Patient reported outcomes following breast conserving surgery are improved by minimizing re-excisions and excessive breast tissue removal.

BACKGROUND: Patient reported outcomes (PRO's) are a valuable tool in obtaining the patients' perspective on the effectiveness of breast conservation surgery. Investigation has primarily been focused on patient and disease related factors impacting PRO's, with a limited focus on surgically modifiable factors. We investigate the impact that the volume of breast tissue removed, and performance of re-excisions have on PRO's. METHODS: Retrospective evaluation of the BREAST-Q (breast conservation module) in patients undergoing breast conserving surgery over a 3 year period. Multivariate analysis of patient, disease, and treatment related factors impacting PRO's. RESULTS: 163 patients completed the BREAST-Q. The median satisfaction with breast score was 67 (IQR, 48-88). Increasing volume of resected breast tissue was negatively associated with appearance of the breast (-0.05/cm3 (CI; -0.08 to -0.01)), as was the performance of re-excisions (-6.59 (CI; -14.73 - 0)). Physical well-being of chest was negatively associated with the volume of breast tissue removed (-0.05/cm3 (CI; -0.08 - 0)), but not re-excisions. Psychosocial well-being was negatively affected by the volume of tissue removed ((-0.04/cm3(CI; -0.07 - 0)), and re-excisions (-2.88 (CI; -10.96 - 0)). Patient body mass index, disease stage, receipt of Tamoxifen, as well as axillary lymph node dissection also impacted BREAST-Q domain scores. CONCLUSION: The removal of larger volumes of breast tissue and performance of re-excisions negatively impact patient quality of life and breast satisfaction following breast conserving surgery. Optimal patient reported outcomes are associated with accurate tumour removal, which minimizes re-excisions and the removal of normal breast tissue.

Close Margins Less Than 2 mm Are Not Associated With Higher Risks of 10-Year Local Recurrence and Breast Cancer Mortality Compared With Negative Margins in Women Treated With Breast-Conserving Therapy.

PURPOSE: The 2014 Society of Surgical Oncology-American Society for Radiation Oncology consensus suggested "no ink on tumor" is a sufficient surgical margin for invasive breast cancer treated with breast-conserving surgery (BCS). Whether close margins <2 mm are associated with inferior outcomes remains controversial. This study evaluated 10-year outcomes by margin status in a population-based cohort treated with BCS and adjuvant radiation therapy (RT). METHODS AND MATERIALS: The subjects were 10,863 women with invasive cancer categorized as pT1 to T3, any N, and M0 referred from 2001 to 2011, an era in which the institutional policy was to re-excise close or positive margins, except in select cases. All women underwent BCS and whole-breast RT with or without boost RT. Local recurrence (LR) and breast cancer-specific survival (BCSS) were examined using competing-risk analysis in cohorts with negative (≥2 mm; n = 9241, 85%), close (<2 mm; n = 1310, 12%), or positive (tumor touching ink; n = 312, 3%) margins. Multivariable analysis and matched-pair analysis were performed. RESULTS: The median follow-up period was 8 years. Systemic therapy was used in 87% of patients. Boost RT was used in 34.1%, 76.9%, and 79.5% of patients with negative, close, and positive margins, respectively. In the negative, close, and positive margin cohorts, the 10-year cumulative incidence of LR was 1.8%, 2.0%, and 1.1%, respectively (P = .759). Corresponding BCSS estimates were 93.9%, 91.8%, and 87.9%, respectively (P < .001). On multivariable analysis, close margins were not associated with increased LR (hazard ratio, 1.25; 95% confidence interval 0.79-1.97; P = .350) or reduced BCSS (hazard ratio, 1.25; 95% confidence interval 0.98-1.58, P = .071) relative to negative margins. On matched-pair analysis, close margin cases had similar LR (P = .114) and BCSS (P = .100) to negative margin controls. CONCLUSIONS: Select cases with close or positive margins in this population-based analysis had similar LR and BCSS to cases with negative margins. While these findings do not endorse omitting re-excision for all cases, the data support a policy of accepting carefully selected cases with close margins for adjuvant RT without re-excision.

Revisiting the "10% rule" in breast cancer sentinel lymph node biopsy: an approach to minimize the number of sentinel lymph nodes removed.

BACKGROUND: Sentinel lymph node (SLN) biopsy (SLNB) is an accurate and proven axillary staging procedure for early breast cancer. The aim of this study was to determine if the "10% rule" is applicable to the performance of SLNB at the investigators' institution and if the criteria used for SLNB at their institution could be refined to minimize the number of SLNs removed. METHODS: Retrospective analysis was conducted of a prospectively collected breast cancer SLNB database. Standard statistical methods were used for data analysis. RESULTS: Five hundred nine patients underwent a SLNB for breast cancer over a 5 year period. A mean of 2.5 SLNs were removed per patient. All patients with SLN metastasis were identified within the 1st 4 SLNs removed. CONCLUSIONS: The "10% rule" is best used as a guide at the investigators' institution. Strict adherence to this rule appears to result in the removal of an excessive number of lymph nodes, which may contribute to excessive health care costs and patient morbidity.

The cost-effectiveness of three strategies for the surgical treatment of symptomatic primary hyperparathyroidism.

INTRODUCTION: Modern surgical approaches to the treatment of primary hyperparathyroidism [unilateral neck exploration (UNE) and minimally invasive parathyroidectomy (MIP)] have become commonplace in recent years. However, the cost-effectiveness of these strategies has been questioned since the effectiveness of the gold standard, bilateral neck exploration (BNE), is well established. The objective of our study was to determine the incremental cost effectiveness of UNE and MIP compared with BNE for treatment of primary hyperparathyroidism (HPT). METHODS: Patients presenting to a tertiary endocrine surgical center for treatment of HPT over a 38-month period were included in the study. The primary measure of effectiveness was the rate of postoperative complications (hypocalcemia and paresthesias) observed in our cohort. A decision analytic model was constructed to determine the incremental cost-effectiveness ratios (ICERs) of the UNE and MIP strategies compared with the BNE strategy. Deterministic and probabilistic sensitivity analyses were conducted to evaluate uncertainty around model-based estimates of costs and effectiveness. RESULTS: A total of 94 patients (56 BNEs, 19 UNEs, and 19 MIPs) provided estimates of mean costs (BNE = $4524, UNE = $4784, MIP = $4961) and success rates (BNE = 0.91, UNE = 0.86, MIP = 0.93) for each treatment arm. The gold standard BNE strategy dominated the UNE strategy (lower cost, higher effectiveness) under most model formulations. The MIP strategy had an ICER of $28,439 per complication avoided, which is likely to be above societal willingness to pay to avoid primarily minor postoperative complications. CONCLUSION: Our results suggest that within our institution, and in several different model formulations, bilateral neck exploration remains the cost-effective strategy for the treatment of primary hyperparathyroidism.

Normocalcemic parathyroid carcinoma: an unusual clinical presentation.

BACKGROUND: Parathyroid carcinoma is a rare cause of primary hyperparathyroidism and may be associated with significant disease related morbidity and mortality. Preoperative diagnosis remains a challenge, which may jeopardize appropriate and successful patient treatment. CASE PRESENTATION: We report a case of parathyroid carcinoma diagnosed in a 60-year-old woman that presented with a tender nodule located at the left lower thyroid pole and had been present for several years. Ultrasound examination revealed a 2.7 x 1.6 x 2.7 cm mass within the lower left lobe of the thyroid with cystic and solid areas. Lab measurement of the intact PTH level revealed it to be three times the upper limit of normal and the serum calcium level was within normal limits. A left thyroid lobectomy and isthmusectomy was carried out. Histopathological evaluation was diagnostic for a parathyroid carcinoma. At greater than two years of follow-up, the patient has had no evidence of disease recurrence and her serum PTH and calcium levels have remained within normal. CONCLUSION: Parathyroid carcinoma is a rare endocrine tumor which must be considered in the differential diagnosis of a nodular thyroid mass. En bloc resection remains the treatment of choice for this malignancy. Disease prognosis is influenced by the extent of the initial resection, the presence of metastases, and adequate long-term follow-up.