Management algorithm and outcome evaluation of partial mastectomy defects treated using reduction or mastopexy techniques

BACKGROUND: Reconstruction of the partial mastectomy defect has become increasingly popular because of poor cosmetic results in select patients. The purpose of this series was to try to create a treatment algorithm based on patient selection, diagnosis, margins, and recurrence in an attempt to maintain oncologic safety, as well as to improve esthetic outcome. METHODS: A retrospective review of all patients treated at Emory University Hospital with partial mastectomy and reduction/mastopexy was performed. Reconstruction was performed either simultaneously or following confirmation of negative histologic margins. RESULTS: Sixty-three women were included in the series. Histology was invasive carcinoma (n = 33), ductal carcinoma in situ (DCIS) (n = 20), fibroadenoma (n = 6), and benign breast tissue (n = 4). The Wise pattern was used 84% of the time (n = 53/63). The most common tumor location was upper outer quadrant, and the various pedicles used were superomedial (n = 22), inferior (n = 20), central (n = 7), and other (n = 14). Eight patients had reduction/mastopexy once final pathology confirmed negative margins. The average biopsy weight was 236 g. Total specimen weight on the tumor side was 762 g and 858 g on the contralateral side, to accommodate for radiation fibrosis. Immediate complications were seen in 22% of cases and included delayed healing (n = 9), infection (n = 1), partial nipple loss (n = 1), hematoma (n = 1), and skin necrosis (n = 1). In patients with breast cancer (n = 53), 26% required either fine needle aspiration or excisional biopsy for cancer surveillance postoperatively. Oncoplastic surgery was the definitive procedure 93% of the time. Completion mastectomy with reconstruction was required in 4 patients, 3 for positive margins extensive DCIS and 1 for residual microcalcifications (stereobiopsy DCIS) despite adequate specimen radiograph and negative margins initially. All 4 patients who failed the combined approach were younger women with the diagnosis of extensive DCIS. The locoregional recurrence rate was 2%, and all patients had no evidence of disease at an average follow-up of 3.25 years. CONCLUSION: Therapeutic mammaplasty is a useful procedure for shape and symmetry preservation in women with large or ptotic breasts. Versatility exists using various pedicles and skin patterns to reconstruct all breast shapes and defect locations. Younger patients with extensive DCIS are poor candidates for simultaneous reconstruction, and should be deferred until confirmation of negative margins. If surgical management of residual disease requires completion mastectomy, immediate reconstruction is possible, with skin preservation and no adverse effects.     

Predicting the likelihood of residual disease in women treated for ductal carcinoma in situ

Background: To identify women at risk for residual disease after excision of ductal carcinoma in situ (DCIS), we assessed the relationship between characteristics of the initial biopsy and the presence of residual DCIS at a subsequent operation.Study Design: We identified 134 consecutive “paired” operations from 112 women who had undergone 2 or more operations for DCIS between February 1995 and December 1996. Cancer status of the margins, patient age and leading presentation, tumor subtype and grade, and the presence of multifocal-extensive disease were assessed as potential predictors.Results: Residual DCIS was found in 60 patients (45%): in 2 of 12 patients (17%) with negative margins, in 11 of 36 (31%) with close margins (< 2 mm), in 30 of 52 (58%) with positive margins, and in 17 of 34 patients (50%) with margins of unknown status. Patients with positive or unknown margins were 7.7 and 8.3 times, respectively, more likely to have residual disease than patients with negative margins (95% CI 1.1–59.1; 1.1–66.4). Patients with clinical presentations were 8.0 times more likely to have residual disease than patients who presented with abnormal mammograms (95% CI 2.3–27.6). Multifocal-extensive DCIS was associated with residual disease (adjusted odds ratio [OR] = 7.7, 95% CI 2.9–20.5), as was comedo subtype (OR = 2.7, 95% CI 1.1–6.7).Conclusions: Positive or unknown biopsy margins, a clinical presentation, multifocal-extensive cancer, and the comedo subtype are associated with higher risk of residual DCIS.     

Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy

BACKGROUND: The incidence of local recurrence (LR) after conventional total mastectomy for ductal carcinoma in situ (DCIS) ranges from 1% to 3%. Skin-sparing mastectomy (SSM) preserves the native skin envelope to facilitate immediate breast reconstruction. Because DCIS is generally not clinically apparent, there is a potential for inadequate excision when SSM is performed. Risk factors for local recurrence after SSM for DCIS are examined. STUDY DESIGN: A retrospective review of 223 consecutive patients with DCIS treated by SSM and immediate reconstruction was performed. Age younger than 50 years, tumor size > 40 mm, high tumor grade, tumor necrosis, surgical margins < 1 mm, type of biopsy (excisional versus core), and SSM type were examined as risk factors for recurrence. RESULTS: Mean followup was 82.3 months (range 4.9 to 123.2 months). Recurrences developed in 11 patients (5.1%), including: local (n = 7; 3.3%), regional (n = 2; 0.9%), and distant (n = 2; 0.9%). All seven local recurrences were detected by physical examination. No patients received adjuvant radiation therapy. Two of 19 patients with surgical margins < 1 mm developed LR (10.5%). Univariate analysis showed high tumor grade (p = .019) to influence LR. CONCLUSIONS: The incidence of local recurrence of DCIS after SSM is similar to conventional total mastectomy. Reexcision of close margins should be performed if possible and adjuvant radiation therapy should be considered.     

Cytologic evaluation of lumpectomy margins in patients with ductal carcinoma in situ: Clinical outcome

Backround: Breast conservation therapy is controversial for ductal carcinoma in situ (DCIS) due to recently reported high recurrence rates. We believe that cytologic evaluation of lumpectomy margins improves efficiency and leads to a lower recurrence rate following lumpectomy for DCIS. Methods: A prospectively accrued database of 1255 breast cancer patients at the H. Lee Moffitt Cancer Center and Research Institute was found to have 218 patients with DCIS (17.4%). Of those 218 cases, 114 were treated with lumpectomy, axillary dissection, and radiation therapy; the remaining 104 patients were treated with mastectomy with or without reconstruction. Imprint cytology was used to evaluate all lumpectomy margins. Permanent sections and imprint cytology were reviewed by the same pathologist. Results: All lumpectomy specimens (116 tumors in 114 patients) were evaluated. The median follow up was 57.5 months (range 2–110 months). One hundred and three patients with 104 tumors were selected on the basis of pure DCIS (with or without microinvasion), and treated with lumpectomy, axillary dissection and radiation therapy. Of the 104 tumors utilizing attempted breast conservation therapy, 7 (6.6%) required mastectomy. There were 6 recurrences (6.1%) with a median time for recurrence of 47.5 months (range 27–85 months); four recurrences were comedo and two were noncomedo at original diagnosis. Conclusions: The determination of lumpectomy margins in DCIS patients using imprint cytology leads to an overall recurrence rate of 6.1% with reduction in operative time, and re-excision rate. Significant recurrence rates were associated with microinvasion and multifocal tumors (28%) versus simple DCIS at 5 years. Breast conservation therapy and surgical margin determination with imprint cytology for DCIS is a cost-effective and reliable method of treatment for simple DCIS.     

Oncoplastic surgery: the evolution of breast cancer treatment

Oncoplastic surgery is an establish approach that combines conserving treatment for breast cancer and plastic surgery techniques. It allows wide excisions and prevents breast deformities by immediate reconstruction of large resection defects. The procedures are mostly useful for resection of 20-40% of the breast - a group of patients normally treated by mastectomy in the past. Four features are integral to oncoplastic breast surgery: (i) Appropriate surgery for cancer excision. (ii) Partial reconstruction to correct wide excision defects. (iii) Immediate reconstruction with the full range of available techniques. (iv) Correction of volume and shape asymmetries relative to the contra-lateral healthy breast. There are two fundamentally different approaches: (i) volume-replacement procedures, which combine resection with immediate reconstruction by using local flaps (glandular, fasciocutaneous, and latissimus dorsi mini-flaps), and (ii) volume-displacement procedures, which combine resection with a variety of different breast reduction and reshaping techniques, according to the location of the tumor. Oncoplastic surgery increases the oncological safety of breast-conserving treatment because a much larger breast volume can be excised and wider surgical margins can be achieved. Moreover, a "surgical screening" of the contra-lateral breast allows the diagnosis of occult cancers. Among oncoplastic approaches, a very unique technique is the possibility of implant use (augmentation mammaplasty) in case of quadrantectomy and simultaneous delivery of intraoperative radiotherapy to the tumor bed.     

Clinical impact of oncoplastic surgery in a specialist breast practice

Background: Oncoplastic breast surgery is an integral and fundamental component of the clinical management of breast cancer. The aim of this study was to determine the proportion of oncoplastic and reconstructive breast cancer procedures undertaken within a specialist breast practice. Methods: An audit of breast‐related cancer procedures was undertaken for patients with early breast cancer between 1 January 2001 and 31 December 2005, treated at the Royal Adelaide Hospital and in private practice. The proportion of oncoplastic and breast reconstructive procedures was calculated to determine the clinical effects on a specialist breast‐surgical practice. Results: Breast cancer resection procedures accounted for 1514 of 2113 of operations (72%). Most of these (897 of 1514, 59.2%) were wide local excision or re‐excision procedures. Total breast reconstruction operations (i.e. autogenous tissue flaps, tissue expander/implant reconstructions) accounted for 251 procedures. Of these, 67 (26.7%) were carried out at the time of simple mastectomy. Contralateral breast procedures (i.e. reduction mammaplasty, mastopexy and augmentation) accounted for 138 procedures and nipple–areola reconstruction/tattoo accounted for 153 procedures. Oncoplastic procedures, such as skin‐sparing mastectomy, latissimus dorsi miniflap and therapeutic mammaplasty accounted for 57 of 599 procedures (9.5%). Breast reconstruction and oncoplastic operations accounted for 599 of 2113 procedures (28%). Conclusion: Specialist breast surgeons trained in breast reconstruction and oncoplastic techniques can expect a substantial proportion of their breast practice to include such operative procedures (28% in this series). Subspecialist training in breast surgery should incorporate experience in breast reconstructive and aesthetic surgery for trainees who wish to practise as specialist breast surgeons in the future.     

Ductal carcinoma in situ-associated nipple discharge: A clinical marker for locally extensive disease

Background: This study evaluates the diagnosis and treatment of women with pathologic nipple discharge caused by ductal carcinoma in situ (DCIS). Methods: Women with unilateral spontaneous bloody, serous, or brown nipple discharge who presented between January 1, 1988 and August 1, 1996 were identified by retrospective chart review. Women with nonspontaneous, physiologic discharge were excluded. Results: Two hundred seventy-seven women with a mean age of 59.5 years (range, 24 to 88 years) underwent duct exploration and biopsy for pathologic discharge, with 43 (15.5%) found to have DCIS. The discharge was bloody in 29, clear in eight, and brown in six women. Seven of 12 (58%) women with an associated breast mass were found to have a microinvasive component with the DCIS. Discharge cytology showed malignant cells in only two of 12 (16%) women examined. A ductogram was performed on 20 women, with filling defects seen in 10, ectasia in 3, narrowing in 4, and normal ducts in 3. The DCIS included 17 (40%) specimens with cribriform pattern, 17 (40%) micropapillary, 8 (18%) comedo, and 2 (2%) solid. Twelve microinvasive cancers were found in combination with DCIS. After duct exploration, 37 (86%) patients were found to have extensive or multifocal DCIS to the margin, or both, with 32 (74%) patients requiring mastectomy to achieve free surgical margins. There was residual disease in 27 of 32 (84%) mastectomy specimens after initial biopsy. Breast conservation was possible in only 11 (26%) women. Forty of 43 (93%) are disease-free with a median follow-up of 37 months. Conclusion: Women presenting with pathologic nipple discharge require duct exploration regardless of cytologic or radiologic findings. When discharge is the result of DCIS, extensiveness of disease in relation to central location and intraductal spread may preclude breast conservation in as many as 27 of 43 (63%) cases.     

Impact of core biopsy on the management of screen-detected ductal carcinoma in situ of the breast

Background: Screen‐detected ductal carcinoma in situ (DCIS) usually presents as clinically impalpable microcalcification. Although core biopsy is well established as a diagnostic modality for invasive breast cancers, few reports address its impact on the management of screen‐detected DCIS. We examined the sensitivity of core biopsy in diagnosing screen‐detected DCIS, as well as its role in facilitating one‐step surgery in the community, especially a breast‐conserving approach. Methods: Through the Monash BreastScreen database, we reviewed the management of 148 patients diagnosed with pure DCIS over a 4‐year period. Particular attention was paid to the sensitivity and surgical margin status of 63 patients who underwent initial assessment with core biopsy, compared to patients who underwent excisional biopsy or fine needle aspiration cytology (FNAC). Results: Core specimens in 63 patients yielded positive histology in 57 (90%), allowing for breast‐conserving surgery in 45 and mastectomy in 12. Negative margins were obtained in 73% of those treated by breast‐conserving surgery, compared to 51% negative margins among those who underwent excisional biopsy initially. Overall, 45 of 57 patients with a positive core biopsy histology (79%) underwent one‐step surgery. Those assessed by FNAC had a 48% incidence of non‐diagnostic/benign cytology. Conclusions: Core biopsy facilitates one‐step surgery for screen‐detected DCIS, and potentially reduces the number of surgical procedures. Stereotactic core biopsy for suspicious microcalcifications should replace hookwire‐guided excisional biopsy and FNAC as the diagnostic modality of choice.     

Is mammography useful in screening for local recurrences in patients with TRAM flap breast reconstruction after mastectomy for multifocal DCIS?

Background: Skin-sparing mastectomy with immediate transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction is being used more often for the treatment of breast cancer. Mammography is not used routinely to evaluate TRAM flaps in women who have undergone mastectomy. We have identified the potential value of its use in selected patients. Methods and Results: We report on four women who manifested local recurrences in TRAM flaps after initial treatment for ductal carcinoma in situ (DCIS) or DCIS with microinvasion undergoing skin-sparing mastectomy and immediate reconstruction. All four patients presented with extensive, high-grade, multifocal DCIS that precluded breast conservation. Three of four mastectomy specimens demonstrated tumor close to the surgical margin. Three of the four recurrences were detected by physical examination; the remaining local recurrence was documented by screening mammography. The recurrences had features suggestive of malignancy on mammography. Conclusion: We conclude that all patients undergoing mastectomy and TRAM reconstruction for extensive, multifocal DCIS should undergo regular routine mammography of the reconstructed breast. Our experience with this subgroup of patients raises concern about the value of skin-sparing mastectomy with immediate reconstruction for therapy. Adjuvant radiation therapy should be recommended for those patients with negative but close surgical margins.     

Beneficio de la biopsia del ganglio linfático centinela en pacientes con carcinoma in situ de mama

Introduction

Patients with a diagnosis of breast ductal carcinoma in situ (DCIS) have a low risk of developing axillary metastases. The use of sentinel node biopsy in this group of patients is controversial. The objective of this study is to determine if the sentinel node biopsy benefits a subgroup of patients with DCIS.

Patients and method

Between April 2002 and December 2007, patients with a diagnosis of DCIS and who underwent a sentinel node biopsy were included in the study. In our centre the sentinel node biopsy was performed in patients with DCIS who required a mastectomy, high grade and >2 cm DCIS and palpable DCIS.

Results

Forty-seven patients were included in the study. In all cases the sentinel node was identified. Twenty-five (53.1%) patients underwent a mastectomy due to extensive DCIS; 14 of these (56%) with immediate reconstruction with implants. Twenty-five (53.1%) patients had high grade DCIS. In 7 (14.8%) patients the tumour was palpable. Fourteen patients (29.7%) were upgraded to invasive breast cancer in the definitive histology. In 2 (4.2%) patients who underwent a mastectomy a positive sentinel node was found.

Conclusions

Performing sentinel node biopsy in this group of DCIS patients has lead us to identify 4% of patients with positive sentinel nodes. Furthermore, 29.7% of the patients have avoided a second invasive diagnostic procedure for definitive histology. For these reasons we consider it appropiate to perform sentinel node biopsy in this subgroup of patients with DCIS of the breast.     

Oncoplastic Mammoplasty as a Strategy for Reducing Reconstructive Complications Associated with Postmastectomy Radiation Therapy

Given the high complication rates in patients who require radiation therapy (XRT) after mastectomy and immediate reconstruction, and the low local recurrence rates following neo‐adjuvant chemotherapy and breast conservation therapy, we sought to determine if using neo‐adjuvant chemotherapy and oncoplastic mammoplasty as an alternative to mastectomy and immediate reconstruction is an effective strategy for reducing complication rates in the setting of XRT. A prospectively maintained data base was queried for patients who received neo‐adjuvant chemotherapy and XRT between 2001 and 2010 and underwent either oncoplastic mammoplasty or mastectomy with immediate reconstruction. Rates of postoperative complications between groups were compared using Fisher's exact test. Outcomes from 37 patients who underwent oncoplastic mammoplasty were compared to 64 patients who underwent mastectomy with immediate reconstruction. Mean follow‐up was 33 months (range 4–116 months). Rates of postoperative complications, including unplanned operative intervention for a reconstructive complication (2.7% versus 37.5%, p < 0.001), skin flap necrosis (10.8% versus 29.7%, p = 0.05), and infection (16.2% versus 35.9, p = 0.04) were significantly higher in the mastectomy group. Overall, 45.3% of patients who underwent mastectomy developed at least one breast complication, compared to 18.9% of patients who underwent oncoplastic mammoplasty (p = 0.01). If XRT is indicated after mastectomy, attempts should be made to achieve breast conservation through the use of neo‐adjuvant therapy and oncoplastic surgery in order to optimize surgical outcomes. Breast conservation with oncoplastic reconstruction does not compromise oncologic outcome, but significantly reduces complications compared to postmastectomy reconstruction followed by XRT.     

Outcome of oncoplastic breast surgery in 90 prospective patients

Background

Oncoplastic breast surgery refers to a wide range of techniques with a parallel goal of safely removing all malignant breast tissue while achieving the best possible esthetic outcome. We report the results of our oncoplastic breast operations from 2005 to 2007.

Methods

Ninety selected breast cancer patients were treated with a variety of oncoplastic operations. The patients were prospectively monitored. Radiotherapy and systemic adjuvant treatment were given according to national guidelines.

Results

Fifteen patients had an immediate surgical complication, of which 8 required a reoperation. Eleven patients had an inadequate surgical margin and required a completion mastectomy. During a median follow-up of 26 months no local or regional recurrences were noticed. Three patients developed distant metastases.

Conclusions

Oncoplastic breast surgery offers tools for breast conservation in patients otherwise destined for mastectomy or poor esthetic outcome. Despite the high proportion of patients in this series with large-volume ductal carcinoma in situ (DCIS) or extensive intraductal component, the use of oncoplastic techniques achieved negative margins with acceptable cosmetic results in the majority (84%) of patients.     

Surgical management of ductal carcinoma in situ in Australia in 1995

Background: In the present paper we describe the presentation and management of ductal carcinoma in situ (DCIS) of the breast in women in Australia in 1995. This representative, national data set provides a historical comparator for studies examining DCIS management that follow. Methods: Surgeons identified by population‐based cancer registries as having treated a new diagnosis of DCIS between 1 April and 30 September 1995 completed a questionnaire on the presentation and management of each case. Results: Two hundred and five surgeons supplied treatment details on 418 DCIS tumours in 415 women . Half of all tumours were detected at BreastScreen clinics and a further 25% were detected at other mammography centres. Twenty‐six percent of tumours were palpable at presentation, 33% were multifocal and 55% were high grade (including comedocarcinoma). Breast conserving therapy (BCT) rather than mastectomy was utilized in 260 (62%) of cases. Tumours that were of low grade, small in size and not multifocal were more likely to be treated by BCT. Surgeons seeing six or more DCIS cases in the 6‐month period were more likely to utilize BCT. Of the conservatively treated cases, 22% were referred for a radiation oncology consultation. The most common reasons for treating DCIS with mastectomy were that the tumour was too extensive or multifocal (63%), it extended to margins of the specimen (42%), or patient concerns about recurrence (34%). Conclusions: In 1995 the majority of DCIS was treated with breast conserving surgery alone. Surgeons treating more DCIS cases were more likely to perform conservative surgery than surgeons treating only one DCIS case in the study period.     

Predictors of positive margins after local excision of ductal carcinoma in situ.

BACKGROUND: This study aimed to examine the association between clinicopathologic parameters and positive margins in women with ductal carcinoma in situ (DCIS) treated by breast-conserving surgery (BCS). METHODS: We retrospectively reviewed the clinical, radiologic, and pathologic data of 100 women who had undergone BCS for DCIS in our center. RESULTS: Sixty-seven percent of patients presented via breast screening and 55% of all cases were diagnosed preoperatively on fine needle aspiration cytology ([FNAC] ie, C5). Overall, 45% of patients had clear margins after initial local excision. Positive margins showed a nonsignificant trend of association with distribution of microcalcifications (MCC), nonconsultant operating surgeon, inconclusive preoperative FNAC, presence of necrosis, and low specimen weight. There was a highly significant association between low grade DCIS (P = 0.003) and incomplete excision. There was no significant association with age, associated invasive focus, morphology of MCC, or with mode of presentation. CONCLUSION: Positive margins after local excision of DCIS are significantly associated with low nuclear grade, and preoperative determination of nuclear grade by core biopsy may have surgical implications.     

Role of Specimen Radiography in Patients Treated With Skin-Sparing Mastectomy for Ductal Carcinoma In Situ of the Breast

Background: Specimen radiography is an important part of breast conservation surgery for ductal carcinoma in situ (DCIS). The objective of this study was to determine whether mastectomy specimen radiography could help in obtaining negative resection margins in patients with DCIS undergoing skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR).Methods: Of 95 patients treated at our institution with SSM and IBR for DCIS, 35 had specimen radiography. The mastectomy specimen was first examined grossly and then inked, serially sectioned, and sent for radiographic assessment. Tissue slices containing calcifications were identified for pathologic evaluation. Additional tissue was excised if tumor was found near the inked margins or if calcifications were found near the radiographic margins.Results: Of the 35 patients who had specimen radiography, the radiographic margins were free of calcifications in 30 patients (86%); of these patients, the margins on the final histologic examination were free of tumor in 27 and within 1 mm in 3. The other five patients (14%) had calcifications close to the radiographic margin; four underwent an intraoperative re-excision, but the margin for one of those four patients was still positive on final histologic examination. Margins were found to be negative by both mastectomy specimen radiography and histology in 77% of the patients. Of the 95 patients with DCIS, three patients (3%), none of whom had specimen radiography, developed local recurrences. One of these was successfully re-treated, one died as a result of synchronous distant metastases, and one was lost to follow-up. At a median follow-up time of 3.7 years, 93 patients (98%) were alive and free of disease.Conclusions: Intraoperative radiography of mastectomy specimens may be useful for assessing margin status and for identifying the location of microcalcifications within tissue slices.     

Targeted Intraoperative Radiotherapy for the Management of Ductal Carcinoma In Situ of the Breast

Multiple long‐term studies have demonstrated a propensity for breast cancer recurrences to develop near the site of the original breast cancer. Recognition of this local recurrence pattern laid the foundation for the development of accelerated partial breast irradiation (APBI) approaches designed to limit the radiation treatment field to the site of the malignancy. However, there is a paucity of data regarding the efficacy of APBI in general, and intraoperative radiotherapy (IORT), in particular, for the management of ductal carcinoma in situ (DCIS). As a result, use of APBI, remains controversial. A prospective nonrandomized trial was designed to determine if patients with pure DCIS considered eligible for concurrent IORT based on preoperative mammography and contrast‐enhanced magnetic resonance imaging (CE‐MRI) could be successfully treated using IORT with minimal need for additional therapy due to inadequate surgical margins or excessive tumor size. Between November 2007 and June 2014, 35 women underwent bilateral digital mammography and bilateral breast CE‐MRI prior to selection for IORT. Patients were deemed eligible for IORT if their lesion was ≤4 cm in maximal diameter on both digital mammography and CE‐MRI, pure DCIS on minimally invasive breast biopsy or wide local excision, and considered resectable with clear surgical margins using breast‐conserving surgery (BCS). Postoperatively, the DCIS lesion size determined by imaging was compared with lesion size and surgical margin status obtained from the surgical pathology specimen. Thirty‐five patients completed IORT. Median patient age was 57 years (range 42–79 years) and median histologic lesion size was 15.6 mm (2–40 mm). No invasive cancer was identified. In more than half of the patients in our study (57.1%), MRI failed to detect a corresponding lesion. Nonetheless, 30 patients met criteria for negative margins (i.e., margins ≥2 mm) whereas five patients had positive margins (<2 mm). Two of the five patients with positive margins underwent mastectomy due to extensive imaging‐occult DCIS. Three of the five patients with positive margins underwent successful re‐excision at a subsequent operation prior to subsequent whole breast irradiation. A total of 14.3% (5/35) of patients required some form of additional therapy. At 36 months median follow‐up (range of 2–83 months, average 42 months), only two patients experienced local recurrences of cancer (DCIS only), yielding a 5.7% local recurrence rate. No deaths or distant recurrences were observed. Imaging‐occult DCIS is a challenge for IORT, as it is for all forms of breast‐conserving therapy. Nonetheless, 91.4% of patients with DCIS were successfully managed with BCS and IORT alone, with relatively few patients requiring additional therapy.     

Sentinel node procedure is warranted in ductal carcinoma in situ with high risk of occult invasive carcinoma and microinvasive carcinoma treated by mastectomy

Abstract:  Axillary lymph node dissection in patients with ductal carcinoma in situ (DCIS) of the breast is not warranted because DCIS has no metastatic potential. However, the risk of microinvasive carcinoma (MIC) exists in large DCIS treated by mastectomy. The aim of this series is to evaluate the incidence of lymph node metastases in DCIS and DCIS-MIC. We analyzed retrospectively patients treated in six French cancer centers for pure DCIS or DCIS-MIC. Surgical procedures were lumpectomy or mastectomy associated with an axillary sentinel node (SN) procedure. We included 161 patients suffering from pure DCIS (116/161, 72%) or DCIS-MIC (45/161, 28%). Mean age was 56 years (32–78). We observed underestimation between core biopsy and histological result in 43/142 cases (30%). These data show an association between lesion size, solid subtype, high-grade DCIS, and underestimation. Forty-eight breast conservative procedures were performed and 113 mastectomies (70%). SN procedure was performed using blue dye, technetium, or both. In our series, we selected patients with a high risk of occult invasive carcinoma: high grade (55%), mean size (27 mm), and mastectomy (112). Six SN were found positive (3.7%). In the five patients treated with complete axillary dissection, the SN was the only positive node. SN in DCIS is an interesting procedure but not necessary for all patients. We need to focus on the subgroup with or a high risk of occult MIC: extensive calcifications or palpable mass, DCIS diagnosed by core biopsy and underestimation, multifocality, high grade, large tumor size, MIC, and mastectomy.     

Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified?

Sentinel lymph node biopsy for ductal carcinoma in situ (DCIS) of the breast is not standard of care. However, nodal involvement for DCIS patients is reported. Aim of our study was to identify preoperative features predictive of nodal involvement in DCIS patients. We have retrospectively reviewed 175 patients with a preoperative diagnosis of DCIS following a vacuum‐assisted breast biopsy, and undergoing surgery with sentinel node biopsy. Variables distribution was compared between patients upstaged to invasive cancer at final pathology and patients with a confirmed DCIS, and between positive vs negative sentinel node patients. Univariate and multivariate analyses were performed for risk of a positive node. Lymph node biopsy was positive in 13 (7.4%) patients, with 8 (61.5%) macrometastases and 5 (38.5%) micrometastases. In these patients, Breast Imaging Reporting and Data System (BI‐RADS) index >4 (OR 4.69, 95% CI 1.282‐17.224, P = .02), lesion extension ≥20 mm (OR 4.25, 95% CI 1.255‐14.447, P = .02), multifocal disease (OR 4.12, 95% CI 0.987‐17.174, P = .05), comedo type (OR 3.54, 95% CI 1.044‐11.969, P = .04), and upstaging (OR 4.56, 95% CI 1.080‐19.249, P = .04) were all predictive of nodal involvement, although upstaging could not be predicted preoperatively. By multivariate analysis, the only independent factor predictive for positive sentinel node was multifocal disease (OR 5.14, 95% CI 1.015‐26.066, P < .05). A preoperative diagnosis of DCIS, also including advanced biopsy systems such as vacuum‐assisted breast biopsy, may be not always sufficient to exclude patients from sentinel node biopsy. DCIS patients with associated BI‐RADS >4, lesion extension ≥20 mm, comedo type, and above all multifocal disease should be considered for axillary evaluation.     

Predictors of Re-excision among Women Undergoing Breast-Conserving Surgery for Cancer

Background Up to 60% of breast cancer patients who undergo breast-conserving surgery (BCS) require re-excision to obtain clear margins, causing delays in adjuvant treatment and poor aesthetic results. However, patient and treatment-related factors associated with re-excision are not well defined. Methods We surveyed all women undergoing breast conserving surgery between January 2002 and May 2006 regarding their breast disease (n = 714, response rate = 79.5%). The medical record was reviewed to determine the receipt of re-excision lumpectomy following BCS, and obtain tumor stage, histology, and biopsy method (surgical versus needle biopsy). Patient age, breast size, tumor location in the breast, and receipt of chemotherapy were self-reported. Logistic regression was used to determine significant predictors of re-excision lumpectomy. Results In this sample, 51.4% of women required only one breast excision, 41.9% required two breast excisions, and 6.6% required three breast excisions. Overall, 10.8% of women required a mastectomy following initial attempt at BCS. Factors significantly correlated with re-excision lumpectomy included smaller breast size (A cup: OR = 2.7; 95%CI: 1.32–5.52; B cup: 1.63; 95%CI: 1.02–2.62), lobular histology (OR = 1.93; 95%CI: 1.15–3.25), and receipt of surgical biopsy (OR = 3.35; 95%CI: 2.24–5.02). Women who received adjuvant chemotherapy (OR = 2.49; 95%CI: 1.19–5.22) were more likely to require re-excision compared with women who received neoadjuvant chemotherapy. Conclusions Re-excision lumpectomy is common, and is significantly correlated with smaller breast size, lobular histology, surgical biopsy, and chemotherapy timing. Attention to these risk factors can improve the quality of care delivered to BCS patients by decreasing the cost and morbidity associated with multiple re-excision procedures.     

Preoperative breast MRI in the surgical treatment of ductal carcinoma in situ

Accurate determination of the size or extent of ductal carcinoma in situ (DCIS) by imaging is uncertain, and incomplete resection of tumor results in involved margins in up to 81% of cases. This study examined the accuracy of magnetic resonance imaging (MRI) for assessment of DCIS size, and evaluated the effect of preoperative breast MRI on achievement of tumor-free surgical margins after breast-conserving surgery (BCS). One-hundred and fifty-eight female patients with DCIS were identified from a prospective database: 60 patients (62 cases) had preoperative breast MRI, and 98 patients did not have MRI. The accuracy of tumor size assessed by MRI was determined by comparison with histopathologic size. All patients underwent BCS initially. The rate of involved margins after resection was compared in MRI and no-MRI groups. The overall correlation between MRI size and histopathologic size was high (p < 0.0001). MRI assessment of size was significantly more accurate when DCIS was high grade (p < 0.0001) or intermediate grade (p = 0.005) versus low grade (p = 0.187). The rate of tumor-involved margins was not significantly different in MRI and no-MRI groups (30.7% and 24.7%, respectively; p = 0.414). The rate of mastectomy was significantly higher in the MRI group than the no-MRI group (17.7% versus 4.1%; p = 0.004). These findings indicate that MRI can detect DCIS, especially when lesions are high or intermediate grade, but that MRI does not accurately predict the size of DCIS. In this study, MRI did not improve the surgeon's ability to achieve clear margins following BCS.