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Feasibility of breast conserving surgery in multifocal breast cancers
MD Anderson Cancer Center experience. J Clin Oncol. 2004;22: 2303-2312. 11. Chen AM, Meric-Bernstam F, Hunt KK, et al. Breast conservation after neoadjuvant
Feasibility of breast conserving surgery in multifocal breast cancers Kadioglu H, Yücel S, Yildiz S, et al (Bezmialem Vakif Üniversitesi, Fatih/ Istanbul, Turkey) Am J Surg 208:457-464, 2014
Background.dMultifocal breast cancers (MFBCs) present a challenge to surgeons. Although its feasibility is still controversial, breast-conserving surgery (BCS) is not contraindicated for MFBCs. The investigators retrospectively evaluated the feasibility of BCS and reviewed histopathologic findings in patients with MFBC. Methods.dA total of 222 patients with MFBC who were treated with either BCS (119 patients) or mastectomy (103 patients) at a single institution between January 2002 and December 2011 were retrospectively evaluated. Results.dThe median follow-up time was 55 months (range, 10 to 102 months). Lymphovascular invasion and lymph node involvement were significantly less frequent in the BCS group (48.8% vs 62.2% for lymphovascular invasion, P ¼.04; 52.1% vs 71.8% for lymph node involvement, P ¼ .002). There were no differences in local recurrence rates between the 2 groups. The overall survival rates were 92%
chemotherapy. Cancer. 2005;103: 689-695. 12. Mamounas EP, Anderson SJ, Dignam JJ, et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy:
in the BCS group and 72% in the mastectomy group (P ¼ .000). Conclusions.dBCS is a feasible and safe procedure for the removal of multifocal tumors. Extended lymphovascular invasion is associated with mortality in patients who undergo mastectomy. Patients with MFBC can be considered for breast conservation depending on disease extent and breast size. In MFBC, breast conservation remains controversial, although recent data indicate reasonable local control with breast conservation in these cases.1-3 The American College of Surgeons Oncology Group Z11102 trial is a prospective study currently assessing the local recurrence rate after breast conservation in women presenting with multiple ipsilateral breast cancers separated by at least 2 cm of normal breast tissue. In this article, Kadioglu and colleagues report on local recurrence and survival in a cohort of patients with MFBC, comparing those who underwent BCS with those who underwent mastectomy. In this article, multifocal disease was defined as the presence of 2 or more malignant lesions in the same quadrant of the breast separated by normal breast tissue, which is an appropriate, commonly used defini-
Results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27. J Clin Oncol. 2012;30: 3960-3966.
tion. However, these multifocal tumors were not all identified preoperatively, as they could be diagnosed by palpation, radiologic imaging, or pathologic examination from surgery. These different methods of diagnosis introduce significant heterogeneity to the patient population described. Pathologically identified additional foci of disease represent a significantly different patient population and disease volume from those represented by preoperatively identified multifocal disease. The mastectomy group had significantly worse tumor biology than the BCS group, with a higher proportion of human epidermal growth factor receptor 2epositive disease, lymphovascular invasion, lymph node involvement, and number of disease foci in the breast. These critical differences likely account for the significant difference in overall survival between the 2 groups, as supported by the lack of statistically significant differences in survival between the groups when analyzed by disease stage. Unfortunately, patients treated with taxane-based chemotherapy were excluded from this analysis, which is a significant shortfall because taxanes are part of the current standard adjuvant chemotherapy recommendations for patients with breast cancer receiving chemotherapy. It is unclear how this analysis defined cases that on preoperative
Breast Diseases: A Year BookÒ Quarterly Vol 26 No 1 2015
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imaging were determined to be multifocal but on final pathology were found to be 1 contiguous area. Similarly, patients with what appeared to be unifocal disease preoperatively who were found to have 2 or more foci on final pathology were included in this cohort. The 5% local recurrence rate at 55 months reported here is in keeping with reports from other studies of recurrence rates in patients with MFBC.1-3 Unfortunately, this article does not add significantly to the published literature on MFBC. Results from the American College of Surgeons Oncology Group Z11102 trial will be
important for understanding local recurrence rates in patients with multiple ipsilateral tumors who undergo BCS and contemporary adjuvant therapy and will help guide future recommendations.4 J. C. Boughey, MD
References 1. Gentilini O, Botteri E, Rotmensz N, et al. Conservative surgery in patients with multifocal/multicentric breast cancer. Breast Cancer Res Treat. 2009;113:577-583.
2. Lim W, Park EH, Choi SL, et al. Breast conserving surgery for multifocal breast cancer. Ann Surg. 2009;249:87-90. 3. Bauman L, Barth RJ, Rosenkranz KM. Breast conservation in women with multifocalmulticentric breast cancer: is it feasible? Ann Surg Oncol. 2010;17: 325-329. 4. Boughey JC, Rosenkranz K, Nelson H. Multiple ipsilateral breast cancers: can the breast be preserved? Bull Am Coll Surg. 2012;97:43-45.
COSMETIC AND RECONSTRUCTIVE SURGERY Risk of Readmission following Immediate Breast Reconstruction: Results from the 2011 American College of Surgeons National Surgical Quality Improvement Program Data Sets Nelson JA, Fischer JP, Chung C, et al (Univ of Pennsylvania, Philadelphia) Plast Reconstr Surg 134:193e-201e, 2014
Background.dWith health reform increasingly focused on readmission rates as an indicator of quality of care, providers have a duty to identify patients at risk of readmission. The authors assessed the incidence and risk factors for readmission following immediate breast reconstruction. Methods.dPatients who underwent immediate breast reconstruction
68
were identified through the 2011 American College of Surgeons National Surgical Quality Improvement Program database. Patients were grouped by readmission or no readmission and analyzed for trends in comorbidities and intraoperative characteristics. A multivariate regression analysis was performed to identify independently associated predictors of readmission. Results.dOverall, 3097 patients underwent immediate breast reconstruction; 5.8 percent were readmitted within 30 days of discharge. Readmitted patients had significantly higher body mass index [28.7 (6.6) versus 27.0 (6.5) kg/m2; p ¼ 0.005], were more likely to be smokers (17.2 percent versus 11.7 percent; p ¼ 0.03), and were more likely to have comorbid conditions (37.2 percent versus 26.1 percent; p ¼ 0.005). Readmitted patients were more likely to experience
Breast Diseases: A Year BookÒ Quarterly Vol 26 No 1 2015
surgical complications as inpatients (1.7 percent versus 0.3 percent; p ¼ 0.02) or outpatients (40.6 percent versus 2.6 percent; p < 0.001). On multivariate regression analysis, readmission was associated with smoking (OR ¼ 1.60; p ¼ 0.027) and obesity (OR ¼ 1.62; p ¼ 0.004), while total length of stay and inpatient surgical complications neared significance. Conclusions.dPatients undergoing immediate breast reconstruction should be identified and risk-stratified appropriately if they are obese, smokers with extended length of stay, or have surgical complications. Early identification may reduce the impact of readmission on the patient or minimize the likelihood of readmission altogether, whether via greater scrutiny before discharge or frequent postdischarge follow-up. Clinical Question/Level of Evidence.dRisk, III.
Feasibility of breast conserving surgery in multifocal breast cancers Kadioglu H, Yücel S, Yildiz S, et al (Bezmialem Vakif Üniversitesi, Fatih/ Istanbul, Turkey) Am J Surg 208:457-464, 2014
Background.dMultifocal breast cancers (MFBCs) present a challenge to surgeons. Although its feasibility is still controversial, breast-conserving surgery (BCS) is not contraindicated for MFBCs. The investigators retrospectively evaluated the feasibility of BCS and reviewed histopathologic findings in patients with MFBC. Methods.dA total of 222 patients with MFBC who were treated with either BCS (119 patients) or mastectomy (103 patients) at a single institution between January 2002 and December 2011 were retrospectively evaluated. Results.dThe median follow-up time was 55 months (range, 10 to 102 months). Lymphovascular invasion and lymph node involvement were significantly less frequent in the BCS group (48.8% vs 62.2% for lymphovascular invasion, P ¼.04; 52.1% vs 71.8% for lymph node involvement, P ¼ .002). There were no differences in local recurrence rates between the 2 groups. The overall survival rates were 92%
chemotherapy. Cancer. 2005;103: 689-695. 12. Mamounas EP, Anderson SJ, Dignam JJ, et al. Predictors of locoregional recurrence after neoadjuvant chemotherapy:
in the BCS group and 72% in the mastectomy group (P ¼ .000). Conclusions.dBCS is a feasible and safe procedure for the removal of multifocal tumors. Extended lymphovascular invasion is associated with mortality in patients who undergo mastectomy. Patients with MFBC can be considered for breast conservation depending on disease extent and breast size. In MFBC, breast conservation remains controversial, although recent data indicate reasonable local control with breast conservation in these cases.1-3 The American College of Surgeons Oncology Group Z11102 trial is a prospective study currently assessing the local recurrence rate after breast conservation in women presenting with multiple ipsilateral breast cancers separated by at least 2 cm of normal breast tissue. In this article, Kadioglu and colleagues report on local recurrence and survival in a cohort of patients with MFBC, comparing those who underwent BCS with those who underwent mastectomy. In this article, multifocal disease was defined as the presence of 2 or more malignant lesions in the same quadrant of the breast separated by normal breast tissue, which is an appropriate, commonly used defini-
Results from combined analysis of National Surgical Adjuvant Breast and Bowel Project B-18 and B-27. J Clin Oncol. 2012;30: 3960-3966.
tion. However, these multifocal tumors were not all identified preoperatively, as they could be diagnosed by palpation, radiologic imaging, or pathologic examination from surgery. These different methods of diagnosis introduce significant heterogeneity to the patient population described. Pathologically identified additional foci of disease represent a significantly different patient population and disease volume from those represented by preoperatively identified multifocal disease. The mastectomy group had significantly worse tumor biology than the BCS group, with a higher proportion of human epidermal growth factor receptor 2epositive disease, lymphovascular invasion, lymph node involvement, and number of disease foci in the breast. These critical differences likely account for the significant difference in overall survival between the 2 groups, as supported by the lack of statistically significant differences in survival between the groups when analyzed by disease stage. Unfortunately, patients treated with taxane-based chemotherapy were excluded from this analysis, which is a significant shortfall because taxanes are part of the current standard adjuvant chemotherapy recommendations for patients with breast cancer receiving chemotherapy. It is unclear how this analysis defined cases that on preoperative
Breast Diseases: A Year BookÒ Quarterly Vol 26 No 1 2015
67
imaging were determined to be multifocal but on final pathology were found to be 1 contiguous area. Similarly, patients with what appeared to be unifocal disease preoperatively who were found to have 2 or more foci on final pathology were included in this cohort. The 5% local recurrence rate at 55 months reported here is in keeping with reports from other studies of recurrence rates in patients with MFBC.1-3 Unfortunately, this article does not add significantly to the published literature on MFBC. Results from the American College of Surgeons Oncology Group Z11102 trial will be
important for understanding local recurrence rates in patients with multiple ipsilateral tumors who undergo BCS and contemporary adjuvant therapy and will help guide future recommendations.4 J. C. Boughey, MD
References 1. Gentilini O, Botteri E, Rotmensz N, et al. Conservative surgery in patients with multifocal/multicentric breast cancer. Breast Cancer Res Treat. 2009;113:577-583.
2. Lim W, Park EH, Choi SL, et al. Breast conserving surgery for multifocal breast cancer. Ann Surg. 2009;249:87-90. 3. Bauman L, Barth RJ, Rosenkranz KM. Breast conservation in women with multifocalmulticentric breast cancer: is it feasible? Ann Surg Oncol. 2010;17: 325-329. 4. Boughey JC, Rosenkranz K, Nelson H. Multiple ipsilateral breast cancers: can the breast be preserved? Bull Am Coll Surg. 2012;97:43-45.
COSMETIC AND RECONSTRUCTIVE SURGERY Risk of Readmission following Immediate Breast Reconstruction: Results from the 2011 American College of Surgeons National Surgical Quality Improvement Program Data Sets Nelson JA, Fischer JP, Chung C, et al (Univ of Pennsylvania, Philadelphia) Plast Reconstr Surg 134:193e-201e, 2014
Background.dWith health reform increasingly focused on readmission rates as an indicator of quality of care, providers have a duty to identify patients at risk of readmission. The authors assessed the incidence and risk factors for readmission following immediate breast reconstruction. Methods.dPatients who underwent immediate breast reconstruction
68
were identified through the 2011 American College of Surgeons National Surgical Quality Improvement Program database. Patients were grouped by readmission or no readmission and analyzed for trends in comorbidities and intraoperative characteristics. A multivariate regression analysis was performed to identify independently associated predictors of readmission. Results.dOverall, 3097 patients underwent immediate breast reconstruction; 5.8 percent were readmitted within 30 days of discharge. Readmitted patients had significantly higher body mass index [28.7 (6.6) versus 27.0 (6.5) kg/m2; p ¼ 0.005], were more likely to be smokers (17.2 percent versus 11.7 percent; p ¼ 0.03), and were more likely to have comorbid conditions (37.2 percent versus 26.1 percent; p ¼ 0.005). Readmitted patients were more likely to experience
Breast Diseases: A Year BookÒ Quarterly Vol 26 No 1 2015
surgical complications as inpatients (1.7 percent versus 0.3 percent; p ¼ 0.02) or outpatients (40.6 percent versus 2.6 percent; p < 0.001). On multivariate regression analysis, readmission was associated with smoking (OR ¼ 1.60; p ¼ 0.027) and obesity (OR ¼ 1.62; p ¼ 0.004), while total length of stay and inpatient surgical complications neared significance. Conclusions.dPatients undergoing immediate breast reconstruction should be identified and risk-stratified appropriately if they are obese, smokers with extended length of stay, or have surgical complications. Early identification may reduce the impact of readmission on the patient or minimize the likelihood of readmission altogether, whether via greater scrutiny before discharge or frequent postdischarge follow-up. Clinical Question/Level of Evidence.dRisk, III.