Reducing chronic breast cancer‐related lymphedema utilizing a program of prospective surveillance with bioimpedance spectroscopy

This single‐institution experience evaluated the use of bioimpedance spectroscopy to facilitate early detection and treatment of breast cancer‐related lymphedema (BCRL) in a cohort of 596 patients (79.6% high risk). Seventy‐three patients (12%) developed an elevated L‐Dex score with axillary lymph node dissection (P < .001), taxane chemotherapy (P = .008), and regional nodal irradiation (P < .001) associated. At last follow‐up, only 18 patients (3%) had unresolved clinically significant BCRL requiring complete decongestive physiotherapy. This rate of BCRL is lower than reported in contemporary studies, supporting recent NCCN guidelines promoting prospective screening, education and intervention for BCRL.     

Sentinel Node Biopsy in Breast Cancer Patients with Large or Multifocal Tumors

Background  The axillary recurrence (AR) rate after negative sentinel node biopsy (SNB) in patients with high risk of axillary metastases is largely unknown. The aim of this study was to analyze the risk factors for isolated AR after negative SNB with special interest in large or multifocal tumors. Methods  A prospective SNB registry was analyzed for 2,408 invasive breast cancer patients operated between 2001 and 2007. No axillary clearance was performed in 1,309 cases with a negative SNB, including 1,138 small unifocal tumors, 121 small multifocal tumors, 48 large unifocal tumors, and 2 large multifocal tumors. Results  Six (0.5%) isolated AR were observed during a median follow-up of 43 months. Four (0.4%) patients with small unifocal tumors and two (1.6%) with small multifocal tumors had isolated AR (p = 0.179). None of the patients with large unifocal or multifocal tumors had isolated AR. Instead of tumor size and multifocality, estrogen receptor negativity (p < 0.001), nuclear grade III (p < 0.001), Her-2 status (p = 0.002), no radiotherapy (p = 0.005), and mastectomy (p = 0.005) were found to be associated with AR. Conclusions  A remarkable proportion of patients with large unifocal tumors and small multifocal tumors may avoid unnecessary AC due to tumor negative SNB, without an excessive risk of AR.     

Does response to neo‐adjuvant chemotherapy impact breast reconstruction?

Neo‐adjuvant chemotherapy (NAC) is administered in breast cancer treatment for downstaging of disease. Here, we determined the impact of response to NAC on breast reconstruction uptake. A prospective NAC and mastectomy database with or without reconstruction were reviewed with IRB approval. Univariable analyses were conducted using Kruskal‐Wallis or Fisher's exact tests. Multivariable logistic regression was used to adjust for potential confounders. We identified 271 patients with unilateral breast cancer receiving NAC and either unilateral or bilateral mastectomy from 9/2013 to 5/2016. Seventy patients (25.8%) had a pCR to NAC. One hundred and seventy‐five patients (64.6%) had immediate reconstruction (IR), and 96 had no IR. On univariable analysis, younger age (P < .001), lower T‐stage at presentation (P < .001), bilateral versus unilateral mastectomy (P<.001) and HR‐negative tumor subtype (P = .006) were significantly associated with higher IR rates. On multivariable analysis, pCR (P = .792) and tumor subtype (P = 0.061) were not significantly associated with IR; T‐stage was significantly associated with IR (P < .001), such that patients with T4 tumors at presentation had lower odds of IR (OR 0.10, 95% CI 0.02‐0.50), even when accounting for response to NAC. One hundred and seventy‐three patients (63.8%) received adjuvant radiation therapy; this was associated with lower IR frequency (P = .048) but was not associated with reconstruction type (tissue expander versus autologous, P = 1.0) among 175 patients who had IR. In patients who have mastectomy after NAC, IR is influenced by age, T‐stage at presentation, and choice of bilateral mastectomy, but not by response to NAC. A subset of patients who are young, with earlier T‐stage and pCR, is more likely to proceed with bilateral mastectomy.     

Breast cancer subtypes affect the nodal response after neoadjuvant chemotherapy in locally advanced breast cancer: Are we ready to endorse axillary conservation?

We evaluated the impact of breast cancer subtypes on pathologic complete response (pCR) in 181 patients with positive nodes undergoing neoadjuvant chemotherapy (NAC). After NAC, patients underwent surgery, with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND). In 28.2% of cases a pCR was achieved, with the highest rate in Her2+ and triple negative tumors. Overall, nodal pCR was more frequent than breast pCR (P = 0.003) with higher percentages in Her2+ and LLB‐Her2+ (P < 0.05). In the Her2+ group, nodal pCR was observed only with breast pCR. Thus, in Her2+ tumors, breast pCR predicts node pCR, supporting the use of SLNB in this subgroup to stage the axilla avoiding ALND.     

Impact of hormonal status on ductal carcinoma in situ of the breast: Outcome and prognostic factors

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous disease which is increasingly diagnosed through improved screening measures. Multiple prognostic scores have been devised to predict the risk of local recurrence (LR), and the optimal adjuvant management for DCIS is still debated. Hence, the aim of this analysis is to investigate the factors contributing to the prognosis of DCIS, in particular the role of its hormonal status. From 2005 to 2016, a total of 1221 female patients diagnosed with DCIS at the National Cancer Centre Singapore and Singapore General Hospital were studied. The mean age of diagnosis was 54 years of age (sd = 11.0), with estrogen receptor (ER)–positive DCIS tumors presenting earlier (mean age 54 vs 57 years of age; P < .001). DCIS with negative hormonal status (HS) correlates significantly with a larger size (mean 23.5mm vs 13.0 mm, P < .001) and higher grade of tumor (P < .001). Patients with positive HS were more likely to undergo breast conservation surgery over a mastectomy, in contrast to patients with negative HS (P < .001). Patients with negative HS had a poorer prognosis, with a shorter time of overall survival time (HR = 26.3, P = .020). In conclusion, our study shows that the hormonal status, age of diagnosis, and positive margins are important prognostic factors for DCIS, at least in our Asian population.     

Sonographic features of benign and malignant axillary nodes post‐neoadjuvant chemotherapy

The aim was to determine whether sonographic features of metastatic axillary lymph nodes predict pathologic nodal status post‐neoadjuvant chemotherapy (NCT) and help to tailor less invasive surgical management of the axilla. Patients with biopsy‐proven cN1 primary breast malignancy who received NCT between January 2011 and December 2014 and had performed ultrasound were included in this study. Sonographic features of biopsy‐proven clipped metastatic axillary nodes pre‐ and post‐NCT were retrospectively reviewed by two independent readers. Changes in lymph node shape, fatty hilum status, cortical thickness, and cortical echogenicity were compared in patients with and without nodal pathologic complete response (pCR) using univariate and multivariate logistic regression models. Inter‐reader variation was analyzed to determine the reproducibility of data. Of the 195 patients included in the study, 75 (45%) showed nodal pCR and 90 (55%) persistent metastatic disease post‐NCT. pCR was significantly more likely in lymph nodes with isoechoic or hypoechoic cortical echogenicity post‐NCT, (P = .02), conversion to normal cortical thickness (P = .0001), and oval shape (odds ratio = 0.17, P = .004), compared to lymph nodes with anechoic cortical echogenicity, persistent or diffuse cortical thickening, and irregular shape, respectively. The overall accuracy of sonographic nodal features in the prediction of pCR was 65% (95% CI: 58%‐72%). The overall accuracy of sonographic features of biopsy‐proven metastatic axillary lymph nodes post‐NCT is not sufficiently high to predict pCR of axillary nodal status and thereby should not be solely used in guiding less invasive surgical approaches to the axilla.     

Axillary Lymph Node Status and Prognosis in Multifocal and Multicentric Breast Carcinoma

According to tumor‐node‐metastasis classification, tumor size should be based only on the largest tumor for multifocal and multicentric (MFMC) carcinomas. We estimated tumor size of MFMC carcinoma using either largest dimension of the largest tumor (dominant tumor size) or sum of the largest dimension of all tumors (aggregate tumor size), and compared the risk of axillary lymph node metastasis and prognosis between MFMC and unifocal carcinoma. We retrospectively reviewed the file records of 3,616 patients with MFMC (258 patients, 7.1%) and unifocal (3,358 patients) carcinoma. In T1 and T2 tumor subgroups, using dominant (p = 0.001 and p < 0.001) and aggregate (p = 0.017 and p = 0.004) tumor size axilla‐positivity ratio was significantly higher in MFMC carcinoma compared with unifocal carcinoma. In stage I and II disease classified according to either dominant or aggregate tumor size, there was no significant survival difference between MFMC and unifocal carcinoma patients. In patients with stage III disease by dominant and aggregate tumor size disease‐free survival was significantly worse in MFMC carcinoma compared with unifocal carcinoma (p = 0.036 and p = 0.041); multifocality and multicentricity had no independent prognostic significance (p = 0.074 and p = 0.079). The risk of axillary metastasis in MFMC carcinoma was higher than unifocal carcinoma, regardless of the method employed for tumor size estimation. MFMC carcinoma staged according to either dominant or aggregate tumor size had similar survival with unifocal carcinoma. We recommend using the largest dimension of the largest tumor in estimation of tumor size for MFMC carcinoma.     

The clinical significance of metastatic breast carcinoma to intramammary lymph node

The incidence of involved intramammary lymph node (intra‐MLN) with breast carcinoma (BC) is rare. Its clinical significance and impact on the clinical decision making is unclear. A total of 113 BC cases with at least one positive intra‐MLN were collected from 11 academic institutions. The inclusion criteria were subsequent axillary lymph node dissection, and the availability of information on T‐stage, size of node metastasis, extranodal extension status, biomarkers status, and clinical follow‐up. Stage 4 cases and/or neo‐adjuvant treated patients were excluded. AJCC TN‐stage was calculated twice, with and without intra‐MLN. Five‐year overall survival (OS) and relapse (local and/or distant)‐free survival (RFS) were calculated and correlated with the clinicopathologic variables. Excluding intra‐MLN, TN‐stage correlated with OS (P = .016) but not with RFS (P = .19). However, when intra‐MLN was included, TN‐stage correlated with both OS (P < .001) and RFS (P = .016). In the multivariate analysis, when intra‐MLN was excluded, only radiation therapy (RT) correlated with RFS (HR = 0.19, 95% CI: 0.054‐0.66, P = .009). However, when intra‐MLN was included in the TN‐stage both RT (HR = 0.13, 95% CI: 0.04‐0.45, P = .001) and TN‐stage 3 (HR = 8.92, 95% CI: 1.47‐54, P = .017) correlated with RFS. Tumor multifocality was the only variable correlated with OS when the intra‐MLN involvement was excluded. When intra‐MLN was included, multifocality became insignificant but TN‐stage 3 correlated with OS (HR = 8.59, 95% CI: 1.06‐69.71, P = .044). Positive intra‐MLN is an independent factor in predicting both RFS and OS.     

Influence of breast cancer opportunistic screening on aesthetic surgical outcome: A single‐center retrospective study in Switzerland

The aim of this retrospective study is to compare the surgical aesthetic outcome and breast cancer (BC) characteristics in patients with BC detected either by opportunistic screening or clinical diagnosis. 262 women undergoing surgery for BC between 2009 and 2012 were included. The following features were compared in the two groups of patients: (1) age at diagnosis; (2) family history of BC; (3) histology type; (4) tumor diameter; (5) local staging, and (6) type of surgical treatment. In 92/262 (35.1%) cases BC was detected by screening and 170/262 (64.9%) had clinical diagnosis. A positive family history and ductal carcinoma in situ diagnosis were more frequent in patients with clinical diagnosis (P = .001 and P < .0001 respectively). Mean maximum diameter of invasive cancers was significantly greater in symptomatic patients (P < .001). Breast conserving surgery was performed in 76/92 (82.6%) patients with screening and 115/170 (67.6%) with clinical diagnosis. Mastectomy was performed in 16/92 (17.4%) patients with screening and 55/170 (32.3%) with clinical diagnosis. Mastectomy was more frequent in patients with clinical diagnosis of BC (P = .010). No significant group differences were found regarding the other features. This study demonstrated that in opportunistic screening, breast conserving surgery may be applied in a higher number of cases compared to patients presenting with clinical diagnosis, thereby improving life quality of these patients.     

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

BackgroundType of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.Patients and methods1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).ResultsIndependent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75–0.80). After external validation the accuracy of the nomogram was confirmed.ConclusionThe accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.     

Long-Term Morbidity of Sentinel Node Biopsy Versus Complete Axillary Dissection for Unilateral Breast Cancer

Background  Postoperative changes after axillary lymph node surgery may significantly alter breast cancer survivors’ (BCS) quality of life. Although sentinel lymph node biopsy (SLNB) has less immediate morbidity than axillary lymph node dissection (ALND), its long-term impact on shoulder abduction, arm swelling, and neurosensory changes has not been evaluated. The purpose of this study was to compare long-term morbidity after SLNB or ALND and breast-conservation surgery. Methods  Female BCS who remained free of disease at least 3 years after ALND or SLNB for Stage I–III unilateral breast cancer completed a symptom questionnaire and a brief neurosensory physical examination of the upper arm and axilla (range of motion, arm circumference, and sensation to light touch with cotton and needle). Results  The mean age of the 187 participating BCS was 62 years. At a mean follow-up of 6.6 years after ALND and 4.9 years after SLNB, most BCS had full abduction; only 10 cases (8 ALND, 2 SLNB) had a ≥2 cm proximal and/or distal circumference difference on the ipsilateral side compared with the contralateral side. ALND was associated with a significantly greater likelihood of subjective arm numbness (P < .001), chest or axillary numbness (P < .001), arm or hand swelling (P < .001), and objective neurosensory changes in the posterior axilla, medial and distal upper arm (P < .001). Operative procedure was the only significant predictor of neurosensory changes (P < .001). Conclusion  SLNB is associated with significantly less subjective and objective long-term morbidity than ALND.     

T cell–mediated rejection is a major determinant of inflammation in scarred areas in kidney allografts

Inflammation in fibrosis areas (i‐IF/TA) of kidney allografts is associated with allograft loss; however, its diagnostic significance remains to be determined. We investigated the clinicohistologic phenotype and determinants of i‐IF/TA in a prospective cohort of 1539 kidney recipients undergoing evaluation of i‐IF/TA and tubulitis in atrophic tubules (t‐IF/TA) on protocol allograft biopsies performed at 1 year posttransplantation. We considered donor, recipient, and transplant characteristics, immunosuppression, and histological diagnoses in 2260 indication biopsies performed within the first year posttransplantation. Nine hundred forty‐six (61.5%) patients presented interstitial fibrosis/tubular atrophy (IF/TA Banff grade > 0) at 1 year posttransplant, among whom 394 (41.6%) showed i‐IF/TA. i‐IF/TA correlated with concurrent t‐IF/TA (P < .001), interstitial inflammation (P < .001), tubulitis (P < .001), total inflammation (P < .001), peritubular capillaritis (P < .001), interstitial fibrosis (P < .001), and tubular atrophy (P = .02). The independent determinants of i‐IF/TA were previous T cell–mediated rejection (TCMR) (P < .001), BK virus nephropathy (P = .007), steroid therapy (P = .039), calcineurin inhibitor therapy (P = .011), inosine‐5′‐monophosphate dehydrogenase inhibitor therapy (P = .011), HLA‐B mismatches (P = .012), and HLA‐DR mismatches (P = .044). TCMR patients with i‐IF/TA on posttreatment biopsy (N = 83/136, 61.0%) exhibited accelerated progression of IF/TA over time (P = .01) and decreased 8‐year allograft survival (70.8% vs 83.5%, P = .038) compared to those without posttreatment i‐IF/TA. Our results support that i‐IF/TA may represent a manifestation of chronic active TCMR.     

Neo‐adjuvant chemotherapy and axillary de‐escalation management for patients with clinically node‐negative breast cancer

This study aimed to explore the optimal time of sentinel lymph node biopsy (SLNB) and neo‐adjuvant chemotherapy (NAC) and to assess the feasibility of selective elimination of axillary surgery after NAC in clinically node‐negative (cN0) patients. From April 2010 to August 2018, 845 patients undergoing surgery after NAC were included in this retrospective study to analyze the correlation between different clinicopathological characteristics of cN0 patients and negative axillary lymph node after NAC (ypN0). Among the 148 cN0 patients, 83.1% (123/148) were ypN0. The rates of ypN0 in patients with hormone receptor positive (HR+)/HER2?, HR+/HER2+, HR?/HER2+, and triple‐negative (TN) breast cancer were 75.4% (46/61), 82.6% (19/23), 85.2% (23/27), and 94.6% (35/37), respectively (P < 0.001). The rates of ypN0 in TN and HER2+ patients were 94.6% and 95.5%, which were significantly higher than that in HR+/HER2? patients (P < 0.05). Molecular subtypes, clinical stage, radiologic complete response, and pathologic complete response (bpCR) of the breast tumor correlated with ypN0 after full‐course NAC (P < 0.05). Molecular subtypes (OR = 2.374, P = 0.033), clinical stage (OR = 0.320, P = 0.029), and bpCR (OR = 0.454, P = 0.012) were independent predictors for ypN0. The optimal time of SLNB and NAC in cN0 patients might be different among different molecular subtypes: it would be preferable to perform SLNB prior to NAC for HR+/HER2? patients, and SLNB after NAC for TN and HER2+ patients to reduce the risk of axillary lymph node dissection. In view of the high ypN0 rate in cN0 patients, axillary surgical staging might be selectively eliminated, especially for HER2+ and TN patients.     

Does use of axillary ultrasound in clinically node‐negative patients receiving neo‐adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo‐adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty‐three had an abnormal AUS and biopsy‐proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P < .0001). Of those patients with an abnormal AUS and biopsy‐proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N = 23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.     

Breast reconstruction patterns and outcomes in academic and community practices within a single institution

Breast reconstruction is a common procedure that is performed in both community and academic settings. At Yale‐New Haven Hospital (YNHH), both academic (AP) and community‐based (CP) plastic surgeons perform breast reconstructions. We aim to compare practice patterns in breast reconstruction between two practice environments within a single institution. A retrospective chart review of all breast reconstructions at YNHH between 2013 and 2018 was performed. Data collected included demographics, preoperative history, and postoperative outcomes. Results were further subdivided by practice setting. A total of 1045 patients (1683 breasts) underwent breast reconstruction during the study period. About 52.8% were performed by AP while 47.2% were performed by CP. CP had higher rates of autologous reconstruction (P < .001) and nipple‐sparing mastectomy (P < .0001). Age and BMI were similar between the cohorts. However, patients cared for by AP had 2.6% increased prevalence of diabetes (P = .064), 5.5% greater prevalence of psychiatric diagnoses (P = .004), and 7.1% higher open abdominal surgery rates (P < .001). Outcomes were similar between the groups except for higher infection rates (P = .027) and explant rates (P = .003) in the CP cohort. When evaluating insurance status, the AP cohort had 30.5% fewer patients with commercial insurance, 16.7% more patients with Medicaid and 6.1% more patients with Medicare (P < .001). Within our institution, academic and community‐based plastic surgeons perform breast reconstruction with overall similar complication rates. Patients treated by AP have a higher rate of preoperative medical and psychiatric comorbidities. Patients treated by CP have higher rates of infection and implant explant. AP plastic surgeons care for a significantly higher rate of Medicare and Medicaid patients with proportionally fewer patients with commercial insurance.     

Role of tranexamic acid in axillary lymph node dissection in breast cancer patients

Axillary lymph node dissection (ALND) is an important step in the management of node‐positive operable breast cancer. It is associated with large amount of axillary drainage and increased risk of wound‐related infection. Tranexamic acid (TA) has antifibrinolytic property and is being extensively used in controlling blood loss. However, its role in reducing axillary drainage after ALND is still not well‐established. The aim of this study is to evaluate the effectiveness of TA in reducing the axillary drainage, early removal of the drain, and decreasing the wound‐related infection in breast cancer patients undergoing ALND. This is a prospective nonrandomized double‐armed cohort study. Total of 47 patients were included in the TA group and 46 in the nontranexamic (NTA) group. All the patients in TA group received a single dose of intravenous (IV) TA at the time of induction followed by oral TA for five days after surgery. Both TA and NTA groups had similar proportions of locally advanced breast cancers (57.4% vs 56.5%, P = .90). Majority of them underwent modified radical mastectomy (MRM) (70.2% vs 67.4%, P = .76). Patients in TA group had significantly lower axillary drainage (440 ml vs 715.5 ml, P = .003) with earlier removal of the drain (8 vs 11 days, P = .046). Seroma formation (19.1% vs 32.6%, P = .13) and wound‐related infection (4.3% vs 8.7%, P = .43) were nonsignificantly lower in the TA group. Tranexamic acid reduces axillary drainage and facilitates early removal of the drain after axillary lymph node dissection.     

The Effect of the 2009 USPSTF breast cancer screening recommendations on breast cancer in Michigan: A longitudinal study

In 2009, the revised United States Preventive Services Task Force (USPSTF) guidelines recommended against routine screening mammography for women age 40‐49 years and against teaching self‐breast examinations (SBE). The aim of this study was to analyze whether breast cancer method of presentation changed following the 2009 USPSTF screening recommendations in a large Michigan cohort. Data were collected on women with newly diagnosed stage 0‐III breast cancer participating in the Michigan Breast Oncology Quality Initiative (MiBOQI) registry at 25 statewide institutions from 2006 to 2015. Data included method of detection, cancer stage, treatment type, and patient demographics. In all, 30 008 women with breast cancer detected via mammogram or palpation with an average age of 60.1 years were included. 38% of invasive cancers were identified by palpation. Presentation with palpable findings decreased slightly over time, from 34.6% in 2006 to 28.9% in 2015 (P < .001). Over the 9‐year period, there was no statistically significant change in rate of palpation‐detected tumors for women age <50 years or ≥50 years (P = .27, .30, respectively). Younger women were more likely to present with palpable tumors compared to older women in a statewide registry. This rate did not increase following publication of the 2009 USPSTF breast cancer screening recommendations.     

The emerging role of pectoral nerve block (PECS block) in breast surgery: A case‐matched analysis

To evaluate the benefits of pectoral nerve block (PECS block) in breast cancer surgery, we compared outcomes of 100 patients receiving PECS vs 107 without PECS. Intraoperative use of fentanyl (P < .001) acetaminophen (P = .02), morphine (P < .01), and nonsteroidal anti‐inflammatory drugs (NSAIDS) (P < .01) was lower in the PECS group. Occurrence of postoperative nausea and vomiting (PONV) was lower in the PECS group (P = .04). On postoperative day 1, the use of acetaminophen (P = .23), morphine (P = .83), and NSAIDS (P = .4) did not differ. Twenty‐one patients received surgery with PECS block plus sedation alone. PECS block can reduce intraoperative use of opioids and analgesic drugs, and is associated with reduced occurrence of PONV. Selected patients can receive breast‐conserving surgery with PECS plus sedation, avoiding general anesthesia.     

Effect of primary tumor resection on overall survival in patients with stage IV breast cancer

We aimed to evaluate the effect of primary tumor resection on overall survival in stage IV breast cancer patients. In total, 284 breast cancer patients presenting with breast cancer at stage IV at initial diagnosis, between 2001 and 2014, were enrolled in the study. Patients were divided into two groups based on surgical resection of the primary tumor. Overall survival (OS) between the two groups was analyzed. Patients in the surgery group (n = 92) had smaller tumors than those in the no‐surgery group (n = 192, T0‐1:17.7% vs 34.8%, P < 0.001). The surgery group more often had negative nodal status (5.7% vs 33.7%, P < 0.001). Multiple metastatic organ sites were more common in the no‐surgery group than in the surgery group (55.7% vs 15.2%, P < 0.001). The surgery group showed a better OS than the no‐surgery group (P = 0.01). Multivariate analysis showed that surgical resection of primary tumors tended to be associated with improved OS (HR = 0.67, P = 0.055). T stage, ER, HER2 and metastatic organ sites were independent prognostic factors for OS in multivariate analysis. Surgical resection of the primary tumor may be a treatment option for patients with stage IV disease and may not have a negative effect on overall survival.     

Triple‐negative breast cancer in the elderly: Prognosis and treatment

Our objective is to characterize treatment of triple‐negative breast cancer (TNBC) in older patients and measure mortality risk relative to younger women. We conducted a retrospective cohort study analysis of patients presenting with primary TNBC, age 25‐93, stage I‐III from 1990 to 2014, identified and tracked by our registry (n=771). Clinical characteristics were chart abstracted at diagnosis and follow‐up. The Kaplan–Meier method was used to measure disease‐specific survival (DSS) by age with Cox regression modeling for relative contribution of patient and clinical characteristics. Of patients, 80% were <65 years (n=612), 13% were 65‐74 years (n=100), and 7% were 75 and older (n=59). Older women presented more often with lower stage BC (stage I: 31% age <65, 48% age 65‐74, 39% age 75+; P=.014). All three age groups were equally likely to have radiation therapy (77%) but older patients were less often treated with adjuvant chemotherapy (<65=95%, 65‐74=76%, 75+=39%; P<.001). Mean follow‐up was 7.34 years and did not differ by age. Five‐year DSS was equivalent across the three age groups (<65=85%, 65‐74=90%, 75+=83%, P=.322). In Cox regression analysis controlling for stage, histologic and nuclear grade, diagnosis year, radiation and chemotherapy treatment, age was not significantly associated with disease‐specific mortality. TNBC survival appears equivalent by age despite less aggressive treatment in patients 75 years and older. This may be a result of lower stage at diagnosis and decreased disease virulence resulting in comparative survival despite less treatment.