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Background Our group previously published data showing that patients could be stratified by constructed molecular subtype with respect to locoregional recurrence (LRR)-free survival after neoadjuvant chemotherapy and breast-conserving therapy (BCT). That study predated use of trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive patients. The current study was undertaken to determine the impact of subtype and response to therapy in a contemporary cohort. Methods Clinicopathologic data from 751 breast cancer patients who received neoadjuvant chemotherapy (with trastuzumab if HER2 + ) and BCT from 2005 to 2012 were identified. Hormone receptor (HR) and HER2 status were used to construct molecular subtypes: HR + /HER2 − ( n  = 369), HR + /HER2 + ( n  = 105), HR − /HER2 + ( n  = 58), and HR − /HER2 − ( n  = 219). Actuarial rates of LRR were determined by the Kaplan–Meier method and compared by the log-rank test. Multivariate analysis was performed to determine factors associated with LRR. Results The pathologic complete response (pCR) rates by subtype were as follows: 16.5 % (HR + /HER2 − ), 45.7 % (HR + /HER2 + ), 72.4 % (HR − /HER2 + ), and 42.0 % (HR − /HER2 − ) ( P  < 0.001). Median follow-up was 4.6 years. The 5-year LRR-free survival rate for all patients was 95.4 %. Five-year LRR-free survival rates by subtype were 97.2 % (HR + /HER2 − ), 96.1 % (HR + /HER2 + ), 94.4 % (HR − /HER2 + ), and 93.4 % (HR − /HER2 − ) ( P  = 0.44). For patients with HR − /HER2 + disease, the LRR-free survival rates were 97.4 and 86.7 % for those who did and those who did not experience pCR, respectively. For patients with HR − /HER2 − disease, the LRR-free survival rates were 98.6 % (pCR) versus 89.9 % (no pCR). On multivariate analysis, the HR − /HER2 − subtype, clinical stage III disease, and failure to experience a pCR were associated with LRR. Conclusions Patients undergoing BCT after neoadjuvant chemotherapy have excellent rates of 5-year LRR-free survival that are affected by molecular subtype and by response to neoadjuvant chemotherapy.

The distinction between pN1 and ≥pN2 breast cancer impacts treatment decisions. Using data from a single institution on women with cN0 invasive breast cancer who were treated with upfront surgery, had 1-3 positive SLNs, and underwent completion ALND, we used gradient boosted trees (XGBoost) to develop a model for predicting ≥pN2 disease using clinicopathologic variables. Model performance was tested in a held-out subsample (20%) and validated using data from the National Cancer Database (NCDB). Of 3574 patients with cN0 breast cancer, 587 underwent upfront surgery and had 1-3 positive SLNs. Of these, 415 (70.7%) underwent completion ALND, with 64 (15.4%) having ≥pN2 disease. The trained algorithm had an AUC of 0.87 (95% CI: 0.74, 0.97) in the held-out test data, and 0.78 (95% CI: 0.76, 0.79) in recent NCDB data where completion ALND was much less commonly performed. The number of positive SLNs and the total number of SLNs removed had the greatest influence on model predictions in the held-out test data. The developed model effectively estimates the probability of ≥pN2 disease in cN0 patients with positive SLNs, providing guidance for the management of patients with breast cancer.

Background No studies have examined the impact of the interval from conclusion of neoadjuvant chemotherapy to surgery in breast cancer patients. This study was undertaken to investigate the relationship between time interval from neoadjuvant chemotherapy to surgery and survival outcomes. Methods Breast cancer patients diagnosed with stage I–III disease who received neoadjuvant chemotherapy June 1995 to April 2007 were identified. The effect of neoadjuvant chemotherapy to surgery interval, defined as ≤4, 4–6, or >6 weeks, on survival outcomes was examined. Descriptive statistics and Cox proportional hazards models were used. Results A total of 1101 patients were identified. Median time to surgery was 33 (range 8–159) days; 335 patients (30.4 %) had surgery within 4 weeks of their last dose of neoadjuvant chemotherapy, 524 (47.6 %) within 4–6 weeks, and 242 (22.0 %) after more than 6 weeks. Median follow-up was 94 (range 3–178) months. The 5-year overall survival (OS) estimates were 79, 87, and 81 % in patients who underwent surgery ≤4, 4–6, and >6 weeks after neoadjuvant chemotherapy, respectively ( p  = 0.03). The three groups did not differ in 5-year recurrence-free survival (RFS) or locoregional recurrence-free survival (LRFS). In multivariable analysis, compared with an interval of ≤4 weeks, patients who underwent surgery at 4–6 or >6 weeks had equivalent OS, LRFS, and RFS; a sensitivity analysis suggested worse OS in patients who underwent surgery at >8 weeks. Conclusions Patients with neoadjuvant chemotherapy to surgery intervals of up to 8 weeks had equivalent OS, RFS, and LRFS.

Surgical management of the axilla in breast cancer has been a topic of great interest. While sentinel lymph node biopsy (SLNB) is an established approach for patients undergoing surgical treatment as the first element of their care, there is continued debate regarding surgical management of the axilla in patients receiving neoadjuvant chemotherapy (NAC). In clinically node-negative patients, it has been debated whether or not SLNB should be performed before chemotherapy to accurately determine the clinical stage, or after chemotherapy, thus prioritizing the response to therapy and potentially minimizing axillary surgery. Node-positive patients have undergone axillary lymph node dissection in the past, however this paradigm has been challenged in recent years. Thus, surgeons must understand the importance of accurate axillary information both before and after NAC, and its role in multidisciplinary planning. We present a summary of the data surrounding axillary management in patients receiving NAC, and recommendations for surgical technique.

Background The accuracy of sentinel lymph node dissection (SLND) in clinically node-positive patients who receive neoadjuvant chemotherapy has been investigated in clinical trials. This survey was designed to assess familiarity and impact of these trial findings into practice. Methods American Society of Breast Surgeons members were invited by e-mail to complete an anonymous online survey. A total of 642 members responded (21% of 3090 eligible members). Results were summarized as proportions based on the number of responses to each question. Results Respondents indicated knowledge of the Z1071 (86%), SENTINA (57%), and SN-FNAC (39%) trials. The published false negative rates (FNR) of the trials were correctly reported by 53% (336/638) of respondents. Before the trials, 45% (285/636) offered SLND compared with 85% (543/638) after the trials. In the 556 respondents who reported knowledge of at least one trial, 310 (56%) currently offer SLND to >50% of patients, 175 (31%) offer to <50%, and 70 (13%) routinely perform axillary lymph node dissection. Respondents who reported knowledge of the trials but did not change their practice to incorporate SLND ( n  = 67) cited concerns over lack of outcome data (64%), worries about FNR (42%), lack of resources (34%), or objections from radiation oncologists (25%), medical oncologists (18%), or other surgeons (8%). Conclusions The publication of trials evaluating SLND in clinically node-positive patients has resulted in changes in practice. Concerns over the FNR and lack of outcome data limit incorporation of SLND into practice by some surgeons.

Background Oncoplastic reconstruction is an approach that enables patients with locally advanced or adversely located tumors to undergo breast conserving surgery (BCS). The objectives were to identify the use of BCS with oncoplastic reconstruction (BCS + R) and determine the operative and oncologic outcomes compared with other breast surgical procedures for breast cancer. Methods This retrospective cohort study interrogated a single institution’s prospectively maintained databases to identify patients who underwent surgery for breast cancer between 2007 and 2014. Surgeries were categorized as BCS, BCS + R, total mastectomy (TM), or TM with immediate reconstruction (TM + R). Demographic and clinicopathologic characteristics and postoperative complications were analyzed. Results There were 10,607 operations performed for 9861 patients. Median follow-up was 3.4 years (range, 0–9.1 years). The use of BCS + R had a nearly fourfold increase in the percentage of all breast cancer surgeries during the study period; 75 % of patients who underwent BCS + R had a T1 or T2 tumor. There was no difference in the use of BCS + R compared with BCS for any quadrant of the breast except the lower outer quadrant (11.1 vs. 6.8 %; p  < .0001). BCS + R had a lower rate of seroma formation (13.4 vs. 18 %; p  = .002) and positive or close margins compared with BCS (5.8 vs. 8.3 %; p  = .04). There was no difference in overall survival or recurrence-free survival when comparing BCS and BCS + R. Conclusions Patients undergoing BCS + R are not disadvantaged in terms of complications and short-term (3-year) outcomes compared with BCS patients or patients who underwent TM.

BackgroundTargeted axillary dissection (TAD) involves locating and removing both clipped nodes and sentinel nodes for assessment of the axillary response to neoadjuvant chemotherapy (NAC) by clinically node-positive breast cancer patients. Initial reports described radioactive seeds used for localization, which makes the technique difficult to implement in some settings. This trial was performed to determine whether magnetic seeds can be used to locate clipped axillary lymph nodes for removal.MethodsThis prospective registry trial enrolled patients who had biopsy-proven node-positive disease with a clip placed in the node and treatment with NAC. A magnetic seed was placed under ultrasound guidance in the clipped node after NAC. All the patients underwent TAD.ResultsMagnetic seeds were placed in 50 patients by 17 breast radiologists. All the patients had successful seed placement at the first attempt (mean time for localization was 6.1 min; range 1–30 min). The final position of the magnetic seed was within the node (n = 44, 88%), in the cortex (n = 3, 6%), less than 3 mm from the node (n = 2, 4%), or by the clip when the node could not be adequately visualized (n = 1, 2%). The magnetic seed was retrieved at surgery from all the patients. In 49 (98%) of the 50 cases, the clip and magnetic seed were retrieved from the same node. Surgeons rated the transcutaneous and intraoperative localization as easy for 43 (86%) of the 50 cases. No device-related adverse events occurred.ConclusionsLocalization and selective removal of clipped nodes can be accomplished safely and effectively using magnetic seeds.

Background Residual disease after neoadjuvant chemotherapy (NAC) is prognostic and informs adjuvant treatment. Targeted axillary dissection (TAD) following NAC has low false-negative rates, facilitating accurate axillary staging. This study evaluates the clipped node status in axillary staging utilizing TAD. Methods Retrospective review identified cN1 breast cancer patients treated with NAC and TAD from July 2013 to June 2023. Nodal ultrasound and biopsy defined cN1 status. Patient, tumor, and treatment characteristics were compared based on clipped node status (sentinel lymph node [SLN] or non-SLN). Multivariate analysis of factors associated with the clipped node as a non-SLN was performed. Results A total of 680 patients underwent TAD, 94.6% with dual-tracer mapping. In three patients (0.4%), no SLN was identified. The clipped node was a SLN in 610 patients (90%) and non-SLN in 70 (10.3%). When the clipped node was a non-SLN, 42 (60%) were positive for metastasis. In 22 of 42 patients (52%), the clipped non-SLN was the only positive node. The clipped non-SLN cohort had a higher proportion with >3 suspicious nodes at presentation ( p = 0.003), fewer SLNs excised (mean 2.2 vs. 3.5, p ≤ 0.001), and fewer positive SLNs ( p ≤ 0.001). On multivariate analysis, > 3 suspicious nodes on ultrasound (odds ratio 3.0, p = 0.001) and tumor size at presentation (odds ratio 0.9, p = 0.02) were significantly associated with the clipped node as a non-SLN. Conclusions When the clipped node was a non-SLN, half of the time it was the only positive node and only residual disease on TAD. Given implications for adjuvant therapy, selective clipped node excision is recommended for precise identification of residual disease after NAC.

BackgroundThe SSO-ASTRO consensus guideline on invasive breast cancer defined negative margin as no ink on tumor, obviating the need for reexcision in some patients. We evaluated the impact of these recommendations on the rates of reexcision in older breast cancer patients undergoing breast-conserving surgery (BCS).Patients and MethodsWomen age ≥ 66 years with stage I–II breast cancer who underwent BCS and radiation were identified in the SEER-Medicare linked database (2012–2015). We divided patients into three cohorts: pre-guideline (January 2012 to September 2013), peri-guideline (October 2013 to March 2014), and post-guideline (April 2014 to September 2016). Descriptive statistics were used, and the relative change in reexcision rate between the pre- and post-guideline periods was calculated. Multivariable logistic regression was used to evaluate factors associated with risk of reexcision.ResultsA total of 11,639 patients were included (pre-guideline, N = 5211; peri-guideline, N = 1366; post-guideline, N = 5062); overall, 21.7% of patients underwent reexcision. The reexcision rates decreased after the guideline was published (23.5% vs. 19.3%, p < 0.001). In the multivariable model, BCS during the post-guideline period was associated with a statistically significant decreased risk of reexcision (RR = 0.84; 95% CI 0.78–0.90). Lobular histology was associated with a higher risk of reexcision (RR = 1.32; 95% CI 1.19–1.46), and greater surgeon volume was associated with lower risk of reexcision (RR = 0.92; 95% CI 0.85–1.0).ConclusionsAmong older breast cancer patients undergoing BCS for invasive cancer, reexcision rates decreased with the dissemination of the SSO-ASTRO consensus guideline. Identifying factors associated with higher rates of reexcision could improve guideline compliance and reduce the frequency of unnecessary interventions in older patients.