ABSTRACT
BACKGROUND: Oncotype Dx (ODx) is a genomic assay which estimates the risk of distant recurrence and predicts adjuvant chemotherapy benefit in early stage breast cancer patients. Most ODx data is derived from excisional specimens. AIM: We assess the utility of ODx on core needle biopsies (CNB) and measure its impact on neoadjuvant treatment decisions, particularly in patients with clinically complicated situations. METHODS: Consecutive ODx results on breast CNBs with invasive carcinoma from 2012-2020 at 3 tertiary care hospitals with dedicated Breast Health Centers were reviewed. Clinical indications to perform ODx on CNB were recorded through a review of patients' electronic medical records. Clinicopathologic features, surgical or oncologic modalities and follow-up data were recorded. RESULTS: Three distinct clinical indications for performing ODx on CNB in 85 ER+ invasive breast carcinomas were identified: 1) Excisions with insufficient tissue to perform ODx, 2) adjudicate neoadjuvant therapy versus primary surgical resection, and 3) select neoadjuvant chemotherapy (NAC) versus neoadjuvant endocrine therapy (NET). Primary surgery was selected in patients with low score RS (<18), and NET was preferred in patients with intermediate or high RS (>18). NET was preferred over NAC in patients with low RS (<18). CONCLUSION: This study shows that CNB ODx RS helps guide treatment decisions in a neoadjuvant setting along with other contributing factors such as the presence of pathogenic mutations, node positivity, patient age, and comorbidities. The use of ODx on CNB is furthermore valuable in the midst of the COVID-19 pandemic for early breast cancer patients to administer effective therapy in a timely manner.
Subject(s)
Breast Neoplasms, Male/diagnosis , Breast Neoplasms/diagnosis , Carcinoma, Ductal, Breast/diagnosis , Neoplasm Recurrence, Local , Adult , Aged , Aged, 80 and over , Biomarkers, Tumor/genetics , Biopsy, Large-Core Needle , Breast Neoplasms/pathology , Breast Neoplasms, Male/pathology , Carcinoma , Carcinoma, Ductal, Breast/pathology , Combined Modality Therapy , Electronic Health Records , Female , Gene Expression Profiling/methods , Genomics , Hormones/therapeutic use , Humans , Male , Medical Oncology , Middle Aged , Neoadjuvant Therapy , Neoplasm Invasiveness , Retrospective Studies , Treatment OutcomeABSTRACT
At the onset of the COVID-19 crisis, a 63-year-old woman with multiple life-limiting comorbidities was referred with a necrotic infected left breast mass on a background of breast cancer treated with conservation surgery and radiotherapy 22 years previously. The clinical diagnosis was locally advanced breast cancer, but four separate biopsies were non-diagnostic. Deteriorating renal function and incipient sepsis and endocarditis resulted in urgent salvage mastectomy during the peak of the COVID19 pandemic. The final diagnosis was infected ischaemic/infarcted breast (wet gangrene) secondary to vascular insufficiency related to diabetes, cardiac revascularisation surgery and breast radiotherapy.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Breast/surgery , Diabetic Angiopathies/therapy , Enterobacteriaceae Infections/therapy , Gangrene/therapy , Mastectomy/methods , Mastitis/therapy , Negative-Pressure Wound Therapy/methods , Breast/blood supply , Breast Neoplasms/diagnosis , COVID-19 , Carcinoma, Ductal, Breast/diagnosis , Coronary Artery Bypass , Debridement/methods , Diabetes Mellitus, Type 2/complications , Diabetic Angiopathies/diagnosis , Diabetic Angiopathies/etiology , Diagnosis, Differential , Enterobacteriaceae Infections/diagnosis , Female , Gangrene/diagnosis , Humans , Infarction , Mammary Arteries/surgery , Mastectomy, Segmental , Mastitis/diagnosis , Middle Aged , Morganella morganii , Neoplasm Recurrence, Local/diagnosis , Radiotherapy , SARS-CoV-2 , Salvage TherapyABSTRACT
BACKGROUND: During the COVID-19 pandemic, surgical delays have been common for patients with ductal carcinoma in situ (DCIS) and early-stage estrogen receptor-positive (ER+) breast cancer, often in favor of neoadjuvant endocrine therapy (NET). To understand possible ramifications of these delays, we examined the association between time to operation and pathologic staging and overall survival (OS). STUDY DESIGN: Patients with DCIS or ER+ cT1-2N0 breast cancer treated from 2010 through 2016 were identified in the National Cancer Database. Time to operation was recorded. Factors associated with pathologic upstaging were examined using logistic regression analyses. Cox proportional hazard models were used to analyze OS. Analyses were stratified by disease stage and initial treatment strategy. RESULTS: There were 378,839 patients identified. Among those undergoing primary surgical procedure, time to operation was within 120 days in > 98% in all groups. Among cT1-2N0 patients selected for NET, operations were performed within 120 days in 59.6% of cT1N0 and 30.9% of cT2N0 patients. Increased time to operation was associated with increased odds of pathologic upstaging in DCIS patients (ER+: 60 to 120 days: odds ratio 1.15; 95% CI, 1.08 to 1.22; more than 120 days: odds ratio 1.44; 95% CI, 1.24 to 1.68; ER-: 60 to 120 days: NS; more than 120 days: odds ratio 1.36; 95% CI, 1.01 to 1.82; 60 days or less: reference), but not in patients with invasive cancer, irrespective of initial treatment strategy. No difference in OS was seen by time to operation in DCIS or NET patients. CONCLUSIONS: Increased time to operation was associated with a small increase in pathologic upstaging in DCIS patients, but did not impact OS. In patients with cT1-2N0 disease, NET use did not impact stage or OS, supporting the safety of delay strategies in ER+ breast cancer patients during the pandemic.