Surgery - Surgical Oncology

Background. Rates of contralateral prophylactic mastec-tomy (CPM) in women with breast cancer have increased, but most studies fail to show a survival benefit. We evaluated survival among CPM patients compared to patients undergoing single mastectomy (SM). Methods. The Surveillance, Epidemiology, and End Results database was used to identify unilateral breast cancer patients who underwent mastectomy with/without CPM from 1998 to 2010. Case-control analysis was performed with CPM cases matched to SM controls on the basis of age group, race/ethnicity, extent of surgery, grade, T classification, N classification, estrogen receptor status, and propensity score. Survival analyses included Kaplan– Meier curves and univariate and multivariate proportional hazard models to determine factors associated with disease specific (DSS) and overall survival (OS). Results. A total of 26,526 CPM patients were identified. On multivariate regression analysis, increasing age, greater extent of surgery, increasing T and N stage, African American race, Hispanic ethnicity, poorly differentiated grade, and estrogen receptor negativity were associated with increased risk of death. CPM was associated with improved DSS (HR 0.86, 95 % CI 0.79–0.93) and even greater OS (HR 0.76, 95 % CI 0.71–0.81) compared with SM. Contralateral breast cancer (CBC) occurred in 1.6 % of women in the cohort. Removing CBC cases from analysis had little impact on CPM DSS (HR 0.86, 95 % CI 0.79–0.93) and OS (0.77, 95 % CI 0.72–0.82) suggesting that prevention of CBC by CPM does not explain the observed survival benefit. Conclusions. CPM rates continue to rise. The improved DSS and OS observed with CPM support selection bias. Prospective trials are needed to determine cohorts of patients most likely to benefit from CPM.

Background. Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. We sought to determine the patterns of care and variables associated with the use of breast reconstruction in Southern California. Materials and Methods. Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development (OSHPD) inpatient database from 2003 to 2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastectomy. Changes in reconstruction rates were examined by calendar year, age, race, type of insurance, and type of hospital using a chi-square test. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (95% CI) were estimated for relative odds of immediate reconstruction versus mastectomy only. Results. In multivariate analysis, calendar year, age, race, type of insurance, and type of hospital were statistically significantly associated with use of reconstruction. The proportion of patients undergoing reconstruction rose from 24.8% in 2003 to 29.2% in 2007. Patients with private insurance were 10 times more likely to undergo reconstruction than patients with MediCal insurance (OR 9.95, 95% CI 8.46–11.70). African American patients were less likely (OR 0.58, 95% CI 0.46–0.73) and Asian patients one-third as likely (OR 0.37, 95% CI 0.29–0.47) to undergo reconstruction as Caucasians patients Most reconstructive procedures were performed at teaching hospitals and designated cancer centers. Conclusions. Although the rate of postmastectomy reconstruction is increasing, only a minority of patients undergo reconstruction. Age, race, type of insurance, and type of hospital appear to be significant factors limiting the use of reconstruction. Breast cancer is the most common cancer affecting women in the United States (US) with 192,000 women diagnosed in 2009. 1 For women with early-stage breast cancer, randomized trials have demonstrated no difference in overall survival for women treated with a total mastec-tomy versus breast-conserving therapy (BCT). 2,3 Currently in the US, the majority of women (57.8%) choose BCT over mastectomy (38.9% unilateral, 3.3% bilateral) according to a recent study evaluating breast cancer surgical trends from 1998 to 2003. 4 Although the rates of BCT are higher, there are reasons why a woman might undergo a mastectomy, whether due to individual preference or contraindications for BCT: limited access to radiation facilities or desire to avoid radiation, multicentric breast cancer, large tumor to breast size ratio, inflammatory breast cancer, or fear of recurrence. For those women who choose mastectomy, breast reconstruction offers a cosmetic and psychological advantage. Many studies have pointed to the psychosocial benefits of reconstruction for both immediate and delayed reconstruction. 5–8 With regard to surveillance of recurrence, immediate reconstruction has been shown to be a safe option. 9–11 Additionally, skin-sparing mastectomies with subsequent reconstruction have not been shown to increase the local recurrence rate or compromise local control. 9,12,13 For some authors, postmastectomy reconstruction can be used as a surrogate for improved patient care. 14

Background. Many factors influence whether breast cancer patients undergo reconstruction after mastectomy. This study was undertaken to determine the patterns of care and variables associated with the use of reconstruction for ductal carcinoma in situ (DCIS) and to compare previous results for invasive carcinoma. Methods. Postmastectomy reconstruction rates were collected from the California Office of Statewide Health Planning and Development (OSHPD) for 2003–2007. International Classification of Disease-9 codes were used to identify patients undergoing reconstruction after mastec-tomy. Variations in reconstruction rates were examined by type of breast cancer (DCIS vs. invasive), calendar year, age, type of insurance, type of hospital, and race/ethnicity. Univariate and multivariate odds ratios (OR) with 95% confidence intervals (CI) were estimated for relative odds of immediate reconstruction versus mastectomy only. Results. For multivariate analysis, age, race/ethnicity, type of insurance, and type of hospital were significantly associated with the use of reconstruction for DCIS patients. DCIS patients were twice as likely to undergo reconstruction as patients with invasive cancer (odds ratio (OR) = 1.93, 95% confidence interval (CI) = 1.75–2.13). DCIS patients with private insurance were nine times more likely to undergo reconstruction as patients with Medicaid (OR = 8.84, 95% CI = 5.92–13.21). Both Hispanic white and Asian patients were one-fifth as likely to undergo reconstruction compared with non-Hispanic white patients (OR = 0.18, 95% CI = 0.1–0.3; OR = 0.17, 95% CI = 0.09–0.31). Conclusions. Postmastectomy rates for DCIS were twice those for invasive cancer mostly because stage was not a limiting factor. However, significant factors remain that limit the use of reconstruction in this breast cancer population: age, race/ethnicity, type of hospital, and type of insurance.

I n patients with early stage breast cancer, axillary nodal status remains the most significant prognostic factor for disease recurrence and survival. To stage the axilla, sentinel lymph node dissection (SLND) has been shown to be an accurate and less invasive alternative to axillary lymph node dissection (ALND) 1,2 and its use already has been incorporated into national practice guidelines set forth by the American Society of Clinical Oncology. 3 Because SLND is a diagnostic tool, to validate test performance, SLND has most appropriately been compared with the results of a completion ALND in the same patient. The effect of SLND on recurrence or survival has been evaluated in very few formal randomized controlled trials. 4 The current study by Zavagno et al in this issue of Annals of Surgery is important in that as a randomized controlled trial (RCT) it supplies further information regarding the technical success, morbidity, and locoregional recurrence rates of SLND versus ALND. 5 However, some of the results are disappointing. The trial involved 18 clinical centers in a variety of settings; 697 patients with tumors 3 cm were available for analysis. The authors report a high SLN identification rate (95.0%) and overall accuracy rate (94.4%) yet had a high false negative rate (FNR) of 16.7%. This FNR is higher than that of the initial studies during which the technical aspects of the procedure were being determined. 1,2 In relation to a large meta-analysis of 69 studies with a total of 8059 patients, 4 the results of this current study do not compare well. In the meta-analysis, the proportion of patients who had successful mapping ranged from 41% to 100% (average 89%, median 92%) with the sensitivity of SLN identification ranging from 71% to 100% and an average false negative rate of 7.3% (range 0% to 29%). Lower false negative rates are associated with a higher proportion of successful mapping. The apparent high identification rate of 95% and overall accuracy of 94.4% in this report are incongruous with the high FNR of 16.7%. The technical results of this current RCT are inferior to those of other RCTs. In Veronesi et al's study, 516 patients with tumors 2 cm were randomly assigned to either SLND followed by ALND or SLND followed by ALND only if tumor was found in the SLN. 6 For the patients who had SLND and ALND, the false negative rate was 8.8% (95% CI, 3.9 to 16.6). Although the primary endpoints including morbidity, regional control, and survival have yet to be reported, the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 trial (with 5611 enrolled patients) indicates an overall accuracy rate of 97.1% and false negative rate of 9.8%. 7 The Zavagno et al study falls within the range of FNR reported in the meta-analysis, which included early studies and training studies, but the FNR is high compared with the average of the 69 studies (16.7% vs. 7.3%) as well as compared with these 2 RCTs (8.8% and 9.8%). One conclusion by the current authors to explain the high FNR was that both academic centers and community hospitals, some with limited experience in breast cancer surgery, participated in the study. The Veronesi study was a single-center trial; the NSABP B-32 study had 80 institutions and 233 surgeons participating. Although NSABP B-32 required only 5 cases prior to initiation, all participating surgeons had their first 20

Background. Reconstruction rates after mastectomy have been reported to range from 25–40 %; however, most studies have focused on patients treated in an inpatient setting. We sought to determine the utilization of outpatient mastectomy and use of breast reconstruction in Southern California. Methods. Postmastectomy reconstruction rates were determined from the California Office of Statewide Health Planning and Development database from 2006–2009 using CPT codes and similarly from an inpatient database using ICD-9 codes. Reconstruction rates were compared between the inpatient and outpatient setting. For the outpatient setting, univariate and multivariate odds ratios with 95 % confidence intervals were estimated for relative odds of immediate reconstruction versus mastectomy alone. Results. The percentage of patients undergoing outpatient mastectomy ranged from 20.4 to 23.9 % of the total number of all patients undergoing mastectomy. Whereas immediate inpatient reconstruction increased from 29.2 to 41.6 % (overall rate 35.5 %), the proportion of outpatients undergoing reconstruction only increased from 7.7 to 10.3 % (overall rate 9.1 %). Similar to the inpatient setting, in multivariate analysis, age, insurance status, race/eth-nicity, and type of hospital were significantly associated with the use of reconstruction in the outpatient setting. Conclusions. A substantial number of patients undergo outpatient mastectomy with low rates of reconstruction. Although the choice of an outpatient mastectomy may certainly represent a selection bias for those not choosing reconstruction, an increase in the use of outpatient mastectomy may result in decreases in the use of post-mastectomy reconstruction. A potential quality measure of breast cancer care is the use of reconstruction following mastectomy. The National Accreditation Program for Breast Centers currently requires that all appropriate patients who undergo mas-tectomy receive preoperative referrals to reconstructive/ plastic surgeons (NAPBC Standard 2.18). At the same time, there has been increasing pressure on surgeons and hospitals to perform mastectomy as an outpatient procedure , with rates steadily increasing since the 1990s. 1–3 These efforts may be in direct conflict with each other. After mastectomy for breast cancer, fewer than half of patients undergo reconstruction despite recognized benefits , such as improved quality of life and overall well-being for those selecting this option. 4–8 Many studies have cited differences in postmastectomy reconstruction rates based on multiple variables with rates ranging from 25 to 40 %; 9–15 however, most of these studies have focused on patients treated in an inpatient setting. For the outpatient setting, most studies have focused on the utilization of mastectomy alone without examining reconstruction rates. Our study had a twofold purpose: to determine the current rates of outpatient mastectomy for patients with breast cancer and to assess utilization of immediate breast reconstruction after mastectomy in the outpatient setting in Southern California. METHODS Patient Population We selected patients with newly diagnosed breast cancer , either invasive carcinoma or ductal carcinoma in situ

Objectives: Although postmastectomy radiation therapy (PMRT) has been shown to reduce breast cancer burden and improve survival, PMRT may negatively influence outcomes after reconstruction. The goal of this study was to compare current opinions of plastic and reconstructive surgeons (PRS) and surgical oncologists (SO) regarding the optimal timing of breast reconstruction for patients requiring PMRT. Oncology (SSO) were asked to participate in an anonymous web-based survey. Responses were solicited in accordance to the Dillman method, and they were analyzed using standard descriptive statistics. Results: A total of 330 members of the ASPS and 348 members of the ASBS and SSO participated in our survey. PRS and SO differed in patientepayor mix (p < 0.01) and practice setting (p < 0.01), but they did not differ by urban versus rural setting (p Z 0.65) or geographic location (p Z 0.30). Although PRS favored immediate reconstruction versus SO, overall timing did not significantly differ between the two specialists (p Z 0.14). The primary rationale behind delayed breast reconstruction differed significantly between PRS and SO (p < 0.01), with more PRS believing that the reconstructive outcome is significantly and adversely affected by

Background. Neoadjuvant chemotherapy (NAC) is commonly used to treat locally advanced breast cancer. Pathologic complete response (pCR) predicts improved overall survival (OS); however, prognosis of patients with partial response remains unclear. We evaluated whether tumor response ratio (TRR) is a better predictor of OS than current staging methods. Methods. Using the National Comprehensive Cancer Network Breast Cancer Outcomes Database, we identified patients with stage I–III breast cancer who had NAC and pretreatment imaging at City of Hope (1997–2010). Patient demographics, tumor characteristics, and OS were analyzed. TRR was calculated as residual in-breast disease divided by size on pre-NAC imaging. Four TRR groups were stratified; TRR 0 (pCR), TRR [ 0–0.4 (strong partial response, SPR), TRR [ 0.4–1.0 (weak partial response, WPR), or TRR [ 1.0 (tumor growth, TG). OS was estimated by the Kaplan–Meier method and tested by the log-rank test. Cox regression was performed to evaluate associations between OS and TRR in a multivariable analysis while controlling for potential confounders. Results. There were 218 eligible patients identified; 59 (27 %) had pCR, 61 (28 %) SPR, 72 (33 %) WPR, and 26 (12 %) TG. Five-year OS decreased continuously with increasing TRR:pCR (90 %), SPR (79 %), WPR (66 %), and TG (60 %). TRR was the only measure that significantly predicted OS (p = 0.0035); pathologic stage (p = 0.23) and pre-NAC clinical tumor stage (cT) (p = 0.87) were not significant. TRR continued to be statistically significant by multivariable analysis (p = 0.016). Conclusions. TRR takes into account both pretreatment and residual disease and more accurately predicts OS than pathologic stage and pre-NAC cT. TRR may be useful to more accurately assess prognosis and OS in breast cancer patients undergoing NAC. Although initially only used in patients with inflamma-tory or inoperable breast cancer, neoadjuvant chemotherapy (NAC) has seen expanded use in patients across almost all stages of breast cancer. 1 The goal of NAC is to shrink the primary tumor and minimize the extent of necessary surgical resection. The use of NAC also serves as an in vivo assay for treatment efficacy. 1 As a result, treatment strategies for patients with stage II and III breast cancer have evolved and continue to adapt. However, staging approaches—and consequently prognostication— have not advanced at the same pace. Currently, pathologic staging of breast cancer is performed using the American Joint Committee on Cancer (AJCC) tumor, node, metastasis classification system, which is universally applied to both determine prognosis and to guide therapy. 2 This system is based on the size of the tumor (T) and the number of positive lymph nodes (N) obtained during surgery, as well as the existence of metastases (M). A pathologic complete response (pCR) to neoadjuvant therapy seen at the time of surgery has been shown to predict improved overall survival (OS). 3 However , the prognosis for patients with partial response remains unclear. Furthermore, other than the ''y'' notation, which categorizes the extent of tumor actually present at the time of surgery, AJCC staging does not specifically take into account the effects of NAC on the tumor. 2 This raises questions as to how best to stage the breast cancer of patients in the neoadjuvant setting. Several methods have been proposed to modify the current staging system. Symmans et al. proposed

We report a series of breast cancer patients with invasive skin and nail infections with Staphylococcus species that we attribute to the addition of pertuzumab to trastuzumab-based therapy. With the suspicion of an increased incidence of cutaneous infection in patients treated with pertuzumab and trastuzumab-based chemo-therapy, treating medical oncologists identified patients receiving therapy who experienced infection. Between March and October 2014, 18 patients treated with pert-uzumab and trastuzumab-based chemotherapy were found to have 21 separate skin/nail infections. Treatment was administered as neoadjuvant therapy in 12 (67 %) patients, adjuvant therapy in four (22 %) patients, and for metastatic disease in two (11 %) patients. Granulocyte growth factors were administered in 11 (61 %) patients and no patients were documented to be neutropenic. New skin and nail lesions developed as early as cycle 1 and as late as 8 months from initial therapy. The 21 separate infections documented were folliculitis and ''bite-like'' lesions (10), abscess (6), paronychia (3), and cellulitis (2). The appearance of these lesions was distinct from typical EGFR-associated skin changes. When cultures were obtained, Staphylococcus species were isolated. Quantitative immunoglobulins were assessed in 14 (78 %) patients and were abnormally low in six (43 %) of these patients. The skin infections resulted in treatment delay in two (11 %) patients and premature discontinuation of therapy in one patient. We believe that the skin/nail infections reported here in patients treated with the combination of pertuzumab and trastuzumab represent a previously unrecognized toxicity of adding pertuzumab to trast-uzumab-based therapies.