Background
Reconstructive alternatives should be discussed with women facing mastectomy for breast cancer. These include immediate and delayed reconstruction, which both have inherent advantages and ...disadvantages. Immediate reconstruction rates vary considerably in Swedish healthcare regions, and the aim of the study was to analyse reasons for this disparity.
Methods
All women who underwent mastectomy for primary breast cancer in Sweden in 2013 were included. Tumour data were retrieved from the Swedish National Breast Cancer Registry and from questionnaires regarding patient information and involvement in preoperative decision‐making sent to women who were still alive in 2015.
Results
Of 2929 women who had undergone 2996 mastectomies, 2906 were still alive. The questionnaire response rate was 76·3 per cent. Immediate reconstruction rates varied regionally, between 3·0 and 26·4 per cent. Tumour characteristics impacted on reconstruction rates but did not explain regional differences. Patient participation in decision‐making, availability of plastic surgery services and patient information, however, were independent predictors of immediate breast reconstruction, and varied significantly between regions. Even in younger patients with low‐risk tumours, rates of patient information ranged between 34·3 and 83·3 per cent.
Conclusion
Significant regional differences in immediate reconstruction rates were not explained by differences in tumour characteristics, but by disparities in patient information, availability of plastic surgery services and involvement in decision‐making.
Information is key
Purpose
The aim of the current study was to evaluate risk factors and timing of revision surgery following immediate implant-based breast reconstruction (IBR).
Methods
This retrospective cohort ...included women with a previous therapeutic mastectomy and implant-based IBR who had undergone implant revision surgery between 2005 and 2015. Data were collected by medical chart review and registered in the Stockholm Breast Reconstruction Database. The primary endpoint was implant removal due to surgical complications, i.e. implant failure.
Results
The cohort consisted of 475 women with 707 revisions in 542 breasts. Overall, 33 implants were removed due to complications. The implant failure rate (4.7%) was lower without RT (2.4%) compared to RT administered after mastectomy (7.5%) and prior to IBR (6.5%) (
p
= 0.007). While post-mastectomy RT (OR 3.39, 95% CI 1.53–7.53), smoking (OR 3.90, 95% CI 1.76–8.65) and diabetes (OR 5.40, 95% CI 1.05–27.85) were confirmed as risk factors, time from completion of RT (> 9 months, 6–9 months, < 6 months) was not (OR 3.17, 95% CI 0.78–12.80, and OR 0.74, 95% CI 0.20–2.71). Additional risk factors were a previous axillary clearance (OR 4.91, 95% CI 2.09–11.53) and a history of a post-IBR infection (OR 15.52, 95% CI 4.15–58.01, and OR 12.93, 95% CI 3.04–55.12, for oral and intravenous antibiotics, respectively).
Conclusions
Previous axillary clearance and a history of post-IBR infection emerged as novel risk factors for implant failure after revision surgery. While known risk factors were confirmed, time elapsed from RT completion to revision surgery did not influence the outcome in this analysis.
Background
The prognostic equivalence between mastectomy and breast‐conserving surgery (BCS) followed by radiotherapy was shown in pivotal trials conducted decades ago. Since then, detection and ...treatment of breast cancer have improved substantially and recent retrospective analyses point towards a survival benefit for less extensive breast surgery. Evidence for the association of such survival data with locoregional recurrence rates is largely lacking.
Methods
The Swedish Multicentre Cohort Study prospectively included clinically node‐negative patients with breast cancer who had planned sentinel node biopsy between 2000 and 2004. Axillary lymph node dissection was undertaken only in patients with sentinel node metastases. For the present investigation, adjusted survival analyses were used to compare patients who underwent BCS and postoperative radiotherapy with those who received mastectomy without radiotherapy.
Results
Of 3518 patients in the Swedish Multicentre Cohort Study, 2767 were included in the present analysis; 2338 had BCS with postoperative radiotherapy and 429 had mastectomy without radiotherapy. Median follow‐up was 156 months. BCS followed by whole‐breast irradiation was superior to mastectomy without irradiation in terms of both overall survival (79·5 versus 64·3 per cent respectively at 13 years; P < 0·001) and breast cancer‐specific survival (90·5 versus 84·0 per cent at 13 years; P < 0·001). The local recurrence rate did not differ between the two groups. The axillary recurrence‐free survival rate at 13 years was significantly lower after mastectomy without irradiation (98·3 versus 96·2 per cent; P < 0·001).
Conclusion
The present data support the superiority of BCS with postoperative radiotherapy over mastectomy without radiotherapy. The axillary recurrence rate differed significantly, and could be one contributing factor in a complex explanatory model.
Radiotherapy to lower axilla key?
Purpose
The clinical significance of lymph node micrometastases and isolated tumor cells (ITCs) in breast cancer is still controversial. After a median follow-up of 52 months, a report from the ...Swedish Multicenter Cohort Study presented a worse cancer-specific and event-free survival for patients with micrometastases than node-negative individuals, but could not demonstrate a significant difference in overall survival (OS). Due to the tendency of breast cancer to relapse after more than 5–10 years, we now report the long-term survival of the cohort.
Methods
Between September 2000 and January 2004, 3355 breast cancer patients were included in a prospective cohort. Sentinel lymph node biopsy was always performed. Patients were classified in four groups according to their overall nodal stage: node negative (N0, 2372), ITCs (113), micrometastases (123), and macrometastases (747). Kaplan–Meier survival estimates and Cox proportional hazard regression models were applied.
Results
Median follow-up was 156 months. Ten-year cancer-specific survival and OS were significantly lower in case of micrometastases than in N0 (84.7 vs. 93.5%,
p
= 0.001, and 75.5 vs. 84.2%,
p
= 0.046, respectively). In case of macrometastases, corresponding survival rates were 82.8 and 74.3%. Only for those aged less than 50 years, cancer-specific survival and OS were significantly worse in case of ITCs than N0. Patients with micrometastases received less often chemotherapy than those with macrometastases (24.4 vs. 53.9%).
Conclusions
Lymph node micrometastases in breast cancer have a prognostic significance. This study demonstrates a similar survival for patients with micrometastases and those with macrometastases, possibly due to systemic undertreatment.
Molecular subtypes of breast cancer and presence of tumor-infiltrating immune cells have both been implicated as important predictive and prognostic factors for improved risk stratification and ...treatment individualization of breast cancer patients. Their association, however, has not been studied in detail. The aim of this study was to evaluate the expression of the T cell markers CD8, FoxP3, CD3 and ζ-chain in molecular subtypes of the invasive margin and tumor center of breast cancer and corresponding sentinel nodes and to deduct prognostic information from these findings.
Tumor and sentinel node sections from 177 patients with primary, invasive, unilateral early-stage breast cancer were stained by immunohistochemistry and T-cell phenotypes quantified manually. Clinical data were collected from medical records.
The degree of T-cell infiltration and expression of all markers differed significantly among the molecular subtypes, being highest in non-luminal, more aggressive tumors: more T-cell infiltration and higher expression of all markers were associated with hormone receptor negativity, higher proliferation and higher histological grades, but also with larger tumor size. Basal-like tumors, and most remarkably their tumor centers, hosted the highest number of FoxP3+ T-cells with an unfavorable ratio to cytotoxic CD8+ T-cells. T-cell infiltration was generally higher in the invasive margin than the tumor center. A scoring system based on densities of CD3 and CD8 could significantly separate molecular subtypes (p < 0.001).
Thus, immunological patterns with functional implications within each subtype are associated with prognostic factors. These findings should be further validated in studies using larger patient populations and longer follow-up.
Purpose
Breast cancer treatment is reported to be influenced by socioeconomic status (SES). Few reports, however, stem from national, equality-based health care systems. The aim of this study was to ...analyse associations between SES, rates of breast-conserving surgery (BCS), patient-reported preoperative information and perceived involvement in Sweden.
Methods
All women operated for primary breast cancer in Sweden in 2013 were included. Tumour and treatment data as well as socioeconomic data were retrieved from national registers. Postal questionnaires regarding preoperative information about breast-conserving options and perceived involvement in the decision-making process had previously been sent to all women receiving mastectomy.
Results
Of 7735 women, 4604 (59.5%) received BCS. In addition to regional differences, independent predictors of BCS were being in the middle or higher age groups, having small tumours without clinically involved nodes, being born in Europe outside Sweden, having a higher education than primary school and an intermediate or high income per household. Women with smaller, clinically node-negative tumours felt more often involved in the surgical decision and informed about breast-conserving options (both
p
< 0.001). In addition, women who perceived that BCS was discussed as an alternative to mastectomy were more often in a partnership (
p
< 0.001), not born in Sweden (
p
= 0.035) and had an employment (
p
= 0.031).
Conclusion
Socioeconomic factors are associated with surgical treatment even in a national health care system that is expected to offer all women the same standard of care. This should be taken into account and adapted to in preoperative counselling on surgical options in breast cancer.
The role of axillary lymph node dissection (ALND) has increasingly been called into question among patients with positive sentinel lymph nodes. Two recent trials have failed to show a survival ...difference in sentinel node-positive breast cancer patients who were randomized either to undergo completion ALND or not. Neither of the trials, however, included breast cancer patients undergoing mastectomy or those with tumors larger than 5 cm, and power was debatable to show a small survival difference.
The prospective randomized SENOMAC trial includes clinically node-negative breast cancer patients with up to two macrometastases in their sentinel lymph node biopsy. Patients with T1-T3 tumors are eligible as well as patients prior to systemic neoadjuvant therapy. Both breast-conserving surgery and mastectomy, with or without breast reconstruction, are eligible interventions. Patients are randomized 1:1 to either undergo completion ALND or not by a web-based randomization tool. This trial is designed as a non-inferiority study with breast cancer-specific survival at 5 years as the primary endpoint. Target accrual is 3500 patients to achieve 80% power in being able to detect a potential 2.5% deterioration of the breast cancer-specific 5-year survival rate. Follow-up is by annual clinical examination and mammography during 5 years, and additional controls after 10 and 15 years. Secondary endpoints such as arm morbidity and health-related quality of life are measured by questionnaires at 1, 3 and 5 years.
Several large subgroups of breast cancer patients, such as patients undergoing mastectomy or those with larger tumors, have not been included in key trials; however, the use of ALND is being questioned even in these groups without the support of high-quality evidence. Therefore, the SENOMAC Trial will investigate the need of completion ALND in case of limited spread to the sentinel lymph nodes not only in patients undergoing any breast surgery, but also in neoadjuvantly treated patients and patients with larger tumors.
NCT 02240472 , retrospective registration date September 14, 2015 after trial initiation on January 31, 2015.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose The oncological safety of nipple-sparing mastectomy in the context of immediate breast reconstruction is debatable. Previous studies report wide variations in local recurrence rates ...and randomised or matched cohort study designs are lacking. The aim of this study is to compare the local recurrence rate after nipple-sparing mastectomy to that after conventional mastectomy. Further, to compare the disease-free, overall and breast cancer-specific survival rates. Methods A retrospective review of all patients undergoing nipple-sparing mastectomy with immediate implant-based breast reconstruction at Karolinska University Hospital, Sweden, in the years 2000–2012 was conducted. These were matched 1:3 to patients operated by conventional mastectomy. Matching variables were age, tumour stage and year of surgery. Results Sixty-nine nipple-sparing mastectomies in 67 patients (study group) and 206 conventional mastectomies in 203 patients (control group) were included in the study. Median follow-up was 36 and 35 months for the study and control group, respectively. No local recurrence occurred in the study group, while seven local recurrences were observed in the control group ( p = 0.197). The estimated 5-year figures were 100% and 95.8% (local recurrence-free survival), 94.1% and 82.5% (disease-free survival), 96.2% and 91.3% (overall survival) and 98.0% versus 94.8% (breast cancer-specific survival). Survival rates did not differ significantly between groups. Conclusions Nipple-sparing mastectomy may be offered to selected breast cancer patients without any negative impact on oncological safety.
This follow-up analysis of a Swedish prospective multicentre trial had the primary aim to determine invasive disease-free (IDFS), breast cancer-specific (BCSS) and overall survival (OS) rates, and ...their association with axillary staging results before and after neoadjuvant systemic therapy for breast cancer.
Women who underwent neoadjuvant systemic therapy for clinically node-positive (cN+) or -negative (cN0) primary breast cancer between 2010 and 2015 were included. Patients had a sentinel lymph node biopsy before and/or after neoadjuvant systemic therapy, and all underwent completion axillary lymph node dissection. Follow-up was until February 2019. The main outcome measures were IDFS, BCSS and OS. Univariable and multivariable Cox regression analyses were used to identify independent factors associated with survival.
The study included a total of 417 women. Median follow-up was 48 (range 7-114) months. Nodal status after neoadjuvant systemic therapy, but not before, was significantly associated with crude survival: residual nodal disease (ypN+) resulted in a significantly shorter 5-year OS compared with a complete nodal response (ypN0) (83·3 versus 91·0 per cent; P = 0·017). The agreement between breast (ypT) and nodal (ypN) status after neoadjuvant systemic therapy was high, and more so in patients with cN0 tumours (64 of 66, 97 per cent) than those with cN+ disease (49 of 60, 82 per cent) (P = 0·005). In multivariable analysis, ypN0 (hazard ratio 0·41, 95 per cent c.i. 0·22 to 0·74; P = 0·003) and local radiotherapy (hazard ratio 0·23, 0·08 to 0·64; P = 0·005) were associated with improved IDFS, and triple-negative molecular subtype with worse IDFS.
The present findings underline the prognostic significance of nodal status after neoadjuvant systemic therapy. This confirms the clinical value of surgical axillary staging after neoadjuvant systemic therapy.
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