Lessons learned from the COVID-19 pandemic: Using telemedicine for pre-operative surgical evaluation in breast disease.

BACKGROUND/OBJECTIVES: The COVID-19 pandemic motivated telemedicine care to decrease potential exposures for both patients and staff. We hypothesized that select breast surgical patients can be successfully evaluated pre-operatively with telemedicine. METHODS: With institutional review board approval, patients with telemedicine surgical consults between 1 March 2020 and 31 August 2020 were identified retrospectively from our prospective breast surgical registry. The frequency of successful pre-operative evaluation using telemedicine alone was assessed, defined as cases in which surgery was completed on the planned day without changes to the surgical plan after physical examination in the pre-operative area. Differences in disease presentation, patient characteristics, and complications were evaluated by whether the first in-person visit occurred on the day of surgery versus the prior. RESULTS: A total of 374 patients underwent breast surgery between 1 March 2020 and 31 August 2020, of which 96 (25.7%) had a telemedicine consultation. After the telemedicine visit, 38 patients (39.6%) had additional in-person visits with the breast surgeon prior to their operative date, and 58 patients (60.4%) did not. Forty-five patients underwent breast-conserving therapies, 41 mastectomies (25 with reconstruction), two axillary dissections, and eight excisional biopsies. All surgeries were completed on the planned operative day, with no changes in surgical plans. Patients with telemedicine only prior to surgery were more likely to speak English (100% vs. 92.1%, p = 0.02) and have lower body mass index (median 24.9 vs. 29.2, p = 0.01). The frequency of in-person pre-operative visits varied significantly by surgeon (p < 0.001). Age, American Society of Anaesthesiologists score, distance from facility, clinical T/N category, surgery type, and complications did not differ between groups. CONCLUSIONS: Telemedicine can be utilized successfully for select breast surgical patients, with the ability to proceed to surgery in the majority of patients without additional in-person visits.

Lack of Clinical Value for Immunohistochemistry for Sentinel Lymph Node Assessment in Invasive Lobular Carcinoma.

BACKGROUND: The distinct histologic appearance of invasive lobular carcinoma (ILC) may pose diagnostic challenges for sentinel lymph node (SLN) analysis. We evaluated the impact of cytokeratin immunohistochemistry (IHC) on SLN assessment in ILC and its contribution to pathologic nodal upstaging. METHODS: We identified ILC patients treated with SLN surgery at our institution between September 2008 and August 2021. IHC for SLN assessment was employed at the discretion of the pathologist. Differences between groups evaluated with and without IHC were compared using Chi-square tests. RESULTS: Overall, 608 cases of ILC were identified in patients who underwent SLN surgery. IHC was used in 301 cases (49.5%) and was not associated with cT category, pT category, or tumor grade. Use of IHC increased detection of SLN+ disease when isolated tumor cells (ITCs) were included in the analysis (35.9% with IHC vs. 21.2% without IHC; p < 0.001). There was no effect on nodal upstaging to micrometastatic disease (pN1mi) or greater (21.9% with IHC vs. 21.2% without IHC; p = 0.82). IHC did not increase the number of positive SLNs detected (median 1 with and without IHC) nor did it increase axillary lymph node dissection (ALND) rates (11.6% with IHC vs. 15.3% without IHC; p = 0.18). CONCLUSION: IHC improved detection of pN0(i+) disease among ILC patients undergoing SLN surgery. IHC did not increase upstaging to pN1mi or higher categories of nodal disease, detection of a greater number of positive SLNs, or ALND rates. Our data suggest routine use of IHC for SLN assessment in ILC patients does not add clinical utility.

Factors Influencing Non-sentinel Lymph Node Involvement in Patients with Positive Sentinel Lymph Node(s) After Neoadjuvant Chemotherapy for Breast Cancer.

BACKGROUND: When a positive sentinel lymph node (SLN) is identified after neoadjuvant chemotherapy (NAC), completion axillary lymph node dissection (cALND) is generally recommended. We sought to evaluate the rate of non-SLN positivity and factors influencing this in patients with a positive SLN following NAC. METHODS: We identified all patients at our hospital between 2006 and 2021 with a positive SLN (> 0.2 mm) following NAC who underwent cALND. Rates of positive non-SLN (NSLN) on cALND were compared by nodal status. Chi-square tests and multivariable logistic regression were used to assess factors predictive of positive NSLN and overall nodal burden. RESULTS: Overall, 229 cases (177 cN+, 52 cN0 prior to NAC) with positive SLN(s) after NAC underwent cALND. Additional NSLN involvement was found in 129/229 (56.3%) patients, including 24/52 (46.2%) cN0 and 105/177 (59.3%) cN+ patients (p = 0.09). There was a trend for patients with SLN micrometastases to be less likely to have positive NSLN(s) than those with SLN macrometastases (38.5% vs. 58.6%; p = 0.05). Subgroup analyses showed no clinicopathologic factors significantly associated with additional axillary involvement for initially cN0 patients. Factors found to significantly influence NSLN positivity in the initially cN+ subgroup were HER2 status, multicentricity/multifocality, number of positive SLNs, and size of SLN metastasis. SLN metastasis size > 5 mm and three or more positive SLNs exerted the greatest influence on NSLN positivity. CONCLUSION: Rates of nodal positivity on cALND in the setting of positive SLN after NAC are high, supporting the current standard of routine cALND. In cN+ disease, NSLN positivity varies by tumor biology, multicentricity/multifocality, number of positive SLNs, and SLN metastasis size.

Contemporary Axillary Management in cT1-2N0 Breast Cancer with One or Two Positive Sentinel Lymph Nodes: Factors Associated with Completion Axillary Lymph Node Dissection Within the National Cancer Database.

BACKGROUND: Management of the axilla in patients with cT1-2N0 breast cancer with one or two positive (+) sentinel lymph nodes (SLNs) is often debated, especially in patients undergoing mastectomy. In 2018, the National Cancer Database (NCDB) began collecting the number of +SLNs, enabling identification of patients with one or two +SLNs for the first time. METHODS: From the 2018 NCDB participant user file (PUF), all cT1-2N0M0 patients with one or two +SLNs were identified. The rates of completion axillary lymph node dissection (cALND) after breast-conserving surgery (BCS) and mastectomy were determined, and logistic regression was used to assess factors associated with cALND. RESULTS: Of 10,531 patients with one or two +SLNs, cALND was performed in 807/6498 (12.4%) BCS patients and 1845/4033 (45.7%) mastectomy patients (p < 0.001). Factors associated with cALND in BCS were cT2 versus cT1 (16.0% versus 11.1%, p < 0.001), two versus one positive SLN (20.7% versus 10.8%, p < 0.001), and higher tumor grade (grade 3: 15.4% versus grade 1-2: 11.7%, p = 0.002). Factors associated with cALND among mastectomy were cT2 versus cT1 (48.2% versus 43.7%, p = 0.004), two versus one positive SLN (56.6% versus 42.8%, p < 0.001), younger age (age < 50 years: 49.0%, age 50+ years: 44.1%, p = 0.004), and Hispanic ethnicity (55.7% versus 45.1%, p = 0.001). After adjusting for pN category, adjuvant radiation was significantly less likely after mastectomy if cALND was performed (odds ratio (OR) 0.51, p < 0.001). CONCLUSIONS: Omission of cALND with one or two +SLNs in BCS is common. Deescalation of axillary therapy in mastectomy is slower, with a cALND rate of 45.7% in 2018. With the recent updates to the National Cancer Care Network (NCCN) guidelines, we anticipate continued deescalation of axillary therapy in mastectomy patients.