, and there were no complications reported. Surgical clips did not negatively affect the assessment of treatment responses to NAC.

Conclusion

Surgical clips may replace commercial tissue markers for tumor localization in breast cancer patients undergoing NAC without migration. Surgical clips are well tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective.     

Real-time intraoperative detection of breast cancer using near-infrared fluorescence imaging and Methylene Blue

Background

Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast conserving surgery. Based on certain physicochemical similarities between Technetium(^99mTc)-sestamibi (MIBI), an SPECT radiodiagnostic with a sensitivity of 83–90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging.

Methods

Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy.

Results

20/24 (83%) of breast tumors (carcinoma in N = 21 and ductal carcinoma in situ in N = 3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue.

Conclusions

This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management.     

Prognosis following local recurrence after breast conserving treatment in young women with early breast cancer

Background

Few studies have focussed on the prognosis of young women with local recurrence (LR) after breast-conserving therapy and the factors that can be used to predict their prognosis.

Methods

We studied the outcome and related prognostic factors in 124 patients with an isolated local recurrence in the breast following breast-conserving surgery and radiotherapy for early stage breast cancer diagnosed at the age of 40 years or younger.

Results

The median follow-up of the patients after diagnosis of LR was 7.0 years. At 10 years from the date of salvage treatment, the overall survival rate was 73% (95% CI, 63–83), the distant recurrence-free survival rate was 61% (95% CI, 53–73), and the local control rate (i.e. survival without subsequent LR or local progression) was 95% (95% CI, 91–99). In the multivariate analysis, the risk of distant metastases also tended to be higher for patients with LR occurring within 5 years after BCT, as compared to patients with LR more than 5 years after BCT (Hazard ratio [HR], 1.89; p = 0.09). A worse distant recurrence-free survival was also observed for patients with a LR measuring more than 2 cm in diameter, compared to those with a LR of 2 cm or smaller (HR, 2.88; p = 0.007), and for patients with a LR causing symptoms or suspicious findings at clinical breast examination, compared to those with a LR detected by breast imaging only (HR 3.70; p = 0.03).

Conclusions

These results suggest that early detection of LR after BCT in young women can improve treatment outcome.     

National survey of breast cancer specimen orientation marking systems

Background

NHS Breast Screening Programme (NHSBSP) guidelines recommend using a protocol to orientate excised specimens, thus allowing accurate reexcision of positive margins. Variation between units, and surgeons, in protocols may cause confusion, labelling errors and specimen misorientation. We investigated variation of, and satisfaction with, specimen labelling protocols in breast surgery units.

Methods

Questionnaires were sent to the lead pathologist of all English breast units, addressing method (clips/staples/ink) and system (eg long suture = lateral) of orientation, and pathologist's satisfaction with the consistency and method used.

Results

Of 141 units, 117 responded: 82 screening and 35 non-screening units. 92 use a standardised orientation protocol. Eleven screening and 15 non-screening units report no protocol.Of responding units, 33 use sutures, 9 use clips, 67 use clips + sutures, 3 use coloured ink and 5 suture the specimen to paper/foam/marginmap^®. The commonest protocol is suture: short-superior, medium–medial, long-lateral, by 50 units. However eleven labelling systems for sutures and 14 for clips were reported. Twenty-six pathologists reported no standardised method, with labelling technique either written on the specimen card (n = 15) or presumed, based on the surgeon-in-charge's usual practice.Thirty-four pathologists are satisfied with a locally established protocol, however 56 want a nationally standardised marking system.

Conclusion

Despite NHSBSP guidelines, nearly one quarter of breast units have no specimen orientation protocol. Specimen marking protocols vary widely – a concern in view of the transient nature of locum and trainee doctors. There is a clear wish by pathologists for specimen marking standardisation, whether this is nationally or locally defined.     

Objectively measured breast symmetry has no influence on quality of life in breast cancer patients

Aims

This study investigates how quality of life (QoL) of breast cancer patients is related to breast symmetry.

Methods

We objectively measured breast symmetry using the breast analyzing tool (BAT) in 101 patients after breast conserving surgery for breast cancer at different time points during follow up. We correlated the results with the quality of life measured at the same time using the breast image scale (BIS), the EORTC QLQ-BR23 scale and a not validated sexual score scale. Age, tumour size, tumour/breast relation and the use of oncoplastic surgery were also correlated with symmetry and quality of life scales. Using multivariate analyses, independent parameters for an improved quality of life were identified.

Results

Mean age was 56 (±11.6), and 75.2% of patients had T1 or T2 tumours. Patient age (p = 0.03) and tumour size (p = 0.01) significantly influenced objectively measured breast symmetry. The cosmetic result was important for 53% of patients while 48% found it not important. Independent from this, neither overall quality of life nor breast self esteem was influenced by breast symmetry in our patients.

Conclusions

After breast cancer surgery, breast symmetry is not a major factor for patients’ quality of life and breast self esteem. Cosmetic result seems to be less important than oncologic outcome in patients with breast cancer.     

The role of radiotherapy in treating small early invasive breast cancer

Aim

The aim of the study was to identify if radiotherapy can be safely avoided in a selected subgroup of largely screening detected small invasive breast cancer.

Methods

One hundred and eighty-eight patients with node negative invasive early breast cancer ≤1 cm (≤T1b) treated in our centre between 1990 and 2004 were retrospectively followed for local, regional and distant recurrences. Treatment involved adequate local excision by breast conserving surgery (BCS). Axillary staging was performed by a four node axillary sampling until 2000, following which sentinel lymph node sampling was employed. All sections were assessed histologically by haematoxylin and eosin stained sections. The inked margins were reported as being involved, close and clear. Radiotherapy (RT) was employed only if the resected margins were inadequate, and in those with involved axillary nodes who refused further completion axillary clearance.

Results

Ninety-four patients (Group A) had BCS alone and 79 patients (Group B) had both BCS and RT. There was no ipsilateral breast tumour recurrence (IBTR) in 88 patients in Group A, corresponding to an actuarial freedom from IBTR of 96%, 91% and 88.1% at 5 years, 8 years and 9 years. In Group B, there was no IBTR in 75 patients corresponding to an actuarial freedom from IBTR of 97%, 94.9% and 90.6% at 5 years, 8 years and 10 years.

Conclusion

Our experience over 14 years has shown that it is possible to safely avoid radiotherapy in a selected subgroup of small invasive breast cancer.     

IORT with electrons as boost strategy during breast conserving therapy in limited stage breast cancer: Long term results of an ISIORT pooled analysis

Purpose

Linac-based intraoperative radiotherapy with electrons (IOERT) was implemented to prevent local recurrences after breast conserving therapy (BCT) and was delivered as an intraoperative boost to the tumor bed prior to whole breast radiotherapy (WBI). A collaborative analysis has been performed by European ISIORT member institutions for long term evaluation of this strategy.

Material and methods

Until 10/2005, 1109 unselected patients of any risk group have been identified among seven centers using identical methods, sequencing and dosage for intra- and postoperative radiotherapy. A median IOERT dose of 10 Gy was applied (90% reference isodose), preceding WBI with 50–54 Gy (single doses 1.7–2 Gy).

Results

At a median follow up of 72.4 months (0.8–239), only 16 in-breast recurrences were observed, yielding a local tumor control rate of 99.2%. Relapses occurred 12.5–151 months after primary treatment. In multivariate analysis only grade 3 reached significance (p = 0.031) to be predictive for local recurrence development. Taking into account patient age, annual in-breast recurrence rates amounted 0.64%, 0.34%, 0.21% and 0.16% in patients <40 years; 40–49 years; 50–59 years and ?60 years, respectively.

Conclusion

In all risk subgroups, a 10 Gy IOERT boost prior to WBI provided outstanding local control rates, comparing favourably to all trials with similar length of follow up.     

Change of aesthetic and functional outcome over time and their relationship to quality of life after breast conserving therapy

Purpose

We analyzed changes in aesthetic and functional outcome over time after breast conserving therapy. Our special interest resides in the question of whether these aspects gain or loose their influence on quality of life (QoL) with temporal progress.

Patients and methods

This prospective single centre cohort study included 138 patients, treated with breast conserving surgery and consecutive radiotherapy. Patients completed two questionnaires one week and one year after surgery: the BCTOS (Breast Cancer Treatment Outcome Scale) to measure Functional, Aesthetic, and Breast Sensitivity Status and the EORTC (European Organisation for Research and Treatment of Cancer) C30-BR23 to assess QoL. We applied correlation and multiple regression analysis as statistical methods.

Results

Aesthetic and Functional Status did not change significantly over one year, whereas Breast Sensitivity Status and several QoL subscales showed significant improvement (p < 0.0001). Correlations between BCTOS scales and EORTC subscales remain similar over time. Functional and Aesthetic Status kept a strong impact on global health (Spearman’s Rho = −0.28 to −0.45 depending on time of assessment). Increasing age and poorer Functional Status shortly after surgery are predictors of a decline in global health over one year (p < 0.001).

Conclusion

Functional and aesthetic outcome after breast conserving surgery maintain their impact on QoL over a one year follow-up period and are valuable predictors of QoL.     

How safe is oncoplastic breast conservation?: Comparative analysis with standard breast conserving surgery

Aim

Oncoplastic techniques are increasingly used to facilitate breast conservation and maintain breast aesthetics but evidence with regards to the oncological safety of oncoplastic breast conservation surgery (oBCS) remains limited. The aim of this study was to compare re-excision and local recurrence rates for oBCS with standard breast conserving surgery (sBCS).

Methods

From June 2003 to Feb 2010 data was obtained from contemporaneously recorded electronic patient records on patients who had oBCS and sBCS within a single breast cancer centre. Re-excision rates and local recurrence rates were compared.

Results

A total of 440 sBCS and 150 oBCS (in 146 women) were included in this study. Median tumour size and specimen weight was 21 mm and 67 g for oBCS and 18 mm and 40 g in the sBCS group (p < 0.001). Re-excision was 2.7% (4/150) and 13.4% (59/440) for oBCS and sBCS respectively (p < 0.001). At a median follow-up of 28 months, local relapse was 2.7% (4) and 2.2% (10) and distant relapse 1.3% (2) and 7.5% (33) for oBCS and sBCS respectively.

Conclusions

Oncoplastic breast conserving techniques decrease re-excision rates. Early follow up data suggests oncological outcomes of oncoplastic breast conservation surgery are similar to standard breast conservation.     

“Axillary recurrences after sentinel lymph node biopsy: A multicentre analysis and follow-up of sentinel lymph node negative breast cancer patients”

Introduction

The objective of this study was to conduct a multicentre data analysis to identify prognostic factors for developing an axillary recurrence (AR) after negative sentinel lymph node biopsy (SLNB) in a large cohort of breast cancer patients with long follow-up.

Patients and methods

The prospective databases from different hospitals of clinically node negative breast cancer patients operated on between, 2000 and 2002 were analyzed. SLNB was performed and pathological analysis done by local pathologists according to national guidelines. Adjuvant treatment was given according to contemporary guidelines. Multivariate analysis was performed using all available variables, a p-value of <0,05 was considered to be significant.

Results

A total of 929 patients who did not undergo axillary lymph node dissection were identified. After a median follow up of 77 (range 1–106) months, fifteen patients developed an isolated AR (AR rate 1,6%). Multivariate analysis showed that young age (p = 0.007) and the absence of radiotherapy (p = 0.010) significantly increased the risk of developing an AR. Distant metastasis free survival (DMFS) was significantly worse for patients with an AR compared to all other breast cancer patients (p < 0,0001).

Conclusion

Even after long-term follow up, the risk of developing an AR after a negative SLN in breast cancer is low. Young age and absence of radiation therapy are highly significant factors for developing an axillary recurrence. DMFS is worse for AR patients compared to patients initially diagnosed with N0 or N1 disease.     

Ipsilateral breast recurrence after breast conserving surgery in patients with small (≤2 cm) breast cancer treated with modern adjuvant therapies

Background

Modern multimodality treatment greatly influences the rate and the predictive factors for ipsilateral cancer recurrence (IBR) after breast conserving surgery.

Material and nethods

The study is based on 1297 patients with pT1 breast cancer and treated with breast conserving surgery in February 2001-August 2005. The median duration of follow-up was 57 months.

Results

IBR occurred in 27 (2.1%) patients. It was located in the quadrant of prior breast resection in 17 (63%) cases. The median time to an IBR was 41 months (range, 6-78) regardless of whether the recurrence was located in the same or in another quadrant. Omission of radiotherapy was associated with a higher IBR incidence, HR 10,344 (95% CI 1904-56,184; p = 0.007). The IBRs occurred particularly often, in 27% of the 11 patients who refused radiotherapy. Patients diagnosed with ER+ cancer had a lower risk of IBR when compared with those with ER−/HER2+ cancer, HR 0.215 (95% CI 0.049-0.935; p = 0.040).

Conclusions

The risk of IBR was low during the first 5 years after breast resection among patients with pT1 breast cancer and treated with modern surgical and adjuvant therapies. The majority IBRs still occur at or close to the prior resection site underlining the importance of local therapies. Omission of radiotherapy was the most significant risk factor for IBR.     

A randomised controlled trial of forward-planned radiotherapy (IMRT) for early breast cancer: Baseline characteristics and dosimetry results

Background and purpose

This large trial was designed to investigate whether correction of dose inhomogeneities using intensity-modulated radiotherapy (IMRT) reduces late toxicity and improves quality of life in patients with early breast cancer. This paper reports baseline characteristics of trial participants and dosimetry results.

Materials and methods

Standard tangential plans of 1145 trials were analysed. Patients with inhomogeneous plans, defined by ICRU recommendations, were randomised to forward-planned IMRT or standard radiotherapy.

Results

Twenty-nine percentage of patients had adequate dosimetry with standard 2D radiotherapy. In the randomised patients, the decreases in mean volumes receiving greater than 107% (Vol > 107) and less than 95% (Vol < 95) of the prescribed dose in the IMRT compared with the control group were 34.0 cm³ (95% CI 26.4-41.6; P < 0.0001) and 48.1 cm³ (95% CI 34.4-61.9; P < 0.0001), respectively. In this study, 90% of patients who had a breast separation greater ?21 cm had Vol > 107 > 2 cm³ on standard radiotherapy plans.

Conclusion

This large trial, in which patients with all breast sizes were eligible, confirmed that breast dosimetry can be significantly improved with a simple method of forward-planned IMRT and has little impact on radiotherapy resources. It is shown that patients with larger breasts are more likely to have dose inhomogeneities and breast separation gives some indication of this likelihood. Photographic assessment of patients at 2 years after radiotherapy, as the next part of this randomised controlled trial, will show whether these results for IMRT translate into improved cosmetic outcome in patients with early breast cancer. This would provide impetus for the widespread adoption of 3D planning and IMRT.     

Predictors of re-operation due to post-surgical bleeding in breast cancer patients: A Danish population-based cohort study

Aim

To assess the risk of re-operation due to post-surgical bleeding after initial breast cancer surgery and to identify predictors of re-operation.

Methods

We conducted a population-based study in Denmark. Patients were categorized according to age group, surgery type, and glucocorticoid use before surgery: never, current (0–90 days), and former (>90 days). We calculated the risk of re-operation due to post-surgical bleeding within 14 days after surgery, risk differences, and risk ratios of re-operation associated with age group, surgery type, and glucocorticoid use.

Results

19,919 women were studied; 508 were re-operated. 3573 of the 19,919 women ever used glucocorticoids. Older age and mastectomy increased the risk of post-surgical bleeding compared with breast conserving surgery and younger age among both ever and never users of glucocorticoids. The crude risk of re-operation was 2.5% among never users of glucocorticoids, 2.6% among ever users and 4.0% among current users. Women aged ≥80 who were ever users of glucocorticoids and who had a mastectomy had 8.1% risk of re-operation due to post-surgical bleeding, whereas women <80 years old who never used glucocorticoids and who had breast conserving surgery had a 1.7% risk of re-operation.

Conclusions

Older age, mastectomy, and – in some women – glucocorticoid use add an extra risk of re-operation due to bleeding. Clinicians and their patients can use this information to evaluate the patient-specific risk of this complication.     

Effect of local therapy on locoregional recurrence in postmenopausal women with breast cancer in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial

Background and purpose

The TEAM trial investigated the efficacy and safety of adjuvant endocrine therapy consisting of either exemestane or the sequence of tamoxifen followed by exemestane in postmenopausal hormone-sensitive breast cancer. The present analyses explored the association between locoregional therapy and recurrence (LRR) in this population.

Material and methods

Between 2001 and 2006, 9779 patients were randomized. Local treatment was breast conserving surgery plus radiotherapy (BCS + RT), mastectomy without radiotherapy (MST-only), or mastectomy plus radiotherapy (MST + RT). Patients with unknown data on surgery, radiotherapy, tumor or nodal stage (n = 199), and patients treated by lumpectomy without radiotherapy (n = 349) were excluded.

Results

After a median follow-up of 5.2 years, 270 LRRs occurred (2.9%) among 9231 patients. The 5-years actuarial incidence of LRR was 4.2% (95% CI 3.3–4.9%) for MST-only, 3.4% (95% CI 2.4–4.2%) for MST + RT and 1.9% (95% CI 1.5–2.3%) for BCS + RT. After adjustment for prognostic factors, the hazard ratio (HR, reference BCS + RT) for LRR remained significantly higher for MST-only (HR 1.53; 95% CI 1.10–2.11), not for MST + RT (HR 0.78; 95% CI 0.50–1.22).

Conclusion

This explorative analysis showed a higher LRR risk after MST-only than after BCS + RT, even after adjustment for prognostic factors. As this effect was not seen for MST + RT versus BCS + RT, it might be explained by the beneficial effects of radiation treatment.     

What a difference a clip makes! Analysis of boost volume definition in radiation therapy for conservative breast surgery

Purpose/objective(s)

To evaluate the role of surgical clips placement in the definition of boost treatment volume.

Skin reducing mastectomy and immediate reconstruction: The effect of radiotherapy on complications and patient reported outcomes

Aim

Skin reducing mastectomy, dermal sling and immediate implant reconstruction (SRMIR) is an emerging technique where, de-epithelialised inferior skin flap sutured to pectoralis major provides vascularised, dermal sling for the implant. We aimed to assess patient satisfaction following SRMIR and determine if radiotherapy affected patient reported outcomes.

Method

A prospective database of women undergoing SRMIR was analysed. SRMIR was performed in 92 women (116 breasts). Radiotherapy was received by 45 women and it was not required in 47 women. Forty eight women had contralateral surgery: 21 breast reduction/mastopexy, 1 augmentation, 26 mastectomy/reconstruction. A validated breast evaluation questionnaire provided patient reported outcomes.

Results

Median follow up was 20 months. Early complications were similar in both groups, but those in the radiotherapy group had a higher incidence of implant loss (6/45 = 13% vs 1/47 = 2%; p = 0.06) and grade III/IV capsular contracture (11/45 = 24% vs 6/47 = 13%; p = 0.20).The outcome questionnaire was sent to 83 women who were disease free and had retained their implants. Sixty three women responded (76%). Patient reported satisfaction was high, with or without radiotherapy. Women receiving radiotherapy gave lower scores, but it was statistically significant only for general appearance and symmetry.

Conclusions

Although complications after radiotherapy are higher in patients who had SRMIR, the majority of women who retained their implant are highly satisfied with their reconstruction. Majority of these patients were happy to recommend SRMIR procedure to their friend.     

Treatment for breast sarcoma: A large, single-centre series

Aims

To report outcomes in breast sarcoma in the context of a major series from a tertiary referral centre.

Methods

Retrospective analysis was performed on patients with histologically-proven breast sarcoma treated between 1996 and 2006. Kaplan-Meier survival curves were constructed and differences assessed by Log-Rank and Wilcoxon tests.

Results

63 patients were identified; 57 underwent treatment with curative intent. 24 patients had undergone previous radiotherapy.36 patients who underwent primary surgery elsewhere were referred for further treatment, of which 22 had at least one involved margin from primary resection. Surgery performed and margins status varied between patients undergoing primary surgery at this institution (n = 21; WLE = 8, mastectomy = 12, chest wall resection = 1, involved margins = 2 [10%]) or at a referring institution (n = 36; lumpectomy = 25, mastectomy = 11, involved margins = 22 [61%]), although there was no difference in tumour size or previous radiotherapy status.Previous irradiation was associated with poor prognosis. A greater proportion of these patients required primary mastectomy to ensure adequate clearance; the majority of the post-irradiation tumours were angiosarcomas (15/19) and significantly more relapsed locally (P < 0.001).All patient disease-free survival (DFS) rates were 71% at 2 and 42% at 5 years. DFS improved when primary surgery was undertaken at a high-volume sarcoma unit; 2-yr 84%vs75%; 5-yr 58%vs37%. There was a trend towards worse DFS with increasing size and increasing grade of tumour but this did not attain significance.

Conclusions

Radiation-induced breast sarcoma has worse local recurrence rates compared to primary breast sarcoma. Involved margins were fewer at a specialist unit, which may translate into improved outcome.