Breast-conserving therapy for centrally located breast cancer

OBJECTIVE: To analyze whether breast-conserving therapy (BCT) may be an oncologically safe approach and result in a good cosmesis in patients with centrally located breast cancer (CLBC). SUMMARY BACKGROUND DATA: Only underpowered, retrospective, single-arm studies have suggested that oncoplastic BCT for CLBC may be oncologically safe and may result in a good cosmesis. METHODS: The authors retrospectively analyzed the overall and recurrence-free survival in 1485 patients with breast cancer undergoing BCT comparing CLBC with non-CLBC. Moreover, the authors described 4 different oncoplastic techniques for BCT in patients with CLBC and compared the cosmetic results with simple lumpectomy according to a recently elaborated objective cosmetic evaluation system, the Breast Symmetry Index. RESULTS: Kaplan-Meier curves show no significant difference in a 5-year overall, local, or distant recurrence-free survival between patients with CLBC and non-CLBC after BCT (94% vs. 96%; 100% vs. 98%; 92% vs. 90%; median follow-up, 35.3 months). The cosmetic outcome after oncoplastic BCT compared with simple lumpectomy differed significantly (Breast Symmetry Index: 22 +/- 6%d vs. 44 +/- 12%d; P < 0.05). CONCLUSIONS: The results demonstrate that BCT for CLBC is oncologically safe and that oncoplastic techniques improve cosmesis.     

Local rotational flaps for breast conservation therapy as an alternative to mastectomy

Background: An anticipated poor cosmetic result has traditionally been deemed a relative contraindication for breast conservation therapy (BCT). We sought to determine whether a local rotational flap could achieve satisfactory cosmesis in patients who were anticipated to have a poor cosmetic result following standard segmental mastectomy but who nevertheless desired BCT. Methods: Within the past 3 years, nine patients were treated with BCT using local rotational flap techniques. Their records were reviewed for patient characteristics, pre- and postoperative treatment, disease-free status, and patient satisfaction with cosmesis. Results: The cosmetic outcome following a segmental mastectomy was anticipated to be unacceptable due to the following features: a large previous biopsy cavity with unknown or positive margins (three patients); initial large primary tumors with unknown extent of residual disease following induction chemotherapy (five patients); and pre-existing poor cosmesis (one patient). One patient had refused modified radical mastectomy and had satellitosis from inadequately treated primary tumor (excisional biopsy with positive margins and no further therapy). The median initial tumor size was 2.7 cm (range, 1.5 cm to 5.0 cm). Final resection margins were negative in all patients. Postoperative radiotherapy was given in seven patients; one patient did not receive radiotherapy because of a pre-lupus condition and one did not require radiotherapy because her pathologic diagnosis was Paget's disease without an invasive component. Cosmesis was judged to be good to excellent by eight of nine patients. The patient who refused mastectomy was dissatisfied with cosmesis because of mild asymmetry. With a median follow-up of 24 months, only one patient has developed a local recurrence. Conclusion: Local rotational flaps composed of adjacent breast tissue are an acceptable method of achieving satisfactory cosmesis in selected patients who desire BCT.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

Patient-perceived cosmesis and satisfaction after breast biopsy: comparison of stereotactic incisional,excisional, and wire-localized biopsy techniques

BACKGROUND: Several options exist for obtaining tissue for pathologic diagnosis of nonpalpable breast lesions. They are generally divided into traditional, open wire-localized biopsy through a 3- to 5-cm incision, stereotactic-guided excisional biopsy through a 1- to 2.5-cm incision, and stereotactic-guided incisional biopsy through a puncture wound a few millimeters long. Because all 3 techniques are reliable, cosmesis has been suggested to be a critical issue driving procedure choice. However, no study has surveyed breast biopsy patients themselves as to the importance of this issue. METHODS: We conducted telephone interviews with 59 women who underwent wire-localized biopsy (WL), stereotactic incisional biopsy with the Mammotome device (Mammo), or stereotactic excisional biopsy with the ABBI device (ABBI). All patients had benign diagnoses, were at least 2 years after procedure, and were matched to age and race. The questions were (1) How would you rate your scar? (2) Were you satisfied or dissatisfied with your biopsy experience? (3) Which is more important to you-complete removal of the abnormality or scar appearance? (4) Do you have any additional comments? RESULTS: Eighty percent of patients ranked complete removal of the abnormality more important than cosmesis. Ninety-five percent of the ABBI and Mammo patients rated their scar as excellent, whereas only 25% of WL did (P =.02). Ninety percent of WL patients, 80% of Mammo patients, and 75% of ABBI patients were satisfied with their experience (P = not significant). Many of the reasons for dissatisfaction were related to service quality rather than medical quality. CONCLUSIONS: Complete removal of the mammographic abnormality may be the priority for patients undergoing breast biopsy. There did not seem to be patient-perceived difference in cosmetic result between the Mammo and ABBI patients. Patient satisfaction is multifactorial, and attention must be paid to these issues generally ignored by physicians.     

Oncoplastic techniques allow extensive resections for breast-conserving therapy of breast carcinomas

OBJECTIVE: To assess the oncologic and cosmetic outcomes in women with breast carcinoma who were treated with breast-conserving therapy using oncoplastic techniques with concomitant symmetrization of the contralateral breast. SUMMARY BACKGROUND DATA: Although breast-conserving therapy is the standard form of treatment for invasive breast tumors up to 4 cm, in patients with large, ill-defined, or poorly situated tumors, cosmetic results can be poor and clear resection margins difficult to obtain. The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities. METHODS: This is a prospective study of 101 patients who were operated on for breast carcinoma between July 1985 and June 1999 at the Institut Curie. The procedure was proposed for patients in whom conservative treatment was possible on oncologic grounds but where a standard lumpectomy would have led to poor cosmesis. Standard institutional treatment protocols were followed. All patients received either pre- or postoperative radiotherapy. Seventeen patients received preoperative chemotherapy to downsize their tumors. Mean follow-up was 3.8 years. Results were analyzed statistically using Kaplan-Meier estimates. RESULTS: Mean weight of excised material on the tumor side was 222 g. The actuarial 5-year local recurrence rate was 9.4%, the overall survival rate was 95.7%, and the metastasis-free survival rate was 82.8%. Cosmesis was favorable in 82% of cases. Preoperative radiotherapy resulted in worse cosmesis than when given postoperatively. CONCLUSIONS: The use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma and results in favorable oncologic and esthetic outcomes. This approach might be useful in extending the indications for conservative therapy.     

Why should diagnostic benign breast biopsies weight less than twenty grams?

To reduce the cosmetic deformity resulting from diagnostic biopsies, current breast screening guidelines recommend that 80% of biopsy specimens that subsequently prove to be benign should weigh less than 20 g. The relationship between specimen weight and cosmesis is unknown and evidence to support a 20 g upper limit is lacking. Patient satisfaction following all benign biopsies weighing more than 20 g (n = 49) and a random sample of 30 of those weighing less than 20 g (n = 103) performed by one screening unit, over a 6 year period, was assessed by a postal questionnaire. Overall, 32% of patients were unhappy with the cosmetic outcome of their surgery. Patient dissatisfaction appeared to increase with specimen weight (6/23 [26%] < 20 g versus 13/36 [36%] > 20 g) but no statistically significant relationship between weight and cosmesis was apparent (P = 0.57). Reducing benign breast biopsy specimen weights to a minimum is a desirable objective. However, the current quality standard is not evidence-based, is too stringent and should be revised. Strategies need to be introduced to improve patient satisfaction following breast wire-localisation biopsies. In particular, patients should be counselled pre-operatively regarding possible adverse cosmetic outcome.     

Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery.

Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456-61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567-72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869-73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166-94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233-50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breast-conserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28-108 g), while mean FDFG weight was 78.3g (range, 35-148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG.     

COSMESIS FOLLOWING COMPLETE LOCAL EXCISION OF BREAST CANCER

Background : With the establishment of the safety of breast conservation in early breast cancer, cosmesis has become an increasingly important end-point of treatment. The aim of the present study was to establish a model to assess breast cosmesis after complete local excision and to assess cosmesis achieved in patients who had surgery using the seroma technique. Methods : A total of 42 patients were retrospectively reviewed and assessed by independent clinical assessment by a surgeon, structured questionnaire and clinical photography. Results : A total of 86% of patients were rated by surgeon and patient as having a good or excellent cosmetic outcome. There was a high degree of concordance between independent clinical assessment and clinical photographic analysis. Conclusions : A model has been established for the assessment of breast cosmesis; the technique of seroma formation without reconstruction of the defect results in good or excellent cosmesis in the majority of patients.     

Breast-conserving therapy and sentinel lymph node biopsy are feasible in cancer patients with previous implant breast augmentation

BACKGROUND: Breast-conserving therapy (BCT) is reported to result in a significant rate of complications and local recurrences in patients with prior implant breast augmentation. The role of sentinel lymph node (SLN) biopsy in these patients is unknown. METHODS: Retrospective review of patients with prior breast augmentation treated with BCT or SLN biopsy. RESULTS: Nineteen breast cancers were treated with BCT. Of 17 breasts undergoing adjuvant radiotherapy, 11 (64.7%) retained favorable aesthetic results. Of 9 subpectoral implants, capsular contracture developed in only 1 (11.1%). During follow-up (median 3 years), 1 local recurrence (5.3%) occurred in a patient who refused adjuvant radiotherapy and systemic therapy. Eleven patients underwent SLN biopsy with an identification rate of 100% and a false-negative rate of 0%. CONCLUSIONS: Breast-conserving therapy inclusive of radiotherapy after implant breast augmentation produced acceptable cosmetic results in nearly two-thirds of patients. Sentinel lymph node mapping in the setting of prior implant augmentation was highly successful and accurate.     

Conservative surgery and radiation therapy for early breast cancer. Long-term cosmetic results

To evaluate the cosmetic outcome of conservative surgery (CS) and radiation therapy (RT) for early-stage breast cancer and its stability over time, we reviewed the records of 593 patients treated from 1968 to 1981. The breast appearance was scored as "excellent," "good," "fair," or "poor". Median follow-up was 76 months (range, 37 to 186 months). Cosmetic results were generally excellent or good. The percents of excellent, good, fair, and poor results at three years were 65%, 25%, 7%, and 3%, respectively. Patients not receiving adjuvant chemotherapy were more likely than those receiving chemotherapy to have excellent scores at five years (71% vs 40%). Tumor size also influenced cosmetic outcome: 73% of patients with T1 tumors vs 55% with T2 tumors had excellent scores at five years. Our results were stable over time: of 36 patients assessable at seven years whose cosmetic scores were good or excellent at three years, 34 (94%) continued to have good or excellent scores, and only two (5%) deteriorated to fair. We conclude that the cosmetic results achieved with CS and RT are good to excellent in approximately 90% of patients and that these results remain stable for at least seven years.     

Six‐year Outcome of a Prospective Study Evaluating Tumor Bed Boost with Intra‐operative Electron Irradiation Followed by whole‐Breast Irradiation for Early‐Stage Breast Cancer

A prospective study was performed for patients with early‐stage breast cancer in which a single fraction of intraoperative electron irradiation (IOERT) was given to the tumor bed, followed by conventional fractionated whole‐breast irradiation (WBRT). Patients with T1/T2N0 breast cancer underwent lumpectomy and sentinel lymph node biopsy. A tumor bed boost of 10 Gy of IOERT using 6–12 MeV electrons was administered by a dedicated mobile linear accelerator in the operating room. After adequate wound healing, 48 Gy WBRT was given to the whole breast in 24 fractions. Fifty‐two patients were enrolled between February 2003 and January 2005. At a median follow‐up of 79 months, there were two local relapses. The 6‐year actuarial overall survival and distant control rates were 89% and 96%, respectively. At last follow‐up, cosmesis was graded as excellent or good in 45 (87%), fair in five (10%), and poor in two patients (4%), respectively. Difficulty in wound healing occurred in two patients who had additional surgery later. One patient developed significant fibrosis after aspiration of a symptomatic seroma. The result of this pilot study shows the feasibility of using IOERT as the tumor bed boost in lieu of 6–8 days of standard electron beam treatment with good local control and cosmetic results. However, late surgical intervention of the lumpectomy bed may result in more pronounced tissue fibrosis and wound healing difficulty.     

Factors determining esthetic outcome after breast cancer conservative treatment

The aim of this study was to evaluate the factors that determine esthetic outcome after breast cancer conservative treatment, based on a consensual classification obtained with an international consensus panel. Photographs were taken from 120 women submitted to conservative unilateral breast cancer surgery (with or without axillary surgery) and radiotherapy. The images were sent to a panel of observers from 13 different countries and consensus on the classification of esthetic result (recorded as excellent, good, fair or poor) was obtained in 113 cases by means of a Delphi method. For each patient, data were collected retrospectively regarding patient characteristics, tumor, and treatment factors. Univariate and multivariate analysis were used to evaluate the correlation between these factors and overall cosmetic results. On univariate analysis, younger and thinner patients as well as patients with lower body mass index (BMI) and premenopausal status obtained better cosmetic results. In the group of tumor- and treatment-related factors, larger removed specimens, clearly visible scars, the use of chemotherapy and longer follow-up period were associated with less satisfactory results. On multivariate analysis, only BMI and scar visibility maintained a significant association with cosmesis. BMI and scar visibility are the only factors significantly associated with cosmetic results of breast cancer conservative treatment, as evaluated by an international consensus panel.     

Wire-guided biopsies of nonpalpable breast lesions

The purpose of this study was to review the results of mammographic wire-guided biopsies of nonpalpable breast lesions and the features of the lesions in the preoperative examinations. Sixty women, mean age 50.2 years (range 31 to 74), underwent a wire-guided biopsy of the lesion. Twenty-nine patients had preoperative fine needle aspiration of the lesion. The radiographic diagnosis was correct in 33 patients (55%); 25 had breast cancer and 8 patients had a benign lesion. In 9 of the 14 patients with clustered microcalcifications in mammography and in 13 of the 15 patients with a mass noted in mammography, the cytological examination was correct. Nonpalpable mammographic masses with regular borders and normal fine needle aspiration examination do not require biopsy. In malignant mammographic appearances associated with a normal fine needle aspiration examination, biopsy of the lesion should always be done.     

680例乳腺癌保留乳房治疗的远期疗效分析

目的探讨对临床Ⅰ、Ⅱ期乳腺癌患者选择性行乳腺癌保留乳房治疗（BCT）的远期生存、同侧乳房复发（IBR）、美容效果及其相关因素。方法1985年10月至2007年12月共对680例临床Ⅰ、Ⅱ期乳腺癌开展BCT临床研究。乳腺癌保乳手术先后采用乳腺象限／区段切除术及肿瘤扩大切除术，联合全腋淋巴结清扫术或前哨淋巴结活检术。术后放疗先后采用Co^60及加速器全乳放疗及瘤床缩野照射。结果中位随访10年，680例BCT患者10年总生存率IBR83．7％、同侧乳房复发为8．5％、远处转移率为23．7％。患者年龄、肿瘤大小、病理组织学类型、腋淋巴结转移状况等临床病理因素对BCT后IBR差异无统计学意义（均P〉0．05）；切缘阳性、术后未行全乳照射的患者IBR显著升高（均P=0．000）。在确保切缘阴性的前提下，不同切除范围的手术方式对IBR差异无统计学意义（P=0．799），但切除范围较大的区段／象限切除术对BCT后乳房美容效果差异有统计学意义（优秀组P=0．043，优秀＋良好组P=0．005）。结论临床Ⅰ、Ⅱ期乳腺癌选择性行BCT有较好的远期疗效、较好的美容效果和较低的IBR，可以安全地替代乳房切除性手术；确保切缘阴性及接受术后全乳放疗仍是现阶段乳腺癌BCT的金标准；在确保切缘阴性的前提下，切除范围较小的肿瘤扩大切除术有较好的美容效果和相同的治疗效果。     

Therapeutic application of ultrasound-guided 8-gauge Mammotome system in presumed benign breast lesions

The stereotactic or ultrasound-guided vacuum-assisted breast biopsy (Mammotome, MMT) system is a minimally invasive surgical technique. Increasingly, it is used to remove benign breast lesions as management. To evaluate the therapeutic value of 8-gauge ultrasound-guided MMT system (UMS) in presumed benign breast lesions, a retrospective analysis was performed on a series of 2,167 consecutive 8-gauge UMS procedures. The parameters used in this analysis included lesion size, location, breast imaging reporting and data system for ultrasound category, histopathologic diagnosis, and others. A total of 1,119 women whose mean ages were 36.6 years (range: 12-71, SD: 9.6) underwent 2,167 consecutive 8-gauge UMS procedures. Among the patients, 298 cases (26.63%) did not have palpable mass, 430 (38.43%) had multiple lesions, and 237 (21.18%) had bilateral ones. The average size of excised lesions was 15.8 mm (range: 5-55, SD: 6.7) in the largest dimension, including 294 lesions < 10 mm (13.57%); 1,359 lesions, 10-19 mm (62.71%); 420 lesions, 20-29 mm (19.38%), and 94 lesions ≥ 30 mm (4.34%). Predominant lesions (81.59%) were solid on ultrasound image and nearly half (48.59%) of them were localized in the upper outer quadrant. Histopathologic diagnosis revealed that the overwhelming majority of specimens (96.61%) were benign, most of which manifested as fibroadenoma and fibrocystic changes, while high-risk lesions were revealed in 31 (2.29%) cases and malignancies in 15 (1.11%). Average time for procedure was 8.6 minutes (range: 3.5-38, SD: 5.4) and mean number of cores removed in the procedure was 9.3 (range: 2-42, SD: 3.7). Complete excision was achieved predominantly (99.82%). Complications (59, 5.27%) in which hematoma (41, 3.66%) was the majority were acceptable. In conclusion, the 8-gauge UMS procedure is a safe and potent therapeutic management with satisfactory cosmetic outcome for benign and high-risk breast lesions, especially for bilateral, multiple, and nonpalpable ones. It is a reliable biopsy tool for suspected lesions as well. Eradication and maximal cosmesis can be achieved with few complications if the targeted lesion is limited to 30 mm.     

Poor esthetic results after conservative treatment of breast cancer. Technics of partial breast reconstruction

A wide consensus exists today in favour of breast saving procedures for the surgical treatment of small breast cancers. The goal of conservative treatment is to preserve the shape of the breast and consequently to avoid the psychological consequences of the mutilation. In this respect, the final esthetic evaluation of conservative treatment is a major point to be considered after the oncological results. To evaluate these cosmetic results, 89 patients treated more than five years ago were analyzed on a standard picture protocol and rated according to a rigorous scale previously defined. In this group, 45% were rated as excellent, 34% as fair and 21% as poor. These results were compared to the cosmetic results of a second group of patients evaluated after the surgical stage of their conservative treatment in order to precise the morphological damage due to the surgical procedure. In the second group, 73% were rated as excellent, 20% as fair and 7% as poor. This study underlines the frequency of skin contractions (16%) and glandular defects (20%). Several rules are proposed to prevent such sequelae at the time of the tumorectomy. The difficulty of cosmetic improvement of the poor esthetic results is emphasized and the techniques of partial reconstructions are discussed in the light of our experience which includes 25 cases of partial reconstruction.     

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??Objective:o compare the effects of breast conservative therapy (BCT) with modified radical mastectomy (MRM) in women with early stage breast cancer. Methods: matched retrospective cohort study using data on patients derived from a prospectively collected breast cancer database was conducted.The database included patients who received MRM or BCT from 1995 to 2002 in Cancer Hospital of Fudan University.The match was conducted according with four variables:age at diagnosis,axillary lymph node status,sexual hormone receptor status and the dimension of tumor.The match ratio was 1??2.Controls were patients who received MRM (n=254).Cases were patients who received BCT (n=127).Median follow??up for the controls and cases were 58 months and 49 months respectively.The differences of incidence of loco??regional recurrence,disease free survival and overall survival at 5 years were compared.There were no significant differences in incidence of loco??regional recurrence,DFS and OS at 5 years between the two groups of patients. Results:he incidence of loco??regional recurrence was 1.4% in MRM group and 3??39% in BCT group (P=0.5).The OS in MRM and BCT patient were 97.7% and 96.73% (P=0.66).The DFS in MRM and BCT patients were 91.57% and 86??04% (P=0.37). Conclusion:For appropriate breast cancer patients,classic lumpectomy plus axillary lymph node dissection and post??operative radiotherapy lead to excellent local control and good survival rate.The BCT can result in the same effects as MRM in breast cancer patients with better cosmetic appearances.     

Factors influencing cosmetic results after breast conserving management (Turkish experience)

We aimed to determine predictive factors affecting cosmetic results after breast conserving management in breast cancer. Data on 96 patients with 97 breast cancer cases, who had been admitted to Uluda? University M.A. Radiotherapy Center between October 1995 and December 1998 and managed with breast-conserving treatment, were analysed to determine the factors affecting cosmetic outcome. Possible factors affecting cosmesis were grouped as patient-related, tumor-related and treatment-related. Mann-Whitney U test was used in univariate analyses whereas logistic regression was used in multivariate analyses. Median follow-up time was 29.5 months ranging between 11 and 53 months and median age at admission was 50 (range 22-84). Cosmetic results were grouped in five categories; excellent; good; fair; poor and, very poor, using criteria, such as presence of fibrosis, telangiectasia, shape of breast, asymmetry, status of areola, pigmentation. Treated breasts were scored by the patients, three radiation oncologists and a breast surgeon independently. In the analysis performed using scores given by the patients, cases with scores 3 and above (unsatisfactory) were compared with cases with scores below 3 (satisfactory). Eighty-two patients (84%) considered cosmetic result as satisfactory (excellent/good) whereas 15 patients (16%) considered unsatisfactory (fair/poor/very poor). In univariate analysis using Mann-Whitney U test, type of surgery (P=0.0655) was the statistically significant factors affecting cosmetic results. In multivariate analysis using logistic regression, tumor quadrant (P=0.0060) and elapsed radiation therapy days (P=0.0090) were the most significant factors. Median values were taken into consideration for the scores given by the physicians and cases with scores 3 and above (unsatisfactory) were compared with cases with scores below 3 (satisfactory). Eighty-two cases were evaluated as satisfactory (84%) whereas 15 cases were unsatisfactory (16%). In this set of data, patient age (P=0.0144), menopausal status (P=0.0111), institution which surgery was performed (P=0.0045), type of surgery (P=0.0044), placement of metallic clips (P=0.0083) and skin fibrosis (P=0.038) were found to be significant in univariate analysis using Mann-Whitney U test. In multivariate analysis using logistic regression, institution where surgery took place (P=0.0015), menopausal status (P=0.0087) and telangiectasia (P=0.0657) were the most significant factors.     

Cryoablation treatment of benign breast lesions with 12-month follow-up

OBJECTIVE: Eighty percent of all breast biopsies reveal benign findings. The most common benign tumor is a fibroadenoma. Despite their benign nature, many women eventually choose to have their bothersome lumps surgically removed. We report the use of cryoablation to treat these benign breast lesions with minimum 12-month follow-up. METHODS: After receiving Institutional Review Board approval, a prospective nonrandomized trial was initiated in June 2000. Ultrasound-guided cryoablation of core biopsy-proven benign fibroadenomas, other benign breast nodules, or nodular fibrocystic change was performed on 78 lesions in 63 patients. Eighty-five percent of lesions treated were benign fibroadenomas. The cryoablation procedure consisted of a double freeze-thaw cycle that lasted between 6 and 30 minutes and was performed most often in an office setting. Each patient was serially evaluated for treatment efficacy, complications, and patient satisfaction. RESULTS: Sixty-four of 78 lesions (mean size 2.0 cm [range 0.8 to 4.2]) were followed-up for at least 12 months after cryoablation per protocol, which included 53 fibroadenomas. At 1 year, ultrasound tumor volume resorption was 88.3% overall (87.3% for fibroadenomas), and 73% of the entire group became nonpalpable to both clinician and patient (75% for fibroadenomas). Two of the fibroadenoma patients had their palpable residual nodule excised, both revealing necrotic debris and no viable tumor in the treated volume. Serial mammograms showed resorption of the lesion leaving minimal residual density without calcifications. Cosmesis was excellent with only a small scar remaining at the probe insertion site. There was no report of visual or palpable volumetric deficit. Patient satisfaction was good to excellent in 92% of cases. CONCLUSIONS: Cryoablation was successful in treating core biopsy-proven benign breast lesions in 63 patients. At 12 months, we found gradual resorption of treated tissue with no cosmetic deficit. Ultrasound-guided cryoablation is an effective and safe treatment for benign breast lesions, as seen at 12-month follow-up, and offers an office-based, minimally invasive alternative to surgical excision.     

Factors Associated with Optimal Cosmetic Results at 36 Months in Patients Treated with Accelerated Partial Breast Irradiation (APBI) on the American Society of Breast Surgeons (ASBrS) MammoSite® Breast Brachytherapy Registry Trial

Purpose

To evaluate factors associated with optimal cosmetic results at 36 months for early-stage breast cancer patients enrolled on the American Society of Breast Surgeons (ASBrS) MammoSite^® Breast Brachytherapy registry trial.

Materials and Methods

1,440 patients (1,449 cases) with early-stage breast cancer undergoing breast-conserving therapy were treated with the MammoSite^® radiation therapy system (RTS) brachytherapy catheter to deliver adjuvant accelerated partial breast irradiation (APBI) (34 Gy in 3.4-Gy fractions). Cosmetic outcome was evaluated at each follow-up visit and dichotomized as excellent/good or fair/poor. Median follow-up for surviving patients was 43.0 months (range 0–73.0 months).

Results

The percentage of patients with good/excellent cosmetic results at 12, 24, 36, and 48 months were as follows: 94.5% (n = 950/1,005), 93.8% (n = 781/833), 93.1% (n = 683/734), and 90.4% (n = 520/575), respectively. Three-year absolute rates of good/excellent cosmesis were as follows: breast-related wound infection (BWI) (83.3%) versus no BWI (94%), <7 mm skin spacing (87.5%) versus ≥7 mm skin spacing (93.6%). Using multiple regression analysis, factors predictive of worse cosmetic outcome at 36 months included smaller skin spacing [odds ratio (OR) 1.06, confidence interval (CI) 1.01–1.12] and BWI (OR 0.33, CI 0.16–0.70). A predictive model developed showed that presence of a BWI, use of chemotherapy, and skin spacing had the most effect on cosmetic outcomes. However, in patients that did not develop a breast infection, skin spacing and use of chemotherapy had the most effect on cosmesis.

Conclusion

APBI delivered by MammoSite^® brachytherapy lead to good/excellent cosmesis in 93% of patients with 3-year follow-up. Breast wound infection, use of chemotherapy, and skin spacing were found to be the three most important predictors of cosmesis at 36 months in our cohort of patients.     

Analysis of malpractice claims in breast care for poor cosmetic outcome

Claims for poor cosmetic outcome account for a large proportion of breast care malpractice litigation in the UK. Detailed analysis of such claims has not been conducted. We sought to analyse National Health Service Litigation Authority (NHSLA) data pertaining to breast care over the period September 2005-April 2008, focussing on claims for poor cosmetic outcome. Data from a medical indemnity organisation detailing similar claims in the private sector were also analysed. Comparison of the NHSLA data with previously obtained NHSLA data (May 1995-September 2005) demonstrated an upward trend in claims for poor cosmetic outcome. The majority of claimants for poor cosmesis had benign disease and the vast majority of claimants with breast malignancy had undergone breast reconstruction. The majority of claims for poor cosmetic outcome were against plastic surgeons. This was more marked in the private sector data than in the NHSLA data, reflecting their workload.