Oncoplastic volume replacement with latissimus dorsi myocutaneous flap in patients with large ptotic breasts. Is it feasible?

BackgroundOncoplastic breast conservative surgery has evolved as a safe alternative to the standard mastectomy in the treatment of early breast cancer. The procedure involves tumour resection with an adequate safety margin and either breast reshaping with volume displacement procedures (large or ptotic breasts) or volume replacement with latissimus dorsi myocutaneous flap (LDF) (small to medium sized non-ptotic breasts). A contra lateral mastopexy procedure is usually necessary with the volume displacement oncoplastic surgery, a procedure that is often rejected by a significant number of patients. This limits the choice of the reconstruction of breast defects in such patients to autologous tissues i.e. LDF.AimAim is to evaluate the feasibility of volume replacement oncoplastic breast conservative surgery with latissimus dorsi myocutaneous flaps for patients with large ptotic breasts. This involves testing the oncologic safety in terms of adequate safety margin, the complications rate and the final cosmetic outcome. The loco regional recurrence rate will be recorded and compared with oncoplastic volume displacement for similar sized breast defects.Patients and methodsA group of 50 female patients with early breast cancers (T2) who presented to the department of surgery at the National Cancer Institute, Cairo, Egypt in the period between January 2004 and November 2009 were included in the study. Bilateral soft tissue mammography was carried out in all patient groups and was used to annually follow up the patients. All patients were detected with T2 N0 breast cancer by both clinical and radiological examinations. All patients underwent partial mastectomy and reconstruction with LDFs.ResultsThe average age at presentation was 46.5 ± 9 years and the range was 26–65 years. Most of the patients were subjected to partial mastectomy in 30 patients (60%), excision of a single quadrant from the four major quadrants was carried out in 15 patients (30%) where skin sparing wide local excision was carried out in only five patients (10%). The safety margin ranged from 1.1 to 3.2 cm with an average of 1.8 ± 0.5 cm. There was no total flap loss in any patient where as we reported partial flap loss in two patients. Nipple and areola sloughing were reported in two patients, wound infection in five patients, haematoma in four patients, seroma in 16 patients, and donor site morbidity in six patients. The vast majority of patients were either satisfied (score >3 out of 5) (62%) or very satisfied (score 4 or more) (18%) with the results of reconstruction.ConclusionThe results of the current study showed the feasibility and the versatility of volume replacement oncoplastic surgery in patients with large ptotic breasts with myocutaneous flaps. The adequacy of safety margin and the acceptable complications rate as well as the comparable local recurrence rate to volume displacement oncoplastic surgery, make it a suitable alternative in a subset of patients who object an immediate contra lateral mastopexy procedure.     

Outcome of different oncoplastic surgical (OPs) techniques for centrally located breast cancer (CLBC)

BackgroundOncoplastic breast surgery is a standard treatment of early breast cancer, offering a balance between good cosmetic outcome and limited risk of locoregional recurrence, by enabling proper resection margins.Aim of studyTo present multiple techniques of partial breast reconstruction following the resection of centrally located breast cancer (CLBC) resection.Patients and methodsFrom January 2011 to August 2014, 21 patients underwent central quadrantectomy for carcinoma of the central region of the breast. Excisions included the nipple/areola complex, in most of the cases, down to the pectoralis fascia with a wide safety margin, and proper axillary management. Oncoplastic approaches included latissimus dorsi flap, inferior pedicle flap, Melon slice, Grisotti and round block techniques.ResultsMean age of patients was 49.5 ± 10.61 years. Tumor size ranged from 1.5 to 4.5 cm. Postoperative pathology revealed a tumor mean safety margin of 2.5 ± 0.83 cm, with positive axillary lymph nodes in 15 (75.0%) patients. Nineteen (95.0%) patients received postoperative breast radiotherapy, while 9/20 (45.0%) and 3/20 (15.0%) received adjuvant chemotherapy or hormonal therapy, respectively, and only 8/20 (40.0%) patients received both therapies. During a median follow-up period of 14.89 months, neither local nor distant metastasis, were detected. The postoperative cosmetic result evaluated by the patients was excellent in 6/20 patients (30.0%), good in 11/20 patients (55.0%), fair in 3/20 (15.0%) with neither poor nor bad results, with an overall mean of 4.0 ± 0.5 equivalent to 80% satisfaction.ConclusionMultiple oncoplastic breast surgery techniques can be used for the resection of CLBC with satisfying cosmetic outcomes.     

Pedicled dermoglandular flap reconstruction following breast conserving surgery

Breast conserving therapy is the gold standard treatment of early breast cancer. However, a balance between good cosmetic outcome and limiting the risk of locoregional recurrence remains the key of success.The aim of this work was to evaluate the outcome of partial breast reconstruction using pedicled dermo-glandular flap from the upper outer quadrant, for central quadrantectomy BCS.Patients & methodsThirty patients underwent wide excision of carcinoma of retroareolar or periareolar regions of the breast, from July 2008 to August 2011. Excisions included the nipple/areola complex down to the pectoralis fascia with a wide safety margin, and complete axillary dissection. Breast reconstruction was done by means of pedicled dermoglandular flap.ResultsMean age of patients was 51.86 years (range from 30 to 70 years). Tumor size ranged from 1 to 4.2 cm. Postoperative pathological results came out with 21 (70.0%) patients mean (range) of the tumor safety margin 2.01 (0.5–2.8). Seventeen (56.7%) patients had positive axillary lymph nodes. All patients received postoperative radiation therapy to the breast, while 17/30 (56.67%) and 6/30 (20%) received endocrine therapy or adjuvant chemotherapy, respectively, and only 7/30 (23.34%) patients received both therapies. During a median follow-up period of 24 months, neither local nor distant metastasis, were detected. The postoperative cosmetic result was excellent in 80% patients, good in 13.3% patients, acceptable in 6.7% with no poor result.ConclusionFollowing central quadrantectomy BCS for small centrally located breast cancer, a pedicled dermoglandular flap from the upper outer quadrant is a good reconstructive option.     

Prognostic value of lymph node ratio in node-positive breast cancer in Egyptian patients

BackgroundBreast cancer in Egypt is the most common cancer among women and is the leading cause of cancer mortality. Traditionally, axillary lymph node involvement is considered among the most important prognostic factors in breast cancer. Nonetheless, accumulating evidence suggests that axillary lymph node ratio should be considered as an alternative to classical pN classification.Materials and methodsWe performed a retrospective analysis of patients with operable node-positive breast cancer, to investigate the prognostic significance of axillary lymph node ratio.ResultsFive-hundred patients were considered eligible for the analysis. Median follow-up was 35 months (95% CI 32–37 months), the median disease-free survival (DFS) was 49 months (95% CI, 46.4–52.2 months). The classification of patients based on pN staging system failed to prognosticate DFS in the multivariate analysis. Conversely, grade 3 tumors, and the intermediate (>0.20 to ⩽0.65) and high (>0.65) LNR were the only variables that were independently associated with adverse DFS. The overall survival (OS) in this series was 69 months (95% CI 60–77).ConclusionThe analysis of outcome of patients with early breast cancer in Egypt identified the adverse prognostic effects of high tumor grade, ER negativity and intermediate and high LNR on DFS. If the utility of the LNR is validated in other studies, it may replace the use of absolute number of axillary lymph nodes.     

Association of the breast reconstruction modality with the development of postmastectomy lymphedema: A long-term follow-up study

BackgroundWhether the breast reconstruction modality could influence the long-term development of post-mastectomy lymphedema has been little investigated. The present study aimed to evaluate the potential association of the breast reconstruction method with the incidence of lymphedema over an extended follow-up period.MethodsPatients with breast cancer who underwent immediate reconstruction from 2008 to 2014 were reviewed. They were categorized into three groups according to the reconstruction method: tissue expander/implant, abdominal flaps, and latissimus dorsi (LD) muscle flaps. Differences in the cumulative incidence of lymphedema by the reconstruction method were analyzed, as well as their independent influence on the outcome. Further analyses were conducted with propensity-score matching for baseline characteristics.ResultsIn total, 664 cases were analyzed with a median follow-up of 83 months (402 prostheses, 180 abdominal flaps, and 82 LD flaps). The rate of axillary lymph node dissection was significantly higher in the LD flap group than in the other two groups. The 5-year cumulative incidences of lymphedema in the LD flap, abdominal flap, and prosthesis groups were 3.7%, 10.6%, and 10.9%, respectively. In multivariable analyses, compared to the use of the LD flap, that of tissue expander/implant and that of abdominal flaps were associated with increased risks of lymphedema. A similar association was observed in the propensity-score matching analysis. The use of abdominal flaps or prostheses was not associated with the outcomes.ConclusionsOur results suggest that the method of immediate breast reconstruction might be associated with the development of postmastectomy lymphedema.     

Irradiation axillaire prophylactique « de diffusion » dans le cancer du sein — revue de la littérature

PurposeIn breast cancer, radiotherapy is an essential component of the treatment. However, indications of irradiation of the internal mammary chain and axillary area are debatables. Axillary recurrence in patients with invasive breast carcinoma remains an issue. Currently, the substitution of axillary lymph node dissection by sentinel node biopsy leads to revisit the role of axillary irradiation. Breast irradiation including level I, II and III might decrease the risk of axillary recurrence.Material and methodsA literature search was performed in PubMed and the Cochrane library to identify articles publishing data regarding dose-volume analysis of axillary levels in breast irradiation aiming to determine the potential therapeutic implications.ResultsEleven articles were retained. A total of 375 treatment plans were analyzed. The results concerning the irradiation technique, initial dose prescribed to breast, delineated volumes and dose received at axillary levels were heterogeneous. The average dose delivered to axilla levels I–III with 3D-conformal radiotherapy using standard fields were between 24 Gy and 43.5 Gy, 3 Gy and 32.5 Gy and between 1.0 Gy and 20.5 Gy respectively. The average doses delivered to axilla levels I–III with 3D-conformal radiotherapy using high tangential fields were between 38 Gy and 49.7 Gy, 11 Gy and 47.1 Gy and 5 Gy 38.7 Gy, 32.1 Gy and 5 Gy (result available for only one study) respectively. Finally, the average doses delivered to axilla levels I–III with intensity modulated radiation therapy were between 14.5 Gy and 42.6 Gy, 3.4 Gy and 35 Gy and between 1.2 Gy and 25.5 Gy respectively.ConclusionsIncidental axillary dose seems insufficient to be therapeutic regardless of the irradiation technique. There are meaningful differences between intensity modulated radiation therapy and 3D-conformal radiotherapy.     

Immediate Reconstruction of Large Ptotic Breasts following Vertical Reduction Pattern Nipple-Sparing Mastectomy

PurposeWomen with large and/or ptotic breasts are generally not considered candidates for nipple-sparing mastectomy because of concerns regarding the high incidence of postoperative complications including ischemic complications. Therefore, we adopted a vertical skin resection technique for nipple-sparing mastectomy, and obtained satisfactory results following immediate autologous breast reconstruction. In this study, we aimed to describe our operative technique and review its outcomes.MethodsBetween January 2010 and March 2017, immediate autologous breast reconstructions were performed in 28 patients with moderate or large ptotic breasts after nipple-sparing mastectomy using the vertical reduction pattern. Grade II ptosis was observed in 12 patients, and 16 patients were classified as having grade III ptosis.ResultsOf the 28 patients, 21 received abdominal free flap reconstruction. In the remaining 7 patients, extended latissimus dorsi flaps were used in conjunction with anatomic implants. The mean weight of the excised breast tissue in the 2 groups was 575 g and 482 g, respectively. Satisfactory esthetic outcomes without major complications were achieved in all patients. Similar vertical reductions or mastopexies in the contralateral breast allowed better postoperative adjustment for symmetry. There was only 1 case of complete nipple necrosis; however, the problem was solved with “skin banking.” No local recurrences or distant metastases were detected at follow-up (mean 18 months, range 4 months to 6 years).ConclusionTo enhance cosmetic outcomes in patients with large and/or ptotic breasts, the vertical skin resection pattern for nipple-sparing mastectomy can be used to achieve better breast shape while preserving the nipple-areola complex. Moreover, it can improve the esthetic outcome without compromising oncologic safety.     

Surgery following neoadjuvant chemotherapy for HER2-positive locally advanced breast cancer. Time to reconsider the standard attitude

BackgroundWhile the addition of targeted therapy to neoadjuvant chemotherapy (NACT) dramatically increases the rate of pathological complete response in HER2-positive breast cancer, no reduction in the rate of mastectomy has been observed in randomised studies.MethodsA retrospective single centre analysis of all patients treated with anti HER2-based NACT for T2–4 breast cancer, focusing on patients treated with mastectomy.ResultsAmong 165 patients treated between June 2005 and July 2012, surgery was performed immediately post-NACT in 152 cases (92%). Breast-conserving surgery could be performed for 108 of the patients (71%), with a 4-year local relapse-free survival of 97%. A mastectomy was performed in two cases following patients’ wishes and in 37 cases based on pre-NACT findings (n = 18) or post-NACT outcomes (n = 19). For 21 out of the 37 cases, a good pathological response was observed, and multidisciplinary reanalysis suggests that breast-conserving surgery outright may have been sufficient for 12 patients. Finally, a salvage mastectomy based on post-lumpectomy pathological results was decided in five cases (11%). The 4-year metastasis-free survival was 84% for all patients operated on after NACT (n = 152).ConclusionsGiven the good efficacy of anti HER2-based NACT, breast-conserving surgery should be standard practice for most patients. Total mastectomy on the other hand should be restricted to a few patients, mainly those with positive margins on the lumpectomy specimen.     

Immediate breast reconstruction with latissimus dorsi flap for patients with local recurrence of breast cancer

BackgroundIpsilateral breast cancer recurrence (IBTR) occurs in about 7% of patients with primary invasive breast tumor. Salvage mastectomy and breast reconstruction are often discussed and latissimus dorsi (LD) flap is frequently proposed.MethodsWe retrospectively investigated 111 consecutive locally relapsing patients who underwent salvage mastectomy and immediate LD reconstruction. All included patients with IBTR previously underwent conserving surgery for BC, and received a postoperative irradiation. Primary endpoints were disease free survival and overall survival. Secondary endpoints were surgical complications and re-interventions.ResultsInvasive ductal cancer was the most frequent histotype (60.4%) of breast cancer reappearance. rpT1, rpT2 and rpT3 were observed respectively in 50.5%, 20,7% and 3,6% of the patients. rpTis occurred in 11,7% of cases. Positive axillary nodes were observed in 9,9% of patients at reappearance. Post-operative complication other than seroma occurred in 17,1% of patients, while seroma at the donor site was observed in 61.3% of cases. At 5-year after surgery overall survival was 92% (95% CI: 85%–96%) and disease free survival was 78% (95% CI: 69%–85%).ConclusionsImmediate latissimus dorsi flap reconstruction in selected patients with isolated breast tumor recurrence, which occurred after breast irradiation, provides an effective treatment with a satisfactory outcome.     

Valeur pronostique des sous-types moléculaires et du Ki67 pour les cancers du sein indemnes d’envahissement ganglionnaire après mastectomie : expérience de l’institut Curie–hôpital René-Huguenin et revue de la littérature

PurposeTo evaluate the prognostic value of Ki67 expression, breast cancer molecular subtypes and the impact of postmastectomy radiotherapy in breast cancer patients with pathologic negative lymph nodes (pN0) after modified radical mastectomy.Patients and methodsSix hundred and ninety-nine breast cancer patients with pN0 status after modified radical mastectomy, treated between 2001 and 2008, were identified from a prospective database in a single institution. Tumours were classified by intrinsic molecular subtype as luminal A or B, HER2+, and triple-negative using estrogen, progesterone, and HER2 receptors. Multivariate Cox analysis was used to determine the risk of locoregional recurrence associated with intrinsic subtypes and Ki67 expression, adjusting for known prognostic factors.ResultsAt a median follow-up of 56 months, 17 patients developed locoregional recurrence. Five-year locoregional recurrence-free survival and overall survival in the entire population were 97%, and 94.7%, respectively, with no difference between the postmastectomy radiotherapy (n = 191) and no-postmastectomy radiotherapy (n = 508) subgroups. No constructed subtype was associated with an increased risk of locoregional recurrence. A Ki67 above 20% was the only independent prognostic factor associated with increased locoregional recurrence (hazard ratio, 4.18; 95% CI, 1.11 to 15.77; P < 0.0215). However, postmastectomy radiotherapy was not associated with better locoregional control in patients with proliferative tumours.ConclusionKi67 expression but not molecular subtypes are predictors of locoregional recurrence in breast cancer patients with negative lymph nodes after modified radical mastectomy. The benefit of adjuvant radiotherapy in patients with proliferative tumours should be further investigated in prospective studies.     

Toxicité aiguë cutanée de l’irradiation mammaire avec modulation d’intensité avec technique de champ dans le champ (optimisation avec pré-segmentation)

PurposeThe optimization with presegmentation irradiation technique (Dosisoft™), used in treatment of breast carcinomas, facilitates the treatment delivery and improves radioprotection. The objective of our study was to evaluate the potential impact of this innovative technique on the acute skin toxicity especially on the rate of moist desquamation during irradiation of the whole breast after conservative surgery.Patients and methodsThe scores of acute skin toxicity observed at 50 Gy in 103 patients treated with the presegmentation technique were compared to those of 101 patients with similar breast size treated with a classic 3D technique. All patients received 50 Gy/2 Gy per fraction, 5 days a week using 4 MV photon beam. The boost on the tumoural bed was realized according to conventional technique. Using the NCI-CTCAE V4, the skin toxicity was recorded every week during the medical visit. Moreover, the following factors that could induce skin toxicity have been studied: breast size, body mass index, age, prior chemotherapy, concurrent administration of trastuzumab, hypertension, diabetes, smoking habits and statin uptake.ResultsThe incidence of moist desquamation observed in all sites, has been decreased to only 9.8% in the presegmentation group versus 16.8% in the test group, the difference being not statistically significant OR = 0.53 [0.23; 1.22] (P = 0.13). In univariate analysis the presegmentation technique enabled a significant decrease of 4.4 Gy in mean, of the value of maximum dose (P = 0.001). The other risk factors of skin toxicity are the increase of breast size (P < 0.001), a high body mass index (P < 0.001), hypertension (P = 0.03) and concurrent administration of trastuzumab (P = 0.07). In multivariate analysis, the two remaining significant factors are breast size (OR = 1.004 [1.002; 1.006]) and trastuzumab administration (OR = 4.95 [1.17; 20.79]).ConclusionThe comparison of the skin toxicity induced by the presegmentation or the reference technique shows a trend regarding the improvement of the skin tolerance when using the presegmentation technique, thus pleading in favour of its use considering its dosimetric interest and the improvement of radioprotection of the patient. The next step will consist to experiment the simultaneous boost on tumoural bed using this technique.     

Implementation of sentinel node biopsy in breast cancer patients in the Netherlands

BackgroundThis population-based study describes the implementation of the sentinel node biopsy (SNB) in breast cancer patients in the Netherlands. We examined the extent of use over time of SNB in women who were considered eligible for SNB on the basis of their clinical status.MethodsThe study included a total of 35,465 breast cancer patients who were diagnosed with T1–2 tumours (⩽5.0 cm), negative axillary lymph node status and no distant metastases upon clinical examination between 1st January 1998 and 31st December 2003 in six Comprehensive Cancer Centre regions in the Netherlands. Information on axillary surgery was classified as SNB alone, SNB+axillary lymph node dissection (ALND), ALND alone or none. Patterns of use of axillary surgery were summarised as the proportion of patients receiving each surgery type.ResultsOverall, 25.7% of patients underwent SNB alone, 19.1% underwent SNB+ALND, 50.0% had ALND alone and 5.2% did not have axillary surgery. SNB was more common in women who had breast-conserving surgery: 50.5% of patients who received breast-conserving surgery underwent SNB compared to 40.7% of patients who had mastectomy (p < 0.0001). Amongst patients receiving breast-conserving treatment, 31.7% had SNB as final axillary surgery, whilst 20.5% of patients who had mastectomy had SNB alone (p < 0.0001). The proportion of women who underwent a SNB alone or in combination with ALND increased over the period 1998–2003, from 2.1% to 45.8% and from 6.7% to 24.8%, respectively. There were marked differences in the patterns of dissemination of the use of SNB between regions: by 2003, the difference between the regions with the highest and lowest proportion of use was 25%.ConclusionsSNB has become the standard-of-care for the treatment of breast cancer patients clinically diagnosed with T1–2 tumours, clinically negative lymph nodes and without distant metastases. In 2003, 70.6% of patients with early breast cancer in the Netherlands received SNB, and within this group, 64.9% of patients had SNB as the final axillary treatment. Implementation of SNB may depend on factors associated with regional organisation of care.     

Reconstruction mammaire immédiate après mastectomie suivie de radiothérapie : facteurs de risque de complications

ObjectivesTo determine prospectively the factors associated with reconstruction failure (i.e. requiring expander removal) and capsular contracture in patients undergoing mastectomy and immediate two-stage breast reconstruction with a tissue expander and implant, and radiotherapy for breast cancer. This is a multi-institutional prospective nonrandomized trial.Patients and MethodsBetween 2/1998 and 9/2006, we prospectively evaluated 141 consecutive patients who received 141 implants after mastectomy and underwent chest wall radiotherapy (46 to 50 Gy in 23 to 25 fractions). Patients were evaluated after 24 to 36 months by two senior physicians (radiation oncologist and surgeon).ResultsMedical follow-up was 37 months. Baker 1 and 2 capsular contracture was observed in 67.5% of patients, Baker 3 and 4 in 32.5%. There were 32 reconstruction failures. In a univariate analysis, the following factors were associated with Baker 3 and 4 capsular contracture: surgeon, use of hormonotherapy and smoking, of which only one remained in the multivariate analysis: surgeon. In a univariate analysis, the following factors were associated with reconstruction failure: tumor size T3 or T4, smoking, pN+ axilla. Three factors remained associated with reconstruction failure in a multiple logistic regression: large tumors T3/T4, smoking and pN+ axilla.ConclusionsMastectomy, radiotherapy and immediate breast reconstruction with a tissue expander and implant should be considered when breast conserving surgery has been denied. Adequate patients can be easily selected by using three factors of favourable outcome.     

Epidemiology and management of breast carcinoma in Egyptian males: Experience of a single Cancer Institute

ObjectiveTo assess the epidemiological and clinico-pathological features, surgical and reconstructive techniques, adjuvant treatments and clinical outcome of breast carcinoma in males (BCM) at the Egyptian National Cancer Institute (NCI).Patients and methodsThirty-two males with breast carcinoma presented to NCI between January 2000 and December 2002. They were evaluated by complete history, physical examination, laboratory and radiological investigations.ResultsMedian age was 59 years. Left sided and retroareolar breast lumps were the commonest presentations. Grade II tumors positive for hormone receptors were very common. Stages I, II, III and IV of the disease were encountered in 6.2%, 34.4%, 34.4% and 25.0% of patients, respectively. Curative surgery was done in 22 patients; they received adjuvant hormonal therapy, chemotherapy and radiotherapy in 22, 16 and 10 patients, respectively. Eight metastatic patients were treated with palliative measures. Surgery was done in 25 patients; the most common procedure was modified radical mastectomy (40.6%). Primary closure was feasible in 17 patients (68%), local flaps were needed in 4 cases (16%), while myocutaneous flap was done in 3 cases (12%). The commonest complication was the development of seroma (9 cases). The overall survival (OS) at 5 years was 65.4%. The disease free survival (DFS) at 5 years was 53.9%. Stage and curative surgery significantly affected OS, while type of surgery was the only variable significantly affecting DFS.ConclusionMale breast carcinoma occurs at older ages than females, usually in advanced stage. This necessitates directing attention of males and awareness on the prevalence and risk factors for this disease.     

MRI and intraoperative pathology to predict nipple–areola complex (NAC) involvement in patients undergoing NAC-sparing mastectomy

BackgroundNipple–areola sparing mastectomy (NSM) with immediate implant reconstruction is an option for patients with non-locally advanced breast cancer. The prediction of occult tumour involvement of the nipple–areola complex (NAC) may help select candidates to NSM.Patients and methodsWe prospectively recorded clinical and pathological data, magnetic resonance imaging (MRI) results and intraoperative pathological assessments of the subareolar (SD) and proximal nipple ducts (ND) of 112 consecutive breast cancer patients scheduled for NSM. All parameters were correlated with final pathological NAC assessment by univariate and multivariate analysis.ResultsThirty-one patients (27.7%) had tumour involvement of the NAC. At univariate analysis, age (p = 0.001), post-menopausal status (0.003), tumour central location (p = 0.03), tumour–NAC distance measured by MRI (p = 0.000) and intraoperative pathologic assessment (SD + ND) (p = 0.000) were significantly correlated with NAC involvement. At multivariate analysis, only MRI tumour–NAC distance (p = 0.008) and menopausal status (p = 0.039) among all preoperative variables retained statistical significance. The sensitivity and specificity of MRI tumour–NAC distance were 32.2% and 88.6% and those of intraoperative pathologic assessment were 46.7% and 100%, respectively. Sensitivity, specificity and accuracy of the double assessment (MRI plus intraoperative pathology) were 50.0%, 96.2% and 84.1%, respectively.ConclusionIntraoperative pathologic assessment and tumour–NAC distance measured by MRI are the most important predictors of occult NAC involvement in breast cancer patients. A negative pathological assessment and a tumour–NAC distance ⩾ 5 mm allow optimal discrimination between NAC positive and NAC negative cases and may serve as a guide for the optimal planning of oncological and reconstructive surgery.     

保留皮肤的乳腺癌改良根治术后即时乳房再造15例

目的探讨一种既达到肿瘤根治性切除,又保留乳房美观外形的乳房再造的手术方法。方法对早期乳腺癌,保留乳房皮肤,切除乳腺组织和腋窝淋巴结。应用下腹部横行腹直肌肌皮瓣或扩大背阔肌肌皮瓣即时乳房再造。结果应用下腹部横行腹直肌肌皮瓣乳房再造10例,扩大背阔肌肌皮瓣再造5例。优11例（73．3％）,良4例（26．7％）。结论保留皮肤乳腺癌根治术后即时乳房再造,切口隐蔽,再造乳房形态效果好。对早期乳腺癌患者是一种安全可行的治疗方法。     

Neoadjuvant therapy for breast cancer has no benefits on overall survival or on the mastectomy rate in routine clinical practice. A population-based study with a median follow-up of 11years using propensity score matching

BackgroundEven though neoadjuvant chemotherapy has shown no benefits on overall survival (OS), it is being widely used in the treatment of breast cancer. This is based on the assumption that it may diminish the mastectomy rate and therefore be clinically relevant for patients. Our objective was to assess the impact of neoadjuvant chemotherapy on OS and on the rate of mastectomy in patients with non-metastatic primary operable breast carcinoma in routine practice.MethodsThe Cote d’Or district breast cancer registry was used to analyse the OS and mastectomy rate in patients with invasive primary operable unilateral breast cancer diagnosed between 1982 and 2006. We performed Cox proportional hazard ratio (HR) analyses for OS and multivariate logistic regression for the mastectomy rate for the overall population. Different matching methods based on the propensity score were used as sensitivity analyses to ensure that corrections for selection bias were adequate.ResultsWe analysed 1578 patients, among whom 174 had received neoadjuvant chemotherapy. Median follow-up was 11.1 years. There was no difference between the two treatment groups for OS (HR = 1.08 (95% confidence interval (CI): 0.77–1.51 for neoadjuvant chemotherapy)). The mastectomy rate was higher among patients treated with neoadjuvant chemotherapy (odds ratio 1.54 (95% CI: 1.03–2.31)). Sensitivity analyses confirmed these results: for OS, there was no difference between the two populations precisely matched using propensity scores (HR 1.08; 95% CI: 0.671–1.65).ConclusionDespite long term follow-up, neoadjuvant chemotherapy provided no benefit for either OS or the mastectomy rate in our population.     

IMMEDIATE BREAST RECONSTRUCTION WITH LATISSIMUS DORSI MUSCULOCUTANEOUS FLAP： A SUITABLE OPTION FOR CHINESE WOMEN AFTER MASTECTOMY

Objective： To discuss the suitable immediate breast reconstruction modalities for Chinese patients by comparing the pedicled transverse rectus abdominis myocytaneous flap （TRAM） reconstruction with latissimus dorsi myocytaneous flap （LTD） reconstruction plus implants or not after mastectomy due to breast cancer. Methods： From Jan. 2000 to Jul. 2005, 74 staged 0-II patients （mean age 39） were performed immediate breast reconstruction with autologous tissue either using LTD flaps or pedicled TRAM flaps with supplemental implants when necessary after mastectomy due to breast cancer and the charts were reviewed. Results： The age, marriage and menses status did not affect the selection of modalities and the need of implants. In 74 patients, 62 cases （83.8%） were performed LTD reconstruction with 13 implants and 12 cases received TRAM with 1 implant. The difference in need of implants or not between the two modalities had no statistical significance （P=0.442, Fisher＇ exact test）. Aesthetic results judged as good or fair were in 88% patients and the cosmetic effects between LTD and TRAM groups or implant and non-implant groups had no differences. All reconstructions were successful, with 4.1% cumulative locoregional recurrence and 100% overall survival by following up to 66 months （median 9 months）. The DFS and RFS between the two modalities had no significant differences by log rank test. Conclusion： Immediate autologous tissue reconstruction makes it possible to regain the natural and symmetric contour of breast without increased local recurrence. The LTD flap reconstruction is a suitable option for most Chinese women as well as the pedicled TRAM flap.     

Mastectomy trends for early-stage breast cancer: A report from the EUSOMA multi-institutional European database

IntroductionRecent single-institution reports have shown increased mastectomy rates during the last decade. Further studies aiming to determine if these reports could be reflecting a national trend in the United States of America (US) have shown conflicting results. We report these trends from a multi-institutional European database.Patients and methodsOur source of data was the eusomaDB, a central data warehouse of prospectively collected information of the European Society of Breast Cancer Specialists (EUSOMA). We identified patients with newly diagnosed unilateral early-stage breast cancer (stages 0, I or II) to examine rates and trends in surgical treatment.ResultsA total of 15,369 early-stage breast cancer cases underwent surgery in 13 Breast Units from 2003 to 2010. Breast conservation was successful in 11,263 cases (73.3%).Adjusted trend by year showed a statistically significant decrease in mastectomy rates from 2005 to 2010 (p = 0.003) with a progressive reduction of 4.24% per year. A multivariate model showed a statistically significant association of the following factors with mastectomy: age <40 or ⩾70 years, pTis, pT1mi, positive axillary nodes, lobular histology, tumour grade II and III, negative progesterone receptors and multiple lesions.ConclusionOur study demonstrates that a high proportion of patients with newly diagnosed unilateral early-stage breast cancer from the eusomaDB underwent breast-conserving surgery. It also shows a significant trend of decreasing mastectomy rates from 2005 to 2010. Moreover, our study suggests mastectomy rates in the population from the eusomaDB are lower than those reported in the US.     

Overall survival in patients with a re-excision following breast conserving surgery compared to those without in a large population-based cohort

AimTo investigate the overall survival of invasive breast cancer patients with primary breast conserving surgery (BCS) followed by re-excision compared to those with primary BCS only. The Dutch re-excision indications are less stringent compared to other European and Northern American countries (Society of Surgical Oncology-American Society for Radiation Oncology (SSO/ASTRO) guideline).MethodsRetrospective analyses in women <75 years with breast cancer stage pT1–T3 treated by BCS and radiotherapy between 1999 and 2012 from a population-based database. The national guideline recommends to reserve re-excision for invasive tumours showing ‘more than focally positive’ margin since 2002. Patients were divided into ‘primary BCS only’, ‘re-excision by BCS’, and ‘re-excision by mastectomy’. Multivariable Cox regression analysis was adjusted for patient and systemic treatment characteristics.ResultsA total of 11,695 patients were included of which 2156 (18.4%) underwent re-excision. Median time of follow-up was 61 months (interquartile range (IQR) 26–101). The 5-year overall survival rates in the ‘primary BCS only’, ‘re-excision by BCS’ and ‘re-excision by mastectomy’ group were 92%, 95% and 91%, respectively. The 10-year overall survival rates were 81%, 82% and 79%, respectively (P = 0.20). After multivariable analyses no significant association was observed between use of and type of re-excision and overall survival.ConclusionsThe overall survival of breast cancer patients with a re-excision did not significantly differ from the survival of women who underwent primary BCS only. Advising re-excision only for those tumours showing ‘more than focally positive’ resection margin appears safe, supposing the long-term safety of the recent SSO/ASTRO guideline that more cautiously recommended re-excision for tumours showing ‘ink on tumour’.