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1.
Br J Surg ; 107(12): 1615-1624, 2020 11.
Article in English | MEDLINE | ID: mdl-32492194

ABSTRACT

BACKGROUND: The aim of this study was to determine preoperative factors and tumour characteristics related to a high nodal tumour burden in patients with clinically node-positive breast cancer. These findings were used to construct a predictive tool to evaluate the patient-specific risk of having more than two axillary lymph node metastases. METHODS: Altogether, 507 consecutive patients with breast cancer and axillary lymph node metastasis diagnosed by preoperative ultrasound-guided needle biopsy were reviewed. These patients underwent breast surgery and axillary lymph node dissection at Helsinki University Hospital between 2010 and 2014. Patients were grouped into those with one or two, and those with more than two lymph node metastases. RESULTS: There were 153 patients (30·2 per cent) with one or two lymph node metastases and 354 (69·8 per cent) with more than two metastases. Five-year disease-free survival was poorer for the latter group (P = 0·032). Five-year overall survival estimates for patients with one or two and those with more than two lymph node metastases were 87·0 and 81·4 per cent respectively (P = 0·215). In multivariable analysis, factors significantly associated with more than two lymph node metastases were: age, tumour size, lymphovascular invasion in the primary tumour, extracapsular extension of metastasis in lymph nodes, and morphology of lymph nodes. These factors were included in a multivariable predictive model, which had an area under the curve of 0·828 (95 per cent c.i. 0·787 to 0·869). CONCLUSION: The present study provides a patient-specific prediction model for evaluating nodal tumour burden in patients with clinically node-positive breast cancer.


Subject(s)
Breast Neoplasms/pathology , Lymphatic Metastasis/pathology , Adult , Aged , Aged, 80 and over , Axilla , Biopsy, Needle , Breast Neoplasms/mortality , Breast Neoplasms/surgery , Female , Humans , Lymph Node Excision , Lymph Nodes/pathology , Lymphatic Metastasis/diagnosis , Middle Aged , Retrospective Studies , Risk Factors , Survival Analysis , Young Adult
2.
Eur J Surg Oncol ; 43(4): 658-664, 2017 Apr.
Article in English | MEDLINE | ID: mdl-28040314

ABSTRACT

BACKGROUND: Recent studies implicate that oncoplastic breast cancer surgery provides better aesthetic outcome than conventional resection. Several factors have been associated with poor aesthetic outcome. This study aims to compare patient-reported aesthetic and functional outcome after conventional and oncoplastic resection and to evaluate prognostic factors for poor aesthetic outcome in a population-based setting. METHODS: 637 patients having breast conserving treatment (BCT) due to unilateral primary breast cancer at a single hospital district during 2010 were included. Aesthetic and functional outcome were evaluated using two questionnaires three years after surgery. RESULTS: Questionnaires were returned by 379 (59%) patients; 293 (77%) of these had conventional and 86 (23%) oncoplastic resection. Patients in oncoplastic resection group had larger tumour diameter (p < 0.001), larger resection specimens (p < 0.001), and more often multifocal tumours (p = 0.032), node positive cancer (p = 0.029) and lower quadrant tumour localization (p = 0.007). Aesthetic outcome according to BCTOS questionnaire was good in 284 (75%) patients; 52 (61%) patients in the oncoplastic group and 230 patients (81%) in the conventional resection group, p < 0.001. Larger tumour diameter (p = 0.033), multifocality (p = 0.022), weight of resection specimen (<0.001) and oncoplastic surgery (p < 0.001) were predicting poor aesthetic outcome, when all patients were included. Tumour multifocality (p = 0.013) remained predictor of poor aesthetic outcome in conventional resection group but not in oncoplastic resection group. CONCLUSIONS: Patient satisfaction to aesthetic outcome after BCT is high. Conventional resection provides good aesthetic outcome in appropriately selected patients. Oncoplastic resection enables BCT in patients with larger and multifocal tumours with favourable aesthetic outcome.


Subject(s)
Breast Neoplasms/surgery , Carcinoma, Intraductal, Noninfiltrating/surgery , Carcinoma, Lobular/surgery , Carcinoma, Pancreatic Ductal/surgery , Mammaplasty/methods , Mastectomy, Segmental/methods , Patient Satisfaction , Adult , Aged , Aged, 80 and over , Breast Neoplasms/pathology , Carcinoma, Intraductal, Noninfiltrating/pathology , Carcinoma, Lobular/pathology , Carcinoma, Pancreatic Ductal/pathology , Case-Control Studies , Esthetics , Female , Humans , Middle Aged , Neoplasm Staging , Retrospective Studies , Surveys and Questionnaires , Tumor Burden
3.
Scand J Surg ; 105(1): 29-34, 2016 Mar.
Article in English | MEDLINE | ID: mdl-25922474

ABSTRACT

BACKGROUND AND AIMS: The aim of this study was to analyze feasibility of day surgery in breast cancer patients with breast conserving surgery and sentinel node biopsy. MATERIAL AND METHODS: The study was a randomized controlled trial comparing day surgery with one night hospital stay in breast cancer patients with breast conserving surgery and sentinel node biopsy. A total of 40 patients with ⩽3-cm tumor and clinically N0 were randomized to one night stay group and 38 patients to day surgery group. Within discharge, patients and their relatives were given questionnaires in order to evaluate their experience regarding the duration of hospital stay. RESULTS: Randomized groups were similar regarding patient age and tumor stage. A total of 18 (47%) day surgery group patients were discharged the same day. The most common reason for overnight hospital stay was axillary clearance, 9 (24%). None of the patients in the day surgery group, but 2 patients in the overnight hospital stay group had re-operation due to complications. Perception and preference results were analyzed both according to randomization and actual treatment groups. Patients in both groups had rather similar experiences on the first postoperative day. Also, spouse's or relative's perception after discharge was similar in both groups. CONCLUSION: Day surgery was well received by the patients and their relatives. Day surgery appears as feasible in patients with breast conservation and sentinel node biopsy.


Subject(s)
Ambulatory Surgical Procedures , Breast Neoplasms/surgery , Mastectomy, Segmental/methods , Sentinel Lymph Node Biopsy , Adult , Aged , Breast Neoplasms/pathology , Feasibility Studies , Female , Humans , Middle Aged , Neoplasm Staging , Patient Safety , Patient Satisfaction , Treatment Outcome
4.
Ann Surg Oncol ; 21(7): 2229-36, 2014 Jul.
Article in English | MEDLINE | ID: mdl-24664623

ABSTRACT

BACKGROUND: Sentinel node biopsy (SNB) is the "gold standard" in axillary staging in clinically node-negative breast cancer patients. However, axillary treatment is undergoing a paradigm shift and studies are being conducted on whether SNB may be omitted in low-risk patients. The purpose of this study was to evaluate the risk factors for axillary metastases in breast cancer patients with negative preoperative axillary ultrasound. METHODS: A total of 1,395 consecutive patients with invasive breast cancer and SNB formed the original patient series. A univariate analysis was conducted to assess risk factors for axillary metastases. Binary logistic regression analysis was conducted to form a predictive model based on the risk factors. The predictive model was first validated internally in a patient series of 566 further patients and then externally in a patient series of 2,463 patients from four other centers. All statistical tests were two-sided. RESULTS: A total of 426 of the 1,395 (30.5 %) patients in the original patient series had axillary lymph node metastases. Histological size (P < 0.001), multifocality (P < 0.001), lymphovascular invasion (P < 0.001), and palpability of the primary tumor (P < 0.001) were included in the predictive model. Internal validation of the model produced an area under the receiver operating characteristics curve (AUC) of 0.731 and external validation an AUC of 0.79. CONCLUSIONS: We present a predictive model to assess the patient-specific probability of axillary lymph node metastases in patients with clinically node-negative breast cancer. The model performs well in internal and external validation. The model needs to be validated in each center before application to clinical use.


Subject(s)
Breast Neoplasms/pathology , Carcinoma, Ductal, Breast/secondary , Carcinoma, Lobular/secondary , Lymph Nodes/pathology , Axilla , Breast Neoplasms/diagnostic imaging , Carcinoma, Ductal, Breast/diagnostic imaging , Carcinoma, Lobular/diagnostic imaging , Female , Follow-Up Studies , Humans , Lymph Nodes/diagnostic imaging , Lymphatic Metastasis , Middle Aged , Neoplasm Grading , Neoplasm Staging , Predictive Value of Tests , Prospective Studies , ROC Curve , Risk Factors , Sentinel Lymph Node Biopsy , Ultrasonography
5.
Eur J Surg Oncol ; 40(4): 435-41, 2014 Apr.
Article in English | MEDLINE | ID: mdl-24534362

ABSTRACT

BACKGROUND: We cross-validated three existing models for the prediction of non-sentinel node metastases in patients with micrometastases or isolated tumor cells (ITC) in the sentinel node, developed in Danish and Finnish cohorts of breast cancer patients, to find the best model to identify patients who might benefit from further axillary treatment. MATERIAL AND METHOD: Based on 484 Finnish breast cancer patients with micrometastases or ITC in sentinel node a model has been developed for the prediction of non-sentinel node metastases. Likewise, two separate models have been developed in 1577 Danish patients with micrometastases and 304 Danish patients with ITC, respectively. The models were cross-validated in the opposite cohort. RESULTS: The Danish model for micrometatases was accurate when tested in the Finnish cohort, with a slight change in AUC from 0.64 to 0.63. The AUC of the Finnish model decreased from 0.68 to 0.58 when tested in the Danish cohort, and the AUC of the Danish model for ITC decreased from 0.73 to 0.52, when tested in the Finnish cohort. The Danish micrometastatic model identified 14-22% of the patients as high-risk patients with over 30% risk of non-sentinel node metastases while less than 1% was identified by the Finish model. In contrast, the Finish model predicted a much larger proportion of patients being in the low-risk group with less than 10% risk of non-sentinel node metastases. CONCLUSION: The Danish model for micrometastases worked well in predicting high risk of non-sentinel node metastases and was accurate under external validation.


Subject(s)
Breast Neoplasms/pathology , Breast Neoplasms/surgery , Lymph Node Excision , Lymph Nodes/pathology , Lymph Nodes/surgery , Models, Statistical , Neoplasm Micrometastasis/diagnosis , Adult , Aged , Area Under Curve , Carcinoma, Ductal, Breast/pathology , Carcinoma, Ductal, Breast/surgery , Carcinoma, Lobular/pathology , Carcinoma, Lobular/surgery , Denmark , Female , Finland , Humans , Lymphatic Metastasis , Middle Aged , Neoplasm Grading , Neoplasm Staging , Predictive Value of Tests , Risk Assessment , Risk Factors , Sentinel Lymph Node Biopsy
6.
Ann Surg Oncol ; 19(7): 2345-51, 2012 Jul.
Article in English | MEDLINE | ID: mdl-22395995

ABSTRACT

BACKGROUND: In sentinel node biopsy (SNB), tumor-positive findings, mainly micrometastases and isolated tumor cells (ITC) have been found in up to 8%-16% of patients with pure ductal carcinoma in situ (DCIS) or microinvasive DCIS (DCISM). The prognostic significance of such findings is largely unknown. The aim of this study is to examine the outcome of DCIS and DCISM patients with SNB. METHODS: A total of 280 breast cancer patients with pure or microinvasive DCIS underwent SNB between April 2001 and December 2010 at the Breast Surgery Unit of Helsinki University Central Hospital. Patient, tumor, SNB procedure, and follow-up data were gathered. The median follow-up was 50 months (range 7-123 months). RESULTS: Altogether, 21 patients had tumor-positive sentinel node findings. Of these, 14 were in pure DCIS patients (1 macrometastasis, 1 micrometastasis, 12 ITC) and 7 in DCISM patients (1 macrometastasis, 2 micrometastases, 4 ITC). Also, 16 patients, 10 with pure DCIS and 6 with DCISM, underwent completion axillary lymph node dissection (ALND). Only 1 of them, a patient with DCISM, had additional tumor positive finding in the ALND. During a median follow-up of 50 months (range 7-123 months) there were 5 local recurrences. One patient with pure DCIS and tumor-negative SNB developed overt axillary metastases and later also distant metastases. CONCLUSIONS: DCIS and DCISM patients do have tumor positive findings, but a majority of these are ITC or micrometastases. In light of this study, these findings do not affect the outcome of DCIS or DCISM patients.


Subject(s)
Breast Neoplasms/pathology , Carcinoma, Intraductal, Noninfiltrating/secondary , Neoplasm Recurrence, Local/diagnosis , Sentinel Lymph Node Biopsy , Adult , Aged , Aged, 80 and over , Axilla , Breast Neoplasms/surgery , Carcinoma, Intraductal, Noninfiltrating/surgery , Female , Follow-Up Studies , Humans , Lymph Node Excision , Lymphatic Metastasis , Mastectomy , Middle Aged , Neoplasm Micrometastasis , Neoplasm Staging , Prognosis , Prospective Studies , Risk Factors
7.
Ann Surg Oncol ; 19(2): 567-76, 2012 Feb.
Article in English | MEDLINE | ID: mdl-21792511

ABSTRACT

BACKGROUND: Tumor-positive sentinel node biopsy (SNB) suggests a risk of nonsentinel node metastases in breast cancer. This risk is lower after micrometastasis or isolated tumor cells (ITC) in the sentinel node (SN), and recent studies suggest that completion axillary lymph node dissection (ALND) might not improve outcome in these patients. We aim to validate existing predictive models and to develop a new model for micrometastatic and ITC patients. METHODS: A series of 484 patients with micrometastases or ITC in SN followed by ALND was used to evaluate factors affecting nonsentinel node involvement. Logistic regression analysis was performed to construct a predictive model, which was validated by a separate series of 51 patients. RESULTS: Only 7.2% of patients had additional metastases on completion ALND. Tumor diameter and multifocality associated with nonsentinel status on multivariate analysis. A predictive model was constructed showing good [area under the curve (AUC) 0.791] discrimination in the validation series. Previously published models performed poorly in our patient population. CONCLUSIONS: Nonsentinel node metastases are rare with micrometastasis or ITC in SN. Most published predictive models for nonsentinel node involvement perform poorly in the present patient population. We developed a new predictive model which seems to perform well in discriminating patients with more than 10% risk of additional metastases. However, the presented nomogram needs to be validated with an independent patient series to evaluate its accuracy, especially for high-risk patients.


Subject(s)
Breast Neoplasms/pathology , Carcinoma, Ductal, Breast/pathology , Carcinoma, Lobular/pathology , Lymph Nodes/pathology , Neoplasm Micrometastasis/pathology , Nomograms , Sentinel Lymph Node Biopsy , Adult , Aged , Aged, 80 and over , Breast Neoplasms/surgery , Carcinoma, Ductal, Breast/surgery , Carcinoma, Lobular/surgery , Female , Follow-Up Studies , Humans , Lymph Node Excision , Lymph Nodes/surgery , Lymphatic Metastasis , Middle Aged , Neoplasm Staging , Prognosis , Prospective Studies
8.
Surg Oncol ; 21(2): 59-65, 2012 Jun.
Article in English | MEDLINE | ID: mdl-22197294

ABSTRACT

Sentinel lymph node (SN) biopsy offers the possibility of selective axillary treatment for breast cancer patients, but there are only limited means for the selective treatment of SN-positive patients. Eight predictive models assessing the risk of non-SN involvement in patients with SN metastasis were tested in a multi-institutional setting. Data of 200 consecutive patients with metastatic SNs and axillary lymph node dissection from each of the 5 participating centres were entered into the selected non-SN metastasis predictive tools. There were significant differences between centres in the distribution of most parameters used in the predictive models, including tumour size, type, grade, oestrogen receptor positivity, rate of lymphovascular invasion, proportion of micrometastatic cases and the presence of extracapsular extension of SN metastasis. There were also significant differences in the proportion of cases classified as having low risk of non-SN metastasis. Despite these differences, there were practically no such differences in the sensitivities, specificities and false reassurance rates of the predictive tools. Each predictive tool used in clinical practice for patient and physician decision on further axillary treatment of SN-positive patients may require individual institutional validation; such validation may reveal different predictive tools to be the best in different institutions.


Subject(s)
Breast Neoplasms/pathology , Lymph Node Excision/methods , Lymph Nodes/pathology , Aged , Breast Neoplasms/surgery , Female , Humans , Lymphatic Metastasis , Middle Aged , Predictive Value of Tests , Retrospective Studies , Sentinel Lymph Node Biopsy
9.
Ann Surg Oncol ; 17(6): 1669-74, 2010 Jun.
Article in English | MEDLINE | ID: mdl-20151214

ABSTRACT

AIM: To investigate whether skin-sparing mastectomy (SSM) and immediate breast reconstruction (IBR) is a possible treatment option in selected cases of locally recurrent breast cancer after previous breast-conserving therapy (BCT). MATERIAL AND METHODS: Sixty consecutive patients were treated by SSM and IBR between 1995 and 2008 for ipsilateral breast tumour recurrence (IBTR). Selection criteria consisted of: IBTR <3 cm size, not infiltrating skin or chest wall, primarily node negative, recurrence >3 years after primary operation, and no metastases. Patient records were analysed retrospectively and follow-up data on patient outcome included. RESULTS: The reconstruction method consisted of 40 free abdominal flaps, 18 latissimus dorsi (LD) flaps with or without an implant, and two cases of implant only. Twenty-three patients received adjuvant oncological therapy. During median follow-up of 66 months, 11 patients (18%) developed disease relapse, including 6 (10%) local re-recurrences. CONCLUSION: IBR is a possible treatment option for patients who develop local recurrence following earlier BCT. Our local re-recurrence rate of 10% compares well with that following salvage mastectomy for IBTR. Of patients, 43% did not actually meet our selection criteria but yet appeared to fare well in terms of outcome. Therefore we should re-evaluate our selection criteria.


Subject(s)
Breast Neoplasms/surgery , Mammaplasty/methods , Mastectomy, Subcutaneous , Neoplasm Recurrence, Local/surgery , Surgical Flaps , Adult , Breast Neoplasms/pathology , Breast Neoplasms/therapy , Combined Modality Therapy , Female , Follow-Up Studies , Humans , Mastectomy, Subcutaneous/methods , Middle Aged , Neoplasm Recurrence, Local/diagnosis , Retrospective Studies , Treatment Outcome
10.
Br J Surg ; 94(10): 1220-5, 2007 Oct.
Article in English | MEDLINE | ID: mdl-17579346

ABSTRACT

BACKGROUND: Skin-sparing mastectomy (SSM) facilitates optimal immediate breast reconstruction (IBR) by preserving the inframammary fold and most of the breast skin. Concerns persist that SSM might increase the rate of local recurrence as the surgical approach is less extensive. Patients who had SSM and IBR over 10 years at a single institution were reviewed. METHODS: A total of 207 consecutive women who underwent SSM and IBR from 1992 to 2001 were included in the study. The patient records were analysed retrospectively and follow-up data were included. RESULTS: Postoperative complications included native skin flap necrosis (10.1 per cent), haematoma (10.6 per cent), infection (3.4 per cent), anastomotic thrombosis (5.3 per cent) and hernia (2.6 per cent). During a mean follow-up of 70 months, 5.8 per cent of patients with stage 0-2 disease developed a locoregional recurrence, although none of these later had a systemic recurrence. The rate of locoregional recurrence was 31 per cent (five of 16) in women with stage 3 breast cancer. CONCLUSION: SSM followed by IBR was both surgically and oncologically safe, especially for early-stage breast cancer.


Subject(s)
Breast Neoplasms/surgery , Carcinoma in Situ/surgery , Carcinoma, Ductal, Breast/surgery , Mammaplasty/methods , Mastectomy/methods , Adult , Aged , Breast Neoplasms/radiotherapy , Carcinoma in Situ/radiotherapy , Carcinoma, Ductal, Breast/radiotherapy , Female , Humans , Middle Aged , Neoplasm Recurrence, Local/surgery , Postoperative Complications/etiology , Radiotherapy, Adjuvant , Retrospective Studies , Surgical Flaps
11.
Eur J Surg Oncol ; 33(10): 1142-5, 2007 Dec.
Article in English | MEDLINE | ID: mdl-17490847

ABSTRACT

AIMS: Since the introduction of skin-sparing mastectomy (SSM) in 1991 concerns on local control and recurrence rates have been discussed in the literature. The aim of this study is to examine in particular incidence of local recurrence in a 15-year consecutive series of breast cancer patients having undergone SSM and immediate breast reconstruction (IBR) at a single population-based institution. METHODS: One hundred and forty-six consecutive patients with either stage 1 or 2 breast cancer who underwent SSM followed by IBR from 1992 to 2006 were included in this study. A retrospective review of patient records was conducted. RESULTS: During a mean follow-up time of 51 months, four local recurrences of the native breast skin were accounted for. In addition, three regional lymph node recurrences and four systemic recurrences took place. All of the local and regional recurrences were handled by salvage surgery followed by adjuvant oncological therapies. During a mean follow-up of 35 months after the detection and treatment of the locoregional recurrences none of the patients developed new recurrences. CONCLUSIONS: Our present study concludes that SSM followed by IBR seems oncologically sound procedure for stage 1 and 2 breast cancer patients. In addition, local recurrences and regional lymph node recurrences are not always associated with systemic relapse.


Subject(s)
Breast Neoplasms/surgery , Neoplasm Recurrence, Local/therapy , Adult , Aged , Breast Neoplasms/pathology , Breast Neoplasms/therapy , Female , Follow-Up Studies , Humans , Mammaplasty , Mastectomy , Middle Aged , Neoplasm Staging , Postoperative Period , Retrospective Studies
12.
Eur J Surg Oncol ; 33(10): 1146-9, 2007 Dec.
Article in English | MEDLINE | ID: mdl-17462851

ABSTRACT

AIMS: False negative cases in the intraoperative assessment of sentinel node (SN) metastases in breast cancer prompt for a secondary axillary lymph node dissection (ALND). Such ALND is technically demanding and prone to complications in patients with immediate breast reconstruction (IBR) if there is a microvascular anastomosis or the thoracodorsal pedicle of a latissimus dorsi flap in the axilla. This study aims to evaluate the feasibility of the intraoperative diagnosis of sentinel node biopsy (SNB) in breast cancer patients undergoing IBR. METHODS: Sixty-two consecutive breast cancer patients undergoing SNB with the intraoperative diagnosis of SN metastases simultaneously with mastectomy and IBR between 2004 and 2006 were included in this study. Results of the SNB and especially the false negative cases in the intraoperative diagnosis were evaluated. RESULTS: Eleven patients had tumor positive SN. Nine of these cases were detected intraoperatively. The two false negative cases in the intraoperative diagnosis constituted of isolated tumor cells only. CONCLUSIONS: Our present study suggests that SNB with intraoperative diagnosis of SN metastases is feasible in patients undergoing IBR if the risk of nodal metastasis is low and the sensitivity of intraoperative SNB diagnosis is high.


Subject(s)
Breast Neoplasms/pathology , Breast Neoplasms/surgery , Sentinel Lymph Node Biopsy , Adult , Aged , Axilla , False Negative Reactions , Feasibility Studies , Female , Humans , Intraoperative Period , Lymph Node Excision , Lymphatic Metastasis , Mammaplasty , Mastectomy , Middle Aged , Neoplasm Staging , Sensitivity and Specificity
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