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Clean surgical margins in breast‐conserving surgery (BCS) are essential for preventing recurrence. Intraoperative pathologic diagnostic methods, such as frozen section analysis and imprint cytology, have been recognized as crucial tools in BCS. However, the complexity and time‐consuming nature of these pathologic procedures still inhibit their broader applicability worldwide. To address this situation, two issues should be considered: 1) the development of nonpathologic intraoperative diagnosis methods that have better sensitivity, specificity, speed, and cost; and 2) the promotion of new imaging algorithms to standardize data for analyzing positive margins, as represented by artificial intelligence (AI), without the need for judgment by well‐trained pathologists. Researchers have attempted to develop new methods or techniques; several have recently emerged for real‐time intraoperative management of breast margins in live tissues. These methods include conventional imaging, spectroscopy, tomography, magnetic resonance imaging, microscopy, fluorescent probes, and multimodal imaging techniques. This work summarizes the traditional pathologic and newly developed techniques and discusses the advantages and disadvantages of each method. Taking into consideration the recent advances in analyzing pathologic data from breast cancer tissue with AI, the combined use of new technologies with AI algorithms is proposed, and future directions for real‐time intraoperative margin assessment in BCS are discussed. Clean surgical margins in breast‐conserving surgery (BCS) are essential for preventing recurrence and repeat surgery. This work describes the advantages and disadvantages of conventional pathologic and newly developed techniques. Future directions and prospectives in real‐time intraoperative margin assessment in BCS as well as recent advances in deep learning and artificial intelligence algorithms are discussed.

Background Patients with left-sided breast cancer have an increased risk of cardiovascular disease (CVD) after radiotherapy (RT). While the awareness of cardiac toxicity has increased enormously over the last decade, the role of individual baseline cardiac risks has not yet been systematically investigated. Aim of the present study was to evaluate the impact of baseline CVD risks on radiation-induced cardiac toxicity. Methods Two hundred ten patients with left-sided breast cancer treated in the prospective Save-Heart Study using a deep inspiration breath-hold (DIBH) technique were analysed regarding baseline risk factors for CVD. Three frequently used prediction tools (Procam, Framingham and Reynolds score) were applied to evaluate the individual CVD risk profiles. Moreover, 10-year CVD excess absolute risks (EAR) were estimated using the individual mean heart dose (MHD) of treatment plans in free breathing (FB) and DIBH. Results The individual baseline CVD risk factors had a strong impact on the 10-year cumulative CVD risk. The mean baseline risks of the non-diabetic cohort ( n  = 200) ranged from 3.11 to 3.58%, depending on the risk estimation tool. A large number of the non-diabetic patients had a very low 10-year CVD baseline risk of ≤1%; nevertheless, 8–9% of patients reached ≥10% baseline 10-year CVD risk. In contrast, diabetic patients ( n  = 10) had significantly higher baseline CVD risks (range: 11.76–24.23%). The mean 10-year cumulative risk (Framingham score) following RT was 3.73% using the DIBH-technique (MHD:1.42Gy) and 3.94% in FB (MHD:2.33Gy), after adding a 10-year-EAR of + 0.34%(DIBH) and + 0.55%(FB) to the baseline risks, respectively. Smoking status was one of the most important and modifiable baseline risk factors. After DIBH-RT, the 182 non-smoking patients had a mean 10-year cumulative risk of 3.55% (3.20% baseline risk, 0.35% EAR) as compared to 6.07% (5.60% baseline risk, 0.47% EAR) for the 28 smokers. Conclusion In the present study, all CVD prediction tools showed comparable results and could easily be integrated into daily clinical practice. A systematic evaluation and screening helps to identify high-risk patients who may benefit from primary prevention. This could result in an even higher benefit than from heart-sparing irradiation techniques alone.

Purpose Oncoplastic breast-conserving surgery (OBCS) prevents compromise of breast aesthetics following large breast cancer excisions. This systematic review was conducted to investigate the outcomes (oncologic, surgical, cosmetic) of OBCS versus standard breast-conserving surgery (SBCS) and mastectomy post-neo-adjuvant systemic therapy. Methods Ovid, Web of Science, Cochrane, ClinicalTrials.gov databases were searched up to 24/08/2024. English language peer-reviewed RCTs or observational/cohort studies with ≥ 18-year-old women treated for breast cancer with neoadjuvant chemotherapy (NACT) and/or hormonal therapy comparing OBCS to SBCS and/or mastectomy were included. Of 6794 articles, 32 underwent full-text assessment and eleven met the inclusion criteria. The review was conducted using PRISMA guidelines. Two reviewers independently extracted data and assessed risk of bias (Newcastle-Ottowa Scale). Meta-analysis using a random-effects model were performed where data allowed. Results Eleven cohort studies (n = 4594) included OBCS (n = 912), SBCS (n = 1122) and mastectomy (n = 2560) after NACT. Post-NACT tumour size was 20(9–44) mm, 13(0–23)mm [SMD 0.62, 95%CI(−0.24,1.48), p = 0.16] and 20(10–31)mm [SMD 0.05, 95%CI(−0.53,0.63), p = 0.86] in the OBCS, SBCS and mastectomy groups respectively. The margin re-excision rate was significantly lower in OBCS than in SBCS [2.9%(0–11.1%) vs. 6.1%(0–18.5%); OR 0.35, 95%CI(0.15,0.80), p = 0.01]. All other oncologic outcomes, including positive margin rate, and overall survival, were not statistically different between the groups. Cosmetic outcomes and patient-reported outcome measures were marginally in favour of OBCS [OBCS 50–66% vs SBCS 37.6–55% very satisfied]. Conclusion OBCS after NACT appears oncologically safe and a potential alternative in patients with partial or poor tumour response to NACT. Further studies are required, directly comparing well-matched OBCS with SBCS and mastectomy patients after NACT.

The long‐term survival benefit of neoadjuvant therapy (NAT) in breast cancer patients eligible for breast‐conserving surgery (BCS) remains uncertain. This retrospective cohort study analyzed 94,677 BCS‐eligible patients from the SEER database (2010–2020), including 8565 who received NAT. After propensity score matching (n = 5734 each), NAT significantly improved overall survival (OS) only in patients with triple‐negative (HR = 0.79), ER‐negative (HR = 0.80), and stage IIA (HR = 0.81) disease. No OS benefit was observed in HER2‐positive patients despite high response rates. To guide treatment decisions, two machine learning models using Random Survival Forest were developed to predict 5‐year OS, showing good discrimination (C‐index: 0.743 for BCS, 0.690 for NAT‐BCS). SHAP analysis identified age, stage, and breast subtype as key prognostic factors. Cross‐stratification based on predicted OS revealed that 8.9% of BCS patients could benefit from NAT, while 90.8% of NAT‐BCS patients might safely omit it. Patients whose treatment matched model recommendations had significantly better survival. These findings suggest that NAT provides limited survival benefit in BCS‐eligible patients, with the advantage concentrated in specific subgroups. Predictive modeling offers a clinically useful approach to personalize NAT use, potentially reducing unnecessary treatment while identifying those most likely to benefit. The survival benefit of neoadjuvant therapy (NAT) for breast‐conserving surgery (BCS)‐eligible patients remains unclear. We identified NAT‐responsive subgroups (triple‐negative, ER‐negative, stage IIA) and developed machine learning models predicting 5‐year survival. Cross‐stratification revealed 8.9% of BCS patients may benefit from adding NAT, while 90.8% of NAT‐BCS patients could avoid it. These tools enable personalized NAT decisions, reducing overtreatment in low‐risk patients while targeting therapy to high‐risk groups

Breast-conserving surgery plus postoperative radiotherapy is the standard surgical treatment mode for early breast cancer. Currently, there are no clear predictive indicators to determine whether a patient can choose breast-conserving surgery, which mainly depends on the surgeon's clinical experience and subjective judgment. Cone-beam breast computed tomography (CBBCT) reconstructs the breast 3D image from three mutually perpendicular angles, helping surgeons to locate and accurately measure the volume of the tumor, mammary gland, and breast. We used CBBCT to retrospectively measure the tumor-to-gland volume ratio and tumor-to-breast volume ratio in breast cancer cases. Then, we analyzed the correlation between the surgical methods and ratios in breast cancer patients. We collected 100 patients undergoing breast-conserving surgery as the study group, and 100 patients undergoing mastectomy as the control group. All patients chose the surgical approach after comprehensive consideration of examination results and assessment of patient condition. Patients underwent CBBCT examination before surgery. We retrospectively measured the volume of tumor, mammary glands and breast, then calculated tumor-to-gland and tumor-to-breast volume ratios. Tumor volume and the ratios of the two groups statistically differed (P < 0.001), while the mammary gland and breast volume did not (P > 0.05). The average tumor-to-gland volume ratio was 4.32% in the study group and 10.74% in the control group, and the average tumor-to-breast volume ratio was 0.74% in the study group and 1.36% in the control group. In breast-conserving surgery, the 95% reference range of tumor-to-gland ratio is (0, 12.90%), and the 95% reference range of tumor-to-breast ratio is (0, 2.17%). The tumor-to-gland volume ratio and tumor-to-breast volume ratio measured using CBBCT are correlated with the choice of surgical methods (breast-conserving surgery or mastectomy) for breast cancer patients. This can be used as possible predictor of breast-conserving surgery to help surgeons.

Neoadjuvant therapy is integral to the treatment of early-stage breast cancer. Goals of treatment include surgical downstaging of the tumor, rendering inoperable tumors resectable, and de-escalating axillary surgery in those with clinically positive nodes. Additionally, response to treatment provides important prognostic information regarding risk of recurrence and guides future adjuvant treatment. Although chemotherapy serves as the backbone of neoadjuvant treatment, an increased understanding of the tumor's clinical course as well as its molecular and genetic make-up aids in individualizing treatment and developing novel agents. This review summarizes current clinical approaches and the future direction to the management of breast cancer patients in the neoadjuvant setting.

Clean operating margins in breast cancer surgery are important for preventing recurrence. However, the current methods for determining margins such as intraoperative frozen section analysis or imprint cytology are not satisfactory since they are time‐consuming and cause a burden on the patient and on hospitals with a limited accuracy. A “click‐to‐sense” probe is developed based on the detection of acrolein, which is a substance released by oxidatively stressed cancer cells and can be visualized under fluorescence microscopy. Using live breast tissues resected from breast cancer patients, it is demonstrated that this method can quickly, selectively, and sensitively differentiate cancer lesion from normal breast gland or benign proliferative lesions. Since acrolein is accumulated in all types of cancers, this method could be used to quickly assess the surgical margins in other types of cancer. A “click‐to‐sense” acrolein probe allows the diagnosis of cancer morphology with high sensitivity and selectivity. The cancer lesion can be discriminated from normal breast gland by simply treating the live tissues from cancer patients with the “click‐to‐sense” acrolein probe.

Breast cancer is one of the leading causes of cancer globally. Radiotherapy following breast-conserving surgery is the standard treatment of breast cancer. Recently, hypofractionated irradiation comprising 42.56 Gy in 16 fractions was selected as a viable radiation therapeutic option. Radiation-induced sarcoma is the most prevalent secondary malignancy in patients undergoing radiotherapy after breast cancer surgery. Angiosarcomas are the predominant type of radiation-induced sarcomas, whereas liposarcomas have rarely been reported. The present report details an uncommon instance of radiation-induced pleomorphic liposarcoma that occurred 8 years after breast-conserving surgery and hypofractionated radiotherapy. The patient visited the hospital due to hardening of the tissue beneath the skin of the right breast. Ultrasonography revealed a hypoechoic mass in the lower part of the right breast containing internal blood flow. An excisional biopsy revealed that the tumor contained infiltrating spindle-shaped cells without a capsule containing pleomorphic cells. Lipoblasts were also observed and tended to differentiate into adipose tissue, leading to a diagnosis of pleomorphic liposarcoma. Immunostaining revealed negativity for cytokeratin AE1/AE3, ERG, MDM2 and S-100 protein; the Ki-67 index was ~20%. An enlargement resection involving a postoperative bed was performed because of close tumor margins. 18F-fluorodeoxyglucose positron emission tomography/computed tomography revealed pale accumulation of 18F-fluorodeoxyglucose in the right chest wall, which was interpreted as a postoperative change owing to the resection biopsy. The tumor was observed in the irradiated field with no distant metastases. Following extensive resection, the patient maintained a recurrence-free survival period of 3 years and 2 months, during which no adjuvant therapy was administered. Therefore, follow-up is necessary in patients with breast cancer treated with radiotherapy.

Purpose The objective of this study was retrospectively to compare the efficacy and safety of hypofractionated radiotherapy (HFRT) with a simultaneous integrated boost (SIB) or with a sequential boost (SB) after breast‐conserving surgery in patients diagnosed with early breast cancer. Methods This study enrolled a total of 343 patients diagnosed with T1‐2N0‐1 breast cancer who had undergone breast‐conserving surgery followed by whole‐breast irradiation (WBI) without nodal irradiation, between March 2018 and April 2021. Out of 343 patients, 176 (51.3%) received HFRT‐SIB treatment, totaling 15 sessions, while the remaining 167 (48.7%) received HFRT‐SB treatment, totaling 18 sessions. Demographic characteristics, skin toxicity, radiation pneumonia, and myelosuppression, were compared in the two groups. Three‐year local progression free survival (LPFS) rates were determined using the Kaplan–Meier method and compared using the log‐rank test. Results The median follow‐up time was 39.7 months (range 24.3–61.3 months). Toxicities rates did not differ significantly in the HFRT‐SIB and HFRT‐SB groups, including rates of grade 2 skin toxicity (14.8% vs. 13.8%, p = 0.721), Grade 2 radiation pneumonia (2.8% vs. 3.6%, p = 0.355), grades 1, 2 and 3 myelosuppression (12.5%, 5.7% and 1.1%, respectively, vs. 9.6%, 7.8%, and 1.2%, respectively; p = 0.744). Three‐year cumulative LPFS rates were similar in the HFRT‐SIB and HFRT‐SB groups (99.3% vs. 98.6%, p = 0.52). Regional nodal recurrences were observed in one patient in the HFRT‐SIB group (after 27.4 months) and in two patients in the HFRT‐SB group (after 29.4 and 56.4 months), and a local recurrence was observed in one patient in the latter group after 36.0 months. One patient in the HFRT‐SIB group was diagnosed with distant metastases to bone, and one patient in the HFRT‐SB group was diagnosed with distant metastases to the liver. Conclusion Similar efficacy and safety of HFRT‐SIB and HFRT‐SB after breast‐conserving surgery in patients with early‐stage (T1‐2N0‐1) breast cancer. Longer‐term follow‐up is required to further compare their efficacy.

Background At present, there is no research on which surgical method can lead to a better prognosis in elderly patients with early breast cancer. The purpose of this study was to establish a nomogram to predict the survival outcome of elderly patients with early breast cancer and to compare the prognosis of the breast‐conserving surgery (BCS) group who did not receive postoperative radiotherapy and the mastectomy group through risk stratification. Methods This study included patients with early breast cancer aged ≥70 years from the Surveillance, Epidemiology, and End Results database (n = 20,520). The group was randomly divided into a development cohort (n = 14,363) and a validation cohort (n = 6157) according to a ratio of 7:3. Risk factors affecting overall survival (OS) and breast‐cancer‐specific survival (BCSS) were analyzed using univariate and multivariate Cox regression. Present results were obtained by constructing nomograms and risk stratifications. Nomograms were evaluated by the concordance index and calibration curve. Kaplan–Meier curves were established based on BCSS and analyzed using the log‐rank test. Results Multivariate Cox regression results showed that age, race, pathological grade, T and N stages, and progesterone receptor (PR) status were independent risk factors for OS and BCSS in the BCS group and mastectomy group. Subsequently, they were incorporated into nomograms to predict 3‐ and 5‐year OS and BCSS in patients after BCS and mastectomy. The concordance index was between 0.704 and 0.832, and the nomograms also showed good calibration. The results of risk stratification showed that there was no survival difference between the BCS group and the mastectomy group in the low‐risk and high‐risk groups. In the middle‐risk group, BCS improved the BCSS of patients to a certain extent. Conclusion This study constructed a well‐performing nomogram and risk stratification model to assess the survival benefit of BCS without postoperative radiotherapy in elderly patients with early breast cancer. The results of the study can help clinicians analyze the prognosis of patients and the benefits of surgical methods individually.