Chest wall perforator flap partial breast reconstruction: a retrospective analysis of surgical, cosmetic and survival outcome.

Introduction: Oncoplastic breast surgery includes volume replacement as well as volume displacement. Autologous tissue is the preferred approach for volume replacement and includes chest wall perforator flaps (CWPF). Although described more than a decade ago, CWPFs have not been adopted widely in clinical practice till recently. We report the largest single-centre institutional data on CWPFs. Patients and methods: The study includes all patients who underwent breast conservation surgery (BCS) using CWPFs from January 2015 to December 2022. Data were retrieved from the institutional electronic record and Redcap database. The analysis was done using SPSS 23 and STATA 14. Results: 150 patients were included in the study. The mean age was 48.8 years (SD 10.4), and the body mass index was (26.6 kg/m2, SD 4.3). >50% of patients had breasts with small cup sizes (A&B) and mild ptosis (Non-ptotic and Grade 1 ptosis). 44.7% of patients underwent lateral intercostal artery perforator flap (LICAP), anterior intercostal artery perforator flap in 31.3%, lateral thoracic perforator flap (LTAP) in 12%, LICAP + LTAP in 11.3% and thoracodorsal artery perforator flap in 1%. Post-operatively, haematoma was seen in 1.3%, complete flap necrosis in 1.3%, seroma in 7%, wound dehiscence in 12%, and positive margin in 6.7%. 92 patients responded to the satisfaction assessment, of which >90% were happy with the surgical scars, comfortable going out in a public place, satisfied with the symmetry of the breast, and no one chose mastectomy in hindsight. The 5-year predicted disease free survival and overall survival were 86.4% and 94.7%, respectively. Conclusion: BCS with CWPF is an excellent option for reconstruction in small to medium-sized breasts. It is associated with minimal morbidity and comparable patient-reported cosmetic and survival outcomes.

Oncologic safety of breast conservation following NACT in women with locally advanced breast cancer.

Introduction: Breast conservation surgery (BCS) is the accepted standard of treatment for early breast cancer, with evidence from randomized controlled and population-based studies. The oncological outcome of BCS in locally advanced breast cancer (LABC) is mainly available from retrospective series with a small sample size and a shorter follow-up duration. Methods: A retrospective observational study of 411 non-metastatic LABC patients who received neoadjuvant chemotherapy (NACT) followed by surgery from 2011 to 2016. We retrieved the data from a prospectively maintained database and electronic medical records. Survival data were analyzed by Kaplan-Meier curves and Cox regression using Statistical Package for the Social Sciences 25 and STATA 14. Results: 146/411 (35.5%) women had BCS with a margin positivity rate of 3.42%. With a median follow-up of 64 months (IQR 61, 66), the local relapse rate was 8.9% in BCS and 8.3% after mastectomy. The estimated 5-year locoregional recurrence-free survival (LRFS), recurrence-free survival (RFS), distant disease-free survival (DDFS) and overall survival (OS) rates of BCS were 86.9%, 63.9%, 71% and 79.3%, and 90.1%, 57.9%, 58.3% and 71.5% in the mastectomy group. On univariate analysis, BCS showed superior survival outcomes compared to mastectomy (unadjusted HR (95% CI) for RFS: 0.70 (0.50-1), DDFS: 0.57 (0.39-0.84), OS: 0.58 (0.36-0.93)). After adjusting for age, cT stage, cN stage, poorer chemotherapy response (ypT0/is, N0) and radiotherapy, BCS and mastectomy groups were found comparable in terms of LRFS (HR: 1.1, 0.53-2.3), DDFS (HR: 0.67, 0.45-1.01), RFS (HR: 0.80, 0.55-1.17) and OS (HR: 0.69, 0.41-1.14). Conclusion: BCS is technically feasible in LABC patients. LABC patients who respond well to NACT can be offered BCS without compromising survival outcomes.

Teaching breast cancer surgery in India: challenges and opportunities.

Breast cancer (BC) incidence is increasing in India, and we need well-trained breast surgeons to deliver quality care to patients. However, BC surgery training in India is highly variable, evolving slowly and needs to be structured urgently. This article summarises the challenges and way forward for BC surgery training in India.

Diagnostic performance and survival outcome following sentinel lymph node biopsy in breast cancer patients from a tertiary cancer centre in India.

Background: Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) for axillary staging in early node-negative breast cancer (BC) patients in developed countries. However, in resource-constrained developing countries, adoption of SLNB is slow due to logistic issues and lack of outcome data from non-screened BC cohort. Therefore, we aim to report diagnostic performance, surgical morbidity and survival outcome of SLNB in BC patients from a tertiary care cancer centre in India. Methodology: 1,521 consecutive early node-negative T1-3N0 BC patients having SLNB from 2011 to 2020 were included in the study. Data were retrieved from the institutional Redcap database and electronic medical records. Analysis was done using Stata14. Results: SLNB was done by dual dye (methylene blue (MB) + radioisotope (RI)/indo cyanine green (ICG)) in 57.7%, MB only in 39.3%, and RI alone in 3% of patients. The identification rate (IR) and SLNB positivity rate were 96% and 27.7%, respectively. IR was highest (98%) with MB + ICG and lowest (94%) with MB alone SLNB. UltraSonoGraphy guided fine needle aspiration cytology of radiological suspicious nodes has significantly reduced the SLNB positivity rate from 34.6% to 26.4% (p < 0.01). One patient had skin necrosis, and 16 had persistent blue staining of the skin in the MB injection site. All were managed conservatively. The lymphedema rate was significantly higher (5.2%) in the ALND versus 0.5% in the SLNB alone patients (p < 0.05). In a median follow up of 27 months, the axillary recurrence rate was 0.04% (4/1,023), and false-negative rate was 0.9% in SLNB negative patients. There were 35 recurrences and 25 deaths in SLNB negative patients, with 10 years predicted disease-free survival of 81% (95% CI 66% to 89%) and overall survival of 79% (95% CI 59% to 90%). Conclusions: SLNB should be offered as an axillary staging procedure to all eligible BC patients from developing countries to avoid the morbidity associated with ALND. Fluorescent dye can be used as an alternative for RI in a resource-constrained setup.

Assessment of skin response in T4b breast carcinoma patients post-neoadjuvant chemotherapy.

BACKGROUND: Breast cancer patients with skin ulcerations, satellite nodules or Peau d'orange at presentation are classified with stage 4 breast cancer (T4b). Neoadjuvant chemotherapy (NACT), followed by mastectomy, is the commonly accepted treatment in such patients for fear of adverse outcomes with breast conservation surgery (BCS) and uncertainty over sparing initially involved skin irrespective of the response to chemotherapy. Identifying patients with skin resolution post-NACT can help surgeons in decision-making. AIM: To assess skin response in T4b breast cancer patients post-NACT and find the correlation between various clinical and pathological factors associated with no skin involvement on final histology. METHODOLOGY: Records of breast cancer patients managed at the Tata Medical Center, Kolkata, with NACT for T4b breast carcinoma patients who underwent mastectomy were reviewed between January 2014 and December 2018. Final histology was checked for dermal involvement with the tumour. The Mann-Whitney U test was used for continuous variables for descriptive data, and Pearson's chi-squared and Fischer's exact tests were applied for categorical data. p-value < 0.05 was taken as significant. RESULTS: A total of 285 records mentioning skin involvement were reviewed, out of which 111 patients fulfilled the AJCC criterion. The median age at diagnosis of T4b breast cancer was 50 years. The median clinical size pre-chemotherapy was 7 cm. Residual median tumour size on final histology was reported as 1 cm. 78/111 patients showed a post-NACT response of 50% or more, and 43/111 showed a response of more than 90%. 57 (51.4%) patients showed skin involvement on final histopathology, while 54 (48.6%) patients did not.ER negative tumours were more likely to show no dermal involvement (p = 0.006). Residual tumour size of less than 1 cm on final histology (p < 0.05) and nodal stage were significant predictors of dermal response. CONCLUSION: Approximately half of the T4b breast cancer patients showed resolution of dermal skin involvement post-NACT. ER negative and those with residual tumour size less than 1 cm post-NACT are more likely to show dermal resolution. This can help surgeons plan a BCS or skin sparing mastectomy for such patients who usually end up having a mastectomy.

Trends in Axillary Management of Early Breast Cancer: a Questionnaire-Based Pattern of Practice Survey for India.

Surgical management of breast cancer (BC) has evolved from radical surgeries to conservative with better cosmetic and comparable oncological outcomes. For axillary staging, it has evolved from axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB). No detailed information exists in terms of the clinical practice pattern of surgical management of axilla for BC patients in India. A questionnaire-based survey was developed. The survey was done at the annual meeting of the Association of Breast Surgeons of India (ABSI) in November 2018. Responses were recorded and analysed by SPSS 23. One hundred twelve out of 400 (28%) responded to the survey. Half of the respondents were surgical oncologist and 36.6% were performing > 150 BC surgeries/year. The primary technique for axillary staging in node-negative BC was SLNB for 68.5% of respondents. Majority of surgeons (47%) reported performing SLNB by methylene blue dye only. Unavailability of radioisotope (46.7%) and lack of frozen section (26.7%) were reported as two major barriers for not performing SLNB. Twenty-three percent did perform SLNB in post-NACT setting. Only 15.8% have omitted completion ALND in Z0011 trial eligible SLN-positive patients. 45.9% skipped completion ALND in SLN positive with micro metastasis only. Many surgeons in India are adopting SLNB as a method of axillary staging into their clinical practice. However, large number of surgeons still believe in conservative approach, most probably due to unavailability of resources and lack of Indian data. Barrier identified in this survey may be useful for future development.

Reliability of Ki67 visual scoring app compared to eyeball estimate and digital image analysis and its prognostic significance in hormone receptor-positive breast cancer.

We analysed the reproducibility of Ki67 labelling index (LI) between two scorers using the International Ki67 Working Group (IKWG) global methods on an Android application (APP), correlated the APP and eyeball estimate (EBE) with digital image analysis (DIA) scores and determined the prognostic significance of Ki67LI. Global weighted (GW) and global unweighted (GUW) Ki67 app scores of hormone receptor-positive and HER2 (human epidermal growth factor receptor 2)-negative breast cancer patients were obtained. Reproducibility of Ki67LI between 2 scorers and correlation of APP and EBE scores with DIA scores were performed. The prognostic significance of APP scores and its correlation with other clinico-pathologic variables were evaluated. The intra-class correlation coefficient (ICC) between 2 scorers showed excellent reliability with both GW and GUW methods. ICC between DIA and APP scores was significantly greater than DIA versus EBE. The three categories of APP scores based on median value and cut points of 10%, 18% and 38% were significantly associated with poor DFS. On multivariate analysis, significant association between Ki67LI, tumour size, nodal involvement and DFS was noted. Our study shows that the visual Ki67 scoring app is effective in bringing consistency to KI67LI and APP scores showed significant correlation with DFS.

Effect of non-sentinel metastasis on adjuvant treatment decisions and survival in Z0011 eligible non-screened detected breast cancer population.

BACKGROUND: The Z0011 trial results have shown that axillary lymph node dissection (ALND) can be avoided in cT1-2 patients undergoing breast conservation surgery with 1-2 metastatic sentinel lymph nodes (SLNs). We compared the clinicopathological characteristics of the Z0011 eligible non-screen detected breast cancer patients' cohort with the Z0011 trial study population. Additionally, we have explored the effect of non-sentinel metastasis on adjuvant treatment decisions and survival. METHODS: The details of early breast cancer (EBC) patients fulfilling Z0011 eligibility criteria were retrieved from a prospectively maintained database (2013-2017) and electronic medical records. We used Statistical Package for the Social Sciences 25 and Stata V15 for the data analysis. RESULTS: 128/194 (66%) sentinel lymph node biopsy positive patients had fulfilled the Z0011 inclusion criteria. Compared to the Z0011 study, our cohort patients were younger, with more aggressive disease (higher T2, Grade 3), had a higher rate of macrometastasis (82.8% versus 58.8%) and non-SLN metastasis (48% versus 27%). The information gained by ALND had changed decisions for chemotherapy in 3% and no change of radiotherapy in Z0011 eligible patients. Further nodal positivity in completion ALND was not significantly associated with overall survival (p = 0.86) and disease-free survival (p = 0.5). CONCLUSION: Z0011 eligible Indian EBC patients are significantly different from the Z0011 study population, with younger age of presentation, higher grade, a higher rate of both SLN macro metastasis and non-SLN positivity. The impact of non-sentinel metastasis on adjuvant treatment decisions and survival is minimal.

Chest wall perforator flaps in partial breast reconstruction after breast conservation surgery: an additional oncoplastic surgical option.

Partial breast reconstruction using chest wall perforator flaps (CWPF) is a recent option used by breast surgeons, mainly for lateral quadrant defects with a relatively large volume of excision. We report a single-centre experience of CWPF with surgery details, complications, re-excision, aesthetic and oncological outcomes. This was a prospective observational cohort study of patients who had undergone breast conservation surgery (BCS) plus CWPF reconstruction. All variables were recorded prospectively in the institutional database. A survey was done to analyse patient satisfaction at about 6 months after completion of radiotherapy. Forty patients had CWPF based reconstruction in 3 years. 57.5 % of patients had lateral intercostal artery perforator (LICAP) flap, 5% had lateral thoracic artery perforator (LTAP) flap, 27.5% had combined LICAP plus LTAP and 10% patients had anterior intercostal artery perforator (AICAP) flap. Tumour excision cavity defect was of the lateral quadrant in 82.5%, central quadrant in 10% and medial quadrant in 7.5% of patients. The margin was positive for five patients, out of which four required cavity shave and one had a mastectomy. One patient had complete flap loss, and two patients developed surgical site infection. 96% of patients were satisfied with the scar, and 88% were happy with the treated breast in comparison to the opposite breast. 92% were comfortable going out in public and felt that in retrospect their decision not to have a mastectomy was correct. With a median follow up of 18 (10, 22) months, one patient died, and four had recurrences. CWPF may be used for partial breast reconstruction in the small non-ptotic breast with excellent outcome and high patient satisfaction scores.

Diagnostic Performance of Indocyanine Green Plus Methylene Blue Versus Radioisotope Plus Methylene Blue Dye Method for Sentinel Lymph Node Biopsy in Node-Negative Early Breast Cancer.

PURPOSE: Sentinel lymph node biopsy (SLNB) by dual-dye method (radioisotope plus blue) is the gold standard for axillary staging in patients with breast cancer, but in developing countries, logistic issues and financial constraint play a vital role. Recently, indocyanine green (ICG) has emerged as an alternative to radioisotope (technetium-99 [Tc-99]) for SLNB in breast cancer. This study compared the diagnostic performance of Tc-99 plus methylene blue (MB) dye versus ICG + MB dye SLNB. METHODS: Two hundred seven patients with early breast cancer (T1-3N0) were included in the study from 2017 to 2019. SLNB was done either with Tc-99 + MB or with ICG + MB as per availability of radioisotope. SLN identification rate (IR), SLN positivity rate, and metastatic SLN counts were compared between the 2 groups. RESULTS: IR was 199 (96%) of 207. IR was 95% in Tc-99 + MB compared with 97% with ICG + MB. The mean number of SLNs identified were 3.17 (standard deviation [SD], 1.84), with > 1 SLN identified in 87% patients by Tc-99 + MB. SLN was positive in 31.3% of patients with a metastatic SLN count of 0.37 (SD, 0.76). With ICG + MB, the number of SLNs was 2.73 (SD, 1.55), with > 1 SLN identified in 79% of patients. Twenty-eight percent of patients had positive SLNs, with a metastatic SLN count of 0.41 (SD, 0.77). A sharp decline in the availability of Tc-99 was observed, with 58% of patients in 2014 and only 12% of patients in 2018. CONCLUSION: ICG is equivalent to Tc-99 for SLNB in early breast cancer and has a good potential to be adopted by surgeons in resource-constrained setups.

Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study.

Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population.

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population: sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as standard of care for management of early breast cancer. This study assessed our SLNB program against 11 published quality indicators (QIs). All breast cancer patients who underwent SLNB in our centre from June 2013-Dec 2015 were included. Clinical, pathological and follow-up data were extracted from the institutional REDCap data system. Analysis was done with SPSS 23. Following validation, 234 patients had SLNB, always performed along with primary surgery. Identification rate was 95.3% and > 1 SLN was identified in 72% of patients. SLNB positivity was 33%, of these, 100% underwent ALND. Overall 91% of QI eligible patients underwent SLNB. No ineligible patients (T4) underwent SLNB. For the patients who had radio colloid, injection criteria were met for 100%. Pathological evaluation and reporting criteria were met for 100% of patients. There were no axillary recurrences in a median follow-up of 2 years. 7.6% patients had SLN negative on frozen section but positive on final histology. 7.2% of patients with clinical negative nodes had pN2 disease in final histopathology report after surgery. Sixty percent of patients who had completion ALND had only positive SLN. This study supports the applicability of published QI of SLNB in a non-screened cohort of early breast cancer patients. Although QI were useful, modification based on patient characteristics and resource availability may be needed. These indicators can be used as audit tools to improve the overall accuracy of the procedure.

Stigma Perceived by Women Following Surgery for Breast Cancer.

CONTEXT: Women undergoing treatment for breast cancer often have psychological morbidity and body image difficulties. The risk factors for increased levels of stigma in women with breast cancer have not been adequately studied. AIMS: This study aimed at investigating the associations of high levels of stigma in women with breast cancer. SETTINGS AND DESIGN: This cross-sectional study was conducted in a comprehensive cancer center in India and recruited women (n = 134) undergoing surgical treatment for breast cancer. METHODS: Body image difficulties, including stigma and affective symptoms, were quantified, alongside disease- and treatment-related variables using standardized questionnaires. STATISTICAL ANALYSIS USED: Univariate analysis followed by multivariate logistic regression was performed to find the risk factors of high levels of stigma related to body image. RESULTS: In the univariate analysis, high levels of stigma were associated with lesser educational attainment (odds ratio [OR] =2.92, confidence interval [CI] 1.25-6.8, P = 0.01), breast conservation surgery (BCS) as opposed to mastectomy (OR = 4.78, CI 2.07-11.03, P < 0.001), having an anxiety disorder (OR = 2.4, CI 1.09-5.33, P = 0.03), and depression (OR = 3.08, CI 1.37-6.89, P < 0.01). On multivariate logistic regression, with stigma as the dependent variable, being less educated (adjusted OR [AOR] 3.08, CI 1.18-8.04, P = 0.02) and opting for BCS (AOR 6.12, CI 2.41-15.5, P < 0.001) were associated with higher stigma. CONCLUSIONS: Women with breast cancer should be screened for distress and stigma. Women opting for BCS may still have unmet emotional needs on completion of surgery and should have access to psychological interventions to address stigma, affective symptoms, and body image problems.