ESTRO consensus guideline for target volume delineation in the setting of postmastectomy radiation therapy after implant-based immediate reconstruction for early stage breast cancer

© 2019 Elsevier B.V. Immediate breast reconstruction (IBR) rates after mastectomy are increasing. Postmastectomy radiation therapy (PMRT) contouring guidelines for target volumes in the setting of IBR are lacking. Therefore, many patients who have had IBR receive PMRT to target volumes similar to conventional simulator-based whole breast irradiation. The aim of this paper is to describe delineation guidelines for PMRT after implant-based IBR based on a thorough understanding of the surgical procedures, disease stage, patterns of recurrence and radiation techniques. They are based on a consensus endorsed by a global multidisciplinary group of breast cancer experts

Perioperative events influence cancer recurrence risk after surgery.

Surgery is a mainstay treatment for patients with solid tumours. However, despite surgical resection with a curative intent and numerous advances in the effectiveness of (neo)adjuvant therapies, metastatic disease remains common and carries a high risk of mortality. The biological perturbations that accompany the surgical stress response and the pharmacological effects of anaesthetic drugs, paradoxically, might also promote disease recurrence or the progression of metastatic disease. When cancer cells persist after surgery, either locally or at undiagnosed distant sites, neuroendocrine, immune, and metabolic pathways activated in response to surgery and/or anaesthesia might promote their survival and proliferation. A consequence of this effect is that minimal residual disease might then escape equilibrium and progress to metastatic disease. Herein, we discuss the most promising proposals for the refinement of perioperative care that might address these challenges. We outline the rationale and early evidence for the adaptation of anaesthetic techniques and the strategic use of anti-adrenergic, anti-inflammatory, and/or antithrombotic therapies. Many of these strategies are currently under evaluation in large-cohort trials and hold promise as affordable, readily available interventions that will improve the postoperative recurrence-free survival of patients with cancer

Abstract S5-2: Iatrogenic Displacement of Tumor Cells to the Sentinel Node after Surgical Excision Biopsy in Primary Breast Cancer

Abstract Background: It is shown that isolated tumor cells are more common in the sentinel node after needle biopsy of a breast cancer, indicating iatrogenic displacement of epithelial cells. This may result in unnecessary axillary lymph node dissections. It is possible that a similar iatrogenic displacement occurs after surgical excision biopsy but the incidence and clinical significance is basically unknown. Material and Methods: By linking data from the Danish Breast Cancer Cooporative Group database and data from the Danish National Health Registry we compared the incidence of isolated tumor cells and micrometastases in the sentinel node of 347 breast cancer patients with prior surgical excision biopsy to a group of 14401 patients without prior surgical excision biopsy in a multivariate analysis adjusting for tumor size, receptor status, type and histological grade. The incidence of isolated tumor cells in the sentinel node was further analysed by histological type. Finally, we investigated the incidence of non-sentinel node metastases in patients with isolated tumor cells and micrometastases in the sentinel node after prior surgical excision biopsy. Results: We found an adjusted odds ratio on 3.99 (95% CI 2.67-5.97; P&amp;lt;0.0001) for having isolated tumor cells in the sentinel node after surgical excision biopsy. Likewise, we found an adjusted odds ratio for having micrometastases on 1.62 (95% CI 1.20 -2.18; P=0.002). Isolated tumor cells were, in general, more common in the sentinel node of lobular carcinomas compared to ductal carcinomas (adjusted OR 3.51; 95% CI 2.80-4.40; P&amp;lt;0.0001). In contrast, the increase in isolated tumor cells after surgical excision biopsy was especially seen in patients with ductal carcinomas with an adjusted odds ratio on 5.41 (95% CI 3.45-8.48; P=0.054) whereas the odds ratio for lobular carcinomas was only 1.53 (95% CI 0.45-5.14) (P=0.054 for heterogeneity). None of the 20 patients with isolated tumor cells in the sentinel node after prior surgical excision biopsy had non-sentinel node metastases compared to 13% in the group without prior surgical excision biopsy (P=0.15). In patients with micrometastases in the sentinel node after prior surgical excision biopsy 13% had non sentinel node metastases compared to 18% in the group without prior surgical excision biopsy (P=0.29). Conclusions: The 4-fold increase in isolated tumor cells in the sentinel node after surgical excision biopsy indicates that this procedure induces iatrogenic displacement of epithelial cells. This displacement is more common in ductal carcinomas, despite the fact that lobular carcinomas, in general, are more likely to present with isolated tumor cells in the sentinel node. We found no further dissemination to non-sentinel lymph nodes, suggesting that isolated tumor cells in the sentinel node in these women do not indicate further spread of disease. Hence, in case of isolated tumor cells in the sentinel node after prior surgical excision biopsy, omission of axillary lymph node dissection should be considered. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S5-2.</jats:p

Abstract S3-08: Radioactive seed localization versus wire guided localization of nonpalpable invasive and in situ breast cancer: A Danish multicenter randomized controlled trial

Abstract Background: The current standard method for locating nonpalpable breast lesions is wire guided localization (WGL) despite several methodological difficulties. Radioactive Seed Localization (RSL) has been developed to reduce these difficulties. The aim of this randomized trial was to compare the rate of positive resection margins between RSL and WGL in patients with nonpalpable invasive breast cancer (IBC) or ductal carcinoma in situ (DCIS). Material and Methods: Patients with nonpalpable IBC or DCIS visible on ultrasound were randomized to either of the two localization methods. Primary outcome was margin status at the final pathological evaluation. According to Danish standard in the study period margins were defined positive if cancer cells were found &amp;lt; 2mm from the inked margin. Secondary outcomes were duration of the surgical procedure, weight of the excised specimen and patient's pain perception. χ2-test, Fisher's exact test and Wilcoxon rank-sum test, respectively, were used to test differences between groups. Level of statistical significance was set to 5%. The average activity of seeds used in the trial was 1.70 MBq (range 0.7-3.27). Results: 413 cases representing 409 patients were randomized; 207 were allocated to RSL and 206 to WGL. 23 cases, who did not meet inclusion criteria, chose to withdraw, or had a change in surgical management, were excluded. The remaining 390 were included in the analysis. Patient, surgical and pathological characteristics between the two groups were alike, except for significantly more patients with DCIS in the WGL group (5.1% vs 0.5%). Significantly more cases in the WGL group (9.7%) needed additional localization compared to the RSL group (2.1%) (p=0.0014). In all cases but one in the RSL group, the index lesion was removed. Margins were positive in 23 cases (11.8%) in the RSL group compared to 26 cases (13.3%) in the WGL group. We were not able to detect a difference in margin status between the two groups (p=0.65). For IBC only, the number of positive margins was 22 (11.3%) in the RSL group and 21 (11.4%) in the WGL group (p=0.997). There was no difference between the two groups in the amount of tissue removed whether the analysis was done on the primary excision (p=0.18) or the total weight including intraoperative re-excisions (p=0.33). There was no difference in pain perception between the two groups whether patients who received local anesthesia were kept in the analysis (p=0.28) or excluded (p=0.91). Local anesthesia was used more frequently in the RSL group. Finally, there was no difference in the duration of the surgical procedure (p=0.12), the complication rate (p=0.89) or the identification rate for SN (p=1.0). Conclusions: We were not able to detect any differences considering positive margins, patient's pain perception or duration of the surgical procedure between the two localization methods. However, RSL offers a major logistic advantage, as the seed localization can be done several days before surgery without any risk or discomfort for the patient, with a low proportion of patients needing additional localization. So the RSL procedure has now been found preferable at our institutions. Citation Format: Langhans L, Tvedskov TF, Klausen TL, Jensen M-B, Talman M-L, Vejborg I, Benian C, Roslind A, Hermansen J, Oturai PS, Bentzon N, Kroman N. Radioactive seed localization versus wire guided localization of nonpalpable invasive and in situ breast cancer: A Danish multicenter randomized controlled trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S3-08.</jats:p

Prognostic significance of axillary dissection in breast cancer patients with micrometastases or isolated tumor cells in sentinel nodes: a nationwide study

We estimated the impact of axillary lymph node dissection (ALND) on the risk of axillary recurrence (AR) and overall survival (OS) in breast cancer patients with micrometastases or isolated tumor cells (ITC) in sentinel nodes. We used the Danish Breast Cancer Cooperative Group (DBCG) database to identify patients with micrometastases or ITC in sentinel nodes following surgery for primary breast cancer between 2002 and 2008. A Cox proportional hazard regression model was developed to assess the hazard ratios (HR) for AR and OS between patients with and without ALND. We identified 2074 patients, of which 240 did not undergo further axillary surgery. The 5-year cumulated incidence for AR was 1.58 %. No significant difference in AR was seen between patients with and without ALND. The age adjusted HR for AR if ALND was omitted was 1.79 (95 % CI 0.41-7.80, P = 0.44) in patients with micrometastases and 2.21 (95 % CI 0.54-8.95, P = 0.27), in patients with ITC after a median follow-up of 6 years and 3 months. There was no significant difference in overall survival between patients with and without ALND, when adjusting for age, co-morbidity, tumor size, histology type, malignancy grade, lymphovascular invasion, hormone receptor status, adjuvant systemic treatment and radiotherapy, with a HR for death if ALND was omitted of 1.21 (95 % CI 0.86-1.69, P = 0.27) in patients with micrometastases and 0.96 (95 % CI 0.57-1.62, P = 0.89) in patients with ITC after a medium follow-up on 8 and 5 years. In this nationwide study, we found a low risk of AR on 1.58 % and we did not find a significantly increased risk of AR if ALND was omitted in patients with micrometastases or ITC in sentinel nodes. Furthermore, no significant difference in overall survival was seen between patients with and without ALND when adjusting for adjuvant treatment.</p