Screening for distant metastases in patients with ipsilateral breast tumor recurrence: the impact of different imaging modalities on distant recurrence-free interval

Purpose In patients with ipsilateral breast tumor recurrence (IBTR), the detection of distant disease determines whether the intention of the treatment is curative or palliative. Therefore, adequate preoperative staging is imperative for optimal treatment planning. The aim of this study is to evaluate the impact of conventional imaging techniques, including chest X-ray and/or CT thorax-(abdomen), liver ultrasonography(US), and skeletal scintigraphy, on the distant recurrence-free interval (DRFI) in patients with IBTR, and to compare conventional imaging with 18F-FDG PET-CT or no imaging at all. Methods This study was exclusively based on the information available at time of diagnoses of IBTR. To adjust for differences in baseline characteristics between the three imaging groups, a propensity score (PS) weighted method was used. Results Of the 495 patients included in the study, 229 (46.3%) were staged with conventional imaging, 89 patients (19.8%) were staged with 18F-FDG PET-CT, and in 168 of the patients (33.9%) no imaging was used (N=168). After a follow-up of approximately 5 years, 14.5% of all patients developed a distant recurrence as frst event after IBTR. After adjusting for the PS weights, the Cox regression analyses showed that the diferent staging methods had no signifcant impact on the DRFI. Conclusions This study showed a wide variation in the use of imaging modalities for staging IBTR patients in the Netherlands. After using PS weighting, no statistically signifcant impact of the diferent imaging modalities on DRFI was shown. Based on these results, it is not possible to recommend staging for distant metastases using 18F-FDG PET-CT over conventional imaging technique

[Secondary breast operations are often necessary and are no indication of poor oncological quality]

Contains fulltext : 69254.pdf (publisher's version ) (Closed access)The most important factor for tumour recurrence after breast-saving surgery is the margin status. In the Netherlands a 1-mm free margin has been formulated as sufficient, and totally free margins are not necessary in all cases. The current Dutch Health Inspectorate performance indicator, i.e. 10% reexcisions allowed to achieve free margins, is a performance indicator of questionable validity. As long as there is worldwide discussion about the ideal margin in breast-saving surgery a specific norm cannot not be dictated. The aim of the discussion should be how to prevent local recurrence. This percentage is the real performance indicator

Magnetic resonance imaging of ductal carcinoma in situ: what is its clinical application? A review.

Contains fulltext : 79912.pdf (publisher's version ) (Closed access)BACKGROUND: After breast-conserving surgery of ductal carcinoma in situ (DCIS) of the breast or invasive breast carcinoma with an extensive intraductal component, tumor-positive surgical margins are frequently found. Therefore, the extent of the intraductal disease needs to be accurately determined preoperatively. METHODS: Data for this review were identified by search of PubMed. Reference lists of selected articles were cross-searched for additional literature. RESULTS: DCIS is accurately detected with magnetic resonance imaging (MRI), but the typical malignant features are inconsistently seen and most often in high-grade DCIS or in DCIS with a small invasive component. The histopathologic extent of DCIS is more accurately demonstrated with MRI. However, overestimation due to benign proliferative lesions does frequently occur. An improved depiction of DCIS could lead to improved preoperative staging. Conversely, the identification of more extensive disease on MRI could give rise to unnecessary interventions. Therefore, MRI should be used carefully and preferable in specialized and experienced centers. CONCLUSSION: To date, there is no evidence that the use of MRI improves outcomes (ie, decreases recurrence rates) in patients with DCIS

Performance characteristics of specimen radiography for margin assessment for ductal carcinoma in situ: a systematic review

Item does not contain fulltextBACKGROUND: Reducing positive margin rate (PMR) and reoperation rate in breast-conserving operations remains a challenge, mainly regarding ductal carcinoma in situ (DCIS). Intra-operative margin assessment tools have emerged to reduce PMR over the last decades, including specimen radiography (SR). No consensus has been reached on the reliability and efficacy of SR in DCIS. OBJECTIVE: We performed a systematic literature review to assess the performance characteristics of SR for margin assessment of breast lesions with pure DCIS and invasive cancers with DCIS components. METHODS: A literature search was conducted for diagnostic studies up to April 2017 concerning SR for intra-operative margin assessment of breast lesions with pure DCIS or with DCIS components. Studies reporting sensitivity and specificity calculated using final pathology report as reference test were included. Due to improved imaging technology, studies published more than 15 years ago were excluded. Methodological quality was assessed using quality assessment of diagnostic accuracy studies-2 checklist. Due to clinical and methodological diversity, meta-analysis was considered not useful. RESULTS: Of 235 citations identified, 9 met predefined inclusion criteria and documented diagnostic efficacy data. Sensitivity ranged from 22 to 77% and specificity ranged from 51 to 100%. Positive predictive value and negative predictive value ranged from 53 to 100% and 32 to 95%, respectively. High or unclear risk of bias was found in reference standard in 5 of 9 studies. High concerns regarding applicability of index test were found in 6 of 9 studies. CONCLUSIONS: The present results do not support the routine use of intra-operative specimen radiography to reduce the rate of positive margins in patients undergoing breast-conserving surgery for pure DCIS or the DCIS component in invasive cancer. Future studies need to differentiate between initial and final specimen margin involvement. This could provide surgeons with a number needed to treat for a more applicable outcome

Risk of Regional Recurrence After Negative Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence

Contains fulltext : 194597.pdf (publisher's version ) (Open Access)BACKGROUND: Repeat sentinel lymph node biopsy (rSLNB) has increasingly been used in patients with ipsilateral breast tumor recurrence (IBTR). The safety in terms of regional disease control after this procedure remains unclear. This study evaluates occurrence of regional recurrence as first event in patients with IBTR and negative rSLNB, treated without additional lymph node dissection. PATIENTS AND METHODS: Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 201 patients, tumor-negative rSLNB was obtained without performing additional lymph node dissections. RESULTS: With median follow-up of 4.7 (range 0.9-12.7) years, regional recurrence occurred after median time of 3.0 (range 0.4-6.7) years in 4.5% (N = 9) of patients as first event after IBTR and rSLNB. In four of these nine patients, the site of recurrence was in concordance with the anatomical location of rSLNB. Two of the nine recurrences were reported in the ipsilateral axilla, resulting in an ipsilateral axillary regional recurrence rate of 1.0%. In the other seven patients, regional recurrence occurred in aberrant basins. Univariable analysis showed that triple-negative IBTR and lower amount of radioactive-labeled tracer ((99m)technetium) used during rSLNB were associated with developing regional recurrence as first event after negative rSLNB (P < 0.05). CONCLUSIONS: The risk of developing regional recurrence after negative rSLNB is low. The low relapse rate supports the safety of rSLNB as primary nodal staging tool in IBTR. The time has come for clinical guidelines to adopt rSLNB as axillary staging tool in patients with IBTR

Low Risk of Development of a Regional Recurrence After an Unsuccessful Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence

Item does not contain fulltextBACKGROUND: Unlike sentinel lymph node biopsy (SLNB) in the primary setting, the repeat SLNB (rSLNB) in patients with ipsilateral breast tumor recurrence (IBTR) is challenging, because it is difficult to visualize and/or harvest a sentinel lymph node in every patient. Regional treatments options and safety in terms of regional disease control after such an unsuccessful rSLNB remain unclear. This study assesses factors associated with the performance of axillary lymph node dissection (ALND) after unsuccessful rSLNB and evaluates the occurrence of regional recurrences. METHODS: Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 239 patients, the rSLNB was unsuccessful, of whom 60 patients underwent ipsilateral ALND. RESULTS: A shorter time interval between primary treatment and IBTR, and a primary negative SLNB were significantly associated with a higher probability to be treated with ALND after unsuccessful rSLNB (P 0.05). CONCLUSIONS: The present study demonstrates that the risk of regional recurrence in patients with an IBTR and an unsuccessful rSLNB is negligible, irrespective of the use of ALND. This suggests that there is no need for additional treatment of the axilla after an unsuccessful rSLNB

The added value of mammography in different age-groups of women with and without BRCA mutation screened with breast MRI

Contains fulltext : 194260.pdf (publisher's version ) (Open Access

Prognostic impact of repeat sentinel lymph node biopsy in patients with ipsilateral breast tumour recurrence

BACKGROUND: Ipsilateral breast tumour recurrence (IBTR) has an unfavourable prognosis, with a significant subsequent risk of distant recurrence. Repeat sentinel lymph node biopsy (rSLNB) has recently been demonstrated to be technically feasible and useful in tailoring adjuvant treatment plans in patients with IBTR. The prognostic impact of rSLNB in patients with IBTR remains unclear. This study analysed the risk of distant recurrence after IBTR, and evaluated the prognostic impact of rSLNB and other patient and tumour characteristics on distant recurrence-free survival. METHODS: Data were obtained from the SNARB (Sentinel Node and Recurrent Breast Cancer) study. Cox proportional hazards analyses were performed to assess the prognostic effect of tumour, patient and treatment factors on distant recurrence-free survival. RESULTS: Of the 515 included patients, 230 (44.7 per cent) had a tumour-negative rSLNB and 46 (8.9 per cent) a tumour-positive rSLNB. In 239 patients (46.4 per cent) the rSLNB procedure was unsuccessful. After a median follow-up of 5.1 years, 115 patients (22.3 per cent) had developed a recurrence. The overall 5-year distant recurrence-free survival rate was 84.2 (95 per cent c.i. 80.7 to 87.7) per cent. An interval of less than 2 years between primary breast cancer treatment and ipsilateral recurrence (P = 0.018), triple-negative IBTR (P = 0.045) and absence of adjuvant chemotherapy after IBTR (P = 0.010) were independently associated with poor distant recurrence-free survival. The association between the outcome of rSLNB and distant recurrence-free survival was not statistically significant (P = 0.682). CONCLUSION: The outcome of rSLNB is not an important prognostic factor for distant recurrence, and its value as a staging tool in patients with IBTR seems disputable

Omitting Postoperative Wound Drainage After Mastectomy With Skin-Flap Quilting

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Influence of Risk Category and Screening Round on the Performance of an MR Imaging and Mammography Screening Program in Carriers of the BRCA Mutation and Other Women at Increased Risk

Contains fulltext : 183935.pdf (publisher's version ) (Closed access