Recurrence rates for patients with early-stage breast cancer treated with IOERT at a community hospital per the ASTRO consensus statement for APBI.

PURPOSE: To report the recurrence rates after single-fraction intraoperative electron radiotherapy (IOERT) in patients with early-stage breast cancer treated on a single institution prospective Phase I/II protocol at a community hospital. Results were retrospectively analyzed according to suitability criteria from the updated American Society for Radiation Oncology (ASTRO) consensus statement for accelerated partial breast irradiation (APBI). METHODS AND MATERIALS: Patients over 40 years with early-stage invasive or in situ breast cancer (<2.5 cm and node negative) were enrolled. IOERT 2100 cGy was delivered during breast conservation surgery, and patients were followed up for a median of 3 years (0.8-6.5 years) to determine toxicity and recurrence rates. RESULTS: Single-fraction IOERT was performed in 215 cases (6 bilateral treatments, 196 patients) with 13 patients receiving whole-breast radiation (WBR) after IOERT for adverse pathologic features. Of 202 cases of IOERT without WBR, 89 patients experienced an ipsilateral breast tumor recurrence (IBTR) giving a cumulative incidence of 3.96%. When the ASTRO APBI suitability criteria were applied, the IBTR rate was significantly lower for suitable patients vs. cautionary or unsuitable patients (1.6% vs. 3.4% vs. 21.0%, p = 0.0002). 3-year progression-free survival after IOERT alone was 93.4%. For patients who received standard WBR (4500-5040 cGy) after IOERT, no Grade 3 or 4 toxicities (acute or late) occurred and all patients are disease-free. CONCLUSIONS: Single-fraction IOERT results in a low rate of IBTR when strictly adhering to ASTRO criteria for APBI suitability. Standard dose WBR for unfavorable pathologic results after 2100 cGy IOERT is well tolerated.

Percutaneous Sentinel Node Biopsy in Breast Cancer: Results of a Phase 1 Study.

BACKGROUND: While sentinel lymph node dissection (SLND) provides axillary staging, recent trials question the necessity of removing positive nonsentinel axillary lymph nodes (LN) in breast cancer. We sought to determine the technical feasibility of percutaneous core needle biopsy (PNB) of axillary sentinel lymph nodes (SLNs). METHODS: After dual tracer injection, 25 patients underwent intraoperative axillary ultrasound and ultrasound guided per PNB of the axillary LN at the site of radiotracer uptake, followed by standard SLND. The primary outcome measure was successful correlation of PNB with SLN, defined as: (1) similar final pathology in core and SLN and (2) presence of blue staining and/or radiotracer in the core or gross evidence of PNB at the SLN (e.g., transected SLN). RESULTS: Preincision axillary ultrasound identified a LN (mean size 1.15 ± 0.67 cm) at the site of radioactive tracer in 92 % (23 of 25) of cases. Gross evidence of PNB at the SLN was found in 76 % (19 of 25) of cases. Blue staining, radioisotope, and pathology matched in core and SLN specimens in 36 % (9 of 25), 64 % (16 of 25), and 72 % (18 of 25) of cases, respectively. Overall, successful correlation of core biopsy with SLN occurred in 72 % (18 of 25) of cases. CONCLUSIONS: Results of this phase I study demonstrate that PNB of the SLN is technically feasible, but further refinement of technique is warranted to improve correlation of core biopsy to SLND.

Evidence-based medicine: Abdominoplasty.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Develop a surgical plan for improving the contour of the abdominal region by means of abdominoplasty surgery. (2) Describe the current modalities for preventing and managing perioperative pain associated with abdominoplasty surgery. (3) Discuss proper techniques for safely performing simultaneous abdominal wall liposuction and abdominoplasty surgery. (4) Determine the means of decreasing seroma formation and drain duration in abdominoplasty patients. (5) Apply current concepts in preventing and minimizing perioperative complications in abdominoplasty patients. SUMMARY: Abdominoplasty continues to be one of the most popular cosmetic surgeries performed by plastic surgeons throughout the world. Advancements in the area continue to surface which can help improve outcomes. We present an extensive review of the most current literature on this topic. This article offers readers an up-to-date and organized approach to abdominoplasty surgery.

When is a lymph node dissection a lymph node dissection? The number of lymph nodes resected in sentinel and axillary lymph node dissections.

PURPOSE: We sought to compare the number of lymph nodes (LN) resected in axillary lymph node dissections (ALND) and sentinel lymph node dissections (SLND), and to assess the validity of registry reporting for axillary staging in breast cancer. METHODS: Women in the California Cancer Registry who underwent surgical axillary staging for T1/T2, M0 breast cancer between 2004 and 2008 were evaluated. The number of LN resected in patients reported as having SLND+ALND and ALND were assessed for compliance with 6 and 10 LN threshold definitions for ALND. The proportion of patients with ≤3 LN removed was assessed for patients receiving SLND only. RESULTS: Of 71,907 patients, 45.5 % had SLND, 24.0 %, SLND+ALND, and 30.5 %, ALND. The median number of LN resected with SLND cases was 2 (range 1-41); SLND+ALND, 9 (range 1-63); and ALND, 11 (range 1-81) (p < 0.0001). Of patients undergoing ALND, 56.7 % had ≥10 LN removed; 46.2 % of patients with SLND+ALND had ≥10 LN removed (p < 0.0001). Overall, 75.5 % of patients with ALND had ≥6 LN removed and 67.8 % of patients with SLND+ALND had ≥6 LN removed (p < 0.0001). Of those receiving only SLND, 83.4 % had ≤3 LN removed. CONCLUSIONS: A significant proportion of patients did not meet the minimum LN count thresholds for full ALND or had excess LN removed in a SLND. Further investigation is required to determine whether absolute LN number or reported operative procedure and implied surgical technique better defines axillary staging in a registry database.

Unnecessary axillary surgery for patients with node-negative breast cancer undergoing total mastectomy.

OBJECTIVE: To identify factors associated with the use of axillary lymph node dissection (ALND) as the initial axillary staging in node-negative breast cancer patients undergoing total mastectomy. DESIGN: California Cancer Registry study. SETTING: Academic research. PATIENTS: Women treated with total mastectomy for Tis, T1, or T2 node-negative breast carcinoma treated between January 1, 2004, and December 31, 2008. MAIN OUTCOME MEASURES: Proportions of patients who underwent ALND without prior sentinel lymph node dissection were compared by demographic characteristics. RESULTS: Of 18,238 women treated with total mastectomy for Tis, T1, or T2 node-negative breast carcinoma, 35.1% underwent initial axillary staging by ALND without prior sentinel lymph node dissection. On multivariable analyses, patients were significantly more likely to undergo ALND if they had T2 disease or were 65 years or older, were hormone receptor negative, of Hispanic or Asian/Pacific Islander race/ethnicity, of lower socioeconomic quintile, operated on during earlier years of the study period, and not treated by a hospital cancer program approved by the American College of Surgeons. CONCLUSIONS: More than one-third of patients in California who underwent total mastectomy for treatment of early-stage node-negative breast carcinoma received ALND without prior sentinel lymph node dissection; furthermore, certain subsets of patients have higher odds of undergoing ALND alone. To avoid the unnecessary morbidity of ALND in early-stage breast carcinoma, further research is required to elucidate how tumor, patient, and system factors can be modified to improve delivery of optimal breast cancer care.

Accuracy and upgrade rates of percutaneous breast biopsy: the surgeon's role.

We sought to evaluate the impact of needle core size and number of core samples on diagnostic accuracy and upgrade rates for image-guided core needle biopsies of the breast. A total of 234 patients underwent image-guided percutaneous needle biopsies and subsequent surgical excision. Large-core needles (9 gauge or less) were used in 14.5 per cent of cases and the remainder were performed with smaller core needles. More than four core samples were taken in 78.9 per cent of patients. In 71.8 per cent of cases, needle biopsy pathology matched surgical excision pathology. After surgical excision, upgraded pathology was revealed in 10.7 per cent of cases. Of 11 patients (52.4%) with benign needle core pathology who had upgraded final pathology on surgical excision, 10 had a Breast Imaging Recording and Data System score 4 or 5 imaging study. Lesions smaller than 10 mm were more likely to be misdiagnosed (P = 0.01) or have upgraded pathology (P = 0.009). Other predictors of upgraded pathology were patient age 50 years or older (P = 0.03) and taking four or fewer core samples (P = 0.003). Needle core size did not impact accuracy or upgrade rates. Surgeons should exercise caution when interpreting needle biopsy results with older patients, smaller lesions, and limited sampling. Discordant pathology and imaging still mandate surgical confirmation.

Are percutaneous biopsy rates a reasonable quality measure in breast cancer management?

BACKGROUND: Utilization of percutaneous needle biopsy (PNB) has been proposed as a quality measure of breast cancer care. We evaluated rates and reasons for failure of patients undergoing PNB as the initial diagnostic procedure for evaluation of breast pathology. METHODS: We performed a retrospective review of sequential patients undergoing image-guided PNB and open surgical excisional breast biopsies from January 2006 to July 2009 at our institution. Factors associated with failure to undergo a percutaneous approach were analyzed. RESULTS: During the study period, 1196 breast biopsies were performed; 87 (7.3%) were open surgical biopsies, and 1109 (92.7%) were PNB. Imaging used for percutaneous guidance or needle localization was ultrasound in 58.9%, mammogram in 40.0%, and magnetic resonance imaging (MRI) in 0.9%. Open surgical excisional biopsy was associated with mammographic guidance (P < .001), location in the central or lower inner quadrant of the breast (P = .002), BIRADS score of 1 or 6 (P < .001), or calcifications as target (P < .001). There were no differences in rates of PNB by age, size of lesion, or breast density. Reasons for failure of PNB were technical (calcifications not visualized, proximity to implant, etc.) in 86.2% of cases. No reason was documented in 10.3%, and 3.4% of patients refused a percutaneous approach. CONCLUSIONS: The majority of patients in this series underwent PNB as an initial diagnostic approach. Most percutaneous failures are due to technical reasons. PNB rates are a reasonable quality measure in breast cancer care. Documentation of failure to meet this benchmark should be stringently monitored.

Factors associated with variance in compliance with a sentinel lymph node dissection quality measure in early-stage breast cancer.

BACKGROUND: Guidelines recommend sentinel lymph node dissection (SLND) for patients with clinical stage I/IIA/IIB breast cancer; however, a significant fraction of patients do not undergo this procedure. We sought to identify factors associated with noncompliance with the SLND benchmark in early-stage breast cancer. MATERIALS AND METHODS: All patients with an initial diagnosis of Stage I/IIA/IIB invasive breast carcinoma who were treated between 2004 and 2007 with records in the California Cancer Registry were evaluated. Odds ratios evaluating receipt of SLND were compared for sex, age, stage, socioeconomic status (SES), race/ethnicity, surgery type, year of diagnosis, and hospital cancer program approval from the American College of Surgery (ACOS). RESULTS: Of 55,207 patients identified, 66% underwent SLND. On multivariable analyses, patients were significantly less likely to undergo SLND if they were >65 years of age, stage IIA or IIB, of lower socioeconomic status, of nonwhite race/ethnicity, treated with total mastectomy, treated during 2004-2005, or at a non-ACOS approved institution. CONCLUSIONS: SLND use in California has increased over time; however, only two-thirds of eligible patients undergo this recommended procedure. Using SLND as a quality measure demonstrates significant disparities that have implications not only for patient and provider education, but also for health care policy and reform.

Disparities in the surgical management of women with stage I breast cancer.

We sought to evaluate factors influencing the choice of surgery for women with early-stage breast cancer. Between 1996 and 2005, 47,837 women who were diagnosed with Stage I breast cancer underwent partial (PM) or total mastectomy (TM) in the California Cancer Registry. A total of 72.8 per cent of women underwent PM. Those treated in the most recent 5-year period were more likely to undergo PM than in the prior 5 years (76.5 vs 69.5%, P < 0.0001). PM rates increased with increasing socioeconomic status (SES): 65.1 per cent of patients in the lowest SES quintile underwent PM versus 77.2 per cent in the highest SES quintile (P < 0.0001). Forty- to 64-year-old women were more likely to receive PM compared with their older and younger counterparts (74.5 vs 71.2 and 67.0%, respectively; P < 0.0001). Asian/Pacific Islander women were least likely to undergo PM (64.0%), whereas non-Hispanic black women were most likely to undergo PM (75.0%) (P < 0.0001). On multivariate analysis, these demographic factors remained independent predictors of surgical treatment. PM rates have increased over time; however, significant differences in surgical management exist among women of different race/ethnic groups, ages, and SES. Further research is required to elucidate modifiable factors that impact the choice of surgery for women with early-stage breast cancer.

Disparities in BRCA testing: when insurance coverage is not a barrier.

BACKGROUND: Strategies to reduce the risk of developing breast and ovarian cancer in carriers of deleterious BRCA 1 and 2 mutations are readily available. However, many people who are at high risk of having these genetic mutations are reluctant to obtain the test. We sought to identify factors associated with choice of testing. METHODS: We performed a retrospective cohort review of high-risk patients referred to a multidisciplinary breast health center for BRCA testing between January 2001 and March 2008. Demographic variables were compared by using logistic regression between those who completed genetic testing and those who did not. RESULTS: A total of 213 patients were referred for BRCA testing. The mean age was 49.2 years (range, 16-84 y). Five patients were male. The majority of individuals (63.4%) were white, 15% were Hispanic, 6.6% were black, and 4.7% were Asian. Insurance coverage for testing was available in 91.1% of patients, of whom 49.2% had private insurance, 26.7% had managed care insurance, and 24.1% had government-sponsored insurance. A total of 111 patients (52.1%) underwent testing. On multivariate analysis, patients were significantly more likely to complete testing if they had a personal history of breast cancer (73.0% of tested patients) (P = .005) and had at least some college education (61.3%) (P = .03). There were no statistically significant differences in tested versus untested groups by age, race, language, family history, parity, marital status, religion, socioeconomic status, or insurance status. Of patients whose insurance plans offered coverage for genetic testing, 51.4% underwent testing and 48.6% did not (P = not significant [NS]). Of those who had no insurance coverage for testing, 41.2% underwent testing and 58.9% did not (P = NS). CONCLUSIONS: Our data show that half of those patients at risk for carrying a BRCA mutation do not undergo testing. Insurance coverage for genetic testing does not influence the decision to test. Developing counseling instruments that explain the benefits of testing to unaffected high-risk individuals or targeted to those with a high school level education may be a strategy to improve testing rates.