Early Onset Angiosarcoma of the Breast Following Breast Conserving Therapy

Introduction: Breast angiosarcoma following treatment for breast cancer is a rare event and generally presents no earlier than 6 years after treatment. We identified 2 cases of early-onset angiosarcoma and evaluated patient and treatment factors. Methods: At our large multi-hospital health system, the tumor registry was searched for breast sarcoma from 2000-2020. Patient, tumor, and treatment details were collected. Results: 39 patients were identified, 4 with radiation induced angiosarcoma following breast cancer treatment (range 3-11 years). Two of the cases were early-onset, diagnosed at 3 and 4 years respectively. Patient 1 underwent BCT at age 44 for T1bN0 estrogen positive Her2 negative breast cancer. She presented 3 years later with progressive skin discoloration. After a delay of 3 months as multiple providers thought this was bruising secondary to trauma sustained during a fall, she was referred to breast surgery and punch biopsy was diagnostic for angiosarcoma (Figure 1). She underwent right mastectomy revealing 9.7-cm of high grade angiosarcoma. Patient 2 underwent BCT at 72 for T1cN1a estrogen positive Her2 negative breast cancer. She presented 4 years later with a suspicious skin finding. Punch biopsy was diagnostic for angiosarcoma. She underwent right mastectomy revealing 8-cm of high grade angiosarcoma. Conclusions: Radiation induced breast angiosarcoma is a known but rare entity typically occurring at least 6 years after treatment for breast cancer; however, it should remain high on the differential for patients with suspicious breast lesions before 6 years to avoid a delay in diagnosis as early-onset angiosarcoma does occur.https://scholarlycommons.henryford.com/merf2020caserpt/1126/thumbnail.jp

Launching Virtual Care in a Benign Breast Surgery Clinic

The aim of this study is to assess the success of implementation of a telemedicine clinic in a benign breast surgery practice, and the hypothesis was that some women may feel uncomfortable virtually discussing breast complaints and problems. Twelve women seen as new patients in the benign breast surgery clinic and scheduled for surgery were asked if they were interested in having their post-operative visit performed virtually. Demographic information was also collected. Ages ranged from 24 to 77 years, and distance from the hospital ranged from 4.3 miles to 14.3 miles. Of the 12 women surveyed, 8 women were interested in the telemedicine visits. The 4 women that declined were either not active on the patient portal, not active on the computer, or without access to a computer, and their ages ranged from 52-77. The 8 women that were interested in telemedicine ranged in age from 24-67, which was a younger group overall. There was no significant difference in distance from the hospital within the two groups. Of the 8 women who were interested in telemedicine, 2 have completed the post-operative virtual visit without requiring an in-person visit and were satisfied with their virtual visits. There is an opportunity for use of telemedicine in the benign breast clinic for routine post-operative visits. The hypothesis that women would be reluctant to participate due to discomfort with discussing breast problems virtually was not demonstrated. Telemedicine visits can be an important way to personalize care for patients and increase satisfaction

Patient and disease pre-operative factors influencing surgical procedure choice for breast cancer treatment

Background/Objective: To address disparities of care in breast cancer treatment, it is important to understand pre‐operative factors that could affect the surgical decision‐making process. Methods: This prospective cohort study evaluates patient‐reported outcomes in women undergoing breast cancer treatment at a metropolitan health care system. Each new breast cancer case undergoes tumor board discussion, and patients have same‐day consultations with various specialties. Based on their procedure choice, women choose to complete pre‐ and post‐operative Breast‐Q© Breast‐ conserving Surgery (BCS), Mastectomy (M), or Reconstruction ® modules and demographic surveys. Individual effects of pre‐operative factors on procedure choice were assessed using ANOVA for continuous variables and chi‐squared for categorical. Significant factors (p≤0.05) were added to a multinomial logistic regression model. Results: A total of 375 women completed pre‐operative surveys (BCS=244, M=39, BR=92). Compared to BR, those chose BCS were older (RRR=1.094, p\u3c0.001) with larger BMIs (RRR=1.094, p=0.001), without a history of breast cancer (RRR=0.130 (yes vs. no), p=0.016), and Stage I disease (RRR=4.920, p\u3c0.001). Women making more than $200K (RRR=4.56x105 (vs. 35K), p\u3c0.0001) were also more likely to undergo BR. Compared to BCS, women undergoing neoadjuvant chemotherapy (RRR=3.591, p=0.047) and Stage II disease (RRR=4.238, p=0.040) were more likely to undergo mastectomy alone, whereas race, education, employment, and most incomes did not correlate with procedure choice. Conclusions: Our data suggest that racial and socioeconomic disparities in procedure type can be addressed by presenting equally effective surgical strategies to all patients in a multidisciplinary model that allows patients to interact with plastic surgeons, radiation oncologists, and surgical and medical oncologists

Patient factors that affect pre-operative patient-reported outcomes in women undergoing breast cancer surgery

Background/Objective: Understanding the impact of patient, disease, and treatment factors on pre‐ operative patient reported outcomes (PROs) is important to guide surgical decision‐making with breast cancer. Methods: This prospective cohort study evaluates PROs in women undergoing breast cancer treatment at a metropolitan health care system. New cases undergo tumor board discussion and same‐day consultations with various specialties. Women choose to complete pre‐ and post‐operative Breast‐Q© Breast‐conserving surgery (BCS), mastectomy (M), or reconstruction ® modules and demographic surveys. Individual associations to pre‐operative Breast‐Q survey scores were assessed using linear regression models (1 for each Breast‐Q survey type). Variables significant for at least 1 survey were included in multiple linear regression models. Results: A total of 375 women completed the pre‐operative surveys (BCS=244, M=39, BR=92). Procedure choice, laterality, race, marital status, employment, prior breast cancer, neoadjuvant chemotherapy, or history of radiation or chemotherapy did not impact PROs. Breast satisfaction decreased with higher BMI (est=‐0.367, p=0.045) and Stage II disease (est=‐11.011 (vs. Stage 0), p=0.008). Lower psychosocial score was associated with younger age (est=0.271, p=0.002), higher BMI (est=‐0.367, p=0.014), and income \u3c$35k (est=0.172 (vs. 35k+), p=0.016). Similarly, lower physical well‐being of the chest was associated with younger age (est=0.207, p=0.011), higher BMI (est=‐0.285, p=0.039), and income \u3c$35k (est=0.218 (vs. 35k+, p=0.039). Sexual well‐being decreased with higher BMI (est=‐0.545, p=0.004) and income \u3c$35k (est=0.135 (vs. 35k+), p=0.016). Conclusions: While factors such as age, BMI, and stage of disease are difficult to change prior to surgery, patients with lower income may need special interventions to assist them through the treatment process

Differences between Breast Conservation‐Eligible Patients and Unilateral Mastectomy Patients in Choosing Contralateral Prophylactic Mastectomies

There has been an increasing use of bilateral mastectomy (BM) for breast cancer. We sought to examine our trends among breast conservation (BCT) candidates and women recommended for unilateral mastectomy (UM). Our prospective breast cancer database was queried for women with a first‐time, unilateral breast cancer. Patient and histologic factors and surgical treatment, including reconstruction, were evaluated. A detailed chart review was performed among patients from two representative time periods as to the reasons the patient underwent mastectomy. We identified 3,892 women between 2000 and 2012 of whom 60% underwent BCT, 1092 (28%) had UM and 12% underwent BM. BM rose from 4% in 2000 to a high of 19% in 2011, increasing around 2002 for women <40. BCT was less likely with decreasing age (p < 0.0001), lobular histology (p < 0.0001), higher stage (p < 0.0001) and decreasing BMI (p < 0.0001). Among mastectomy patients, contralateral mastectomy was associated with decreasing age (p < 0.0001), Caucasian race (p < 0.0001), and lower stage (p = 0.005). Over time, indications for mastectomy decreased while patients deemed BCT‐eligible opting for UM or BM increased dramatically. Increases in the use of BM are in large part among women who were otherwise BCT‐eligible. Factors associated with BM use are different for BCT‐eligible patients and those recommended for UM. A better understanding of the factors driving individual patient choices is needed.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135041/1/tbj12648_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135041/2/tbj12648.pd

The effect of lymphatic microsurgical preventive healing approach (LYMPHA) on the development of upper-extremity lymphedema following axillary lymph node dissection in breast cancer patients

Background/Objective: Lymphedema following axillary lymph node dissection (ALND) is a common complication that can negatively impact quality of life as it reduces the functional capacity of the affected arm. It can also predispose patients to serious infectious complications such as limb cellulitis and development of malignancy. The lymphatic microsurgical preventive healing approach (LYMPHA procedure) involves the creation of a lymphatic‐to‐venous bypass at the time of axillary lymph node dissection (ALND) as a means of preventing lymphedema. The goal of our study is to assess the effect of LYMPHA on the development of clinical and subjective post‐operative lymphedema. Methods: This is a prospective longitudinal study in patients with breast cancer who underwent ALND with or without LYMPHA. The incidence of lymphedema was compared between ALND alone and ALND with LYMPHA using descriptive statistics. Limb circumference of both affected and unaffected limbs were measured and used to calculate limb volume by using an equation that converts limb circumference (cm) to volume (cc). Lymphedema was defined as a volume difference of ≥10% between the affected and unaffected limb. Patient symptoms were also assessed and compared between the 2 groups. Patient demographics including age, preoperative body mass index (BMI), smoking history, comorbidities, receipt of neoadjuvant or adjuvant chemotherapy, and receipt of adjuvant radiation were compared between the groups. Results: In our cohort of 139 patients, 104 underwent ALND with LYMPHA, while 35 underwent ALND alone. Of these, 52.5% of patients had documented interlimb circumference measurements. The mean age was 52.6 years old, mean BMI was 30.16 kg/m2, 4 patients (2.9%) had pre‐operative radiation, 102 patients (73.4 %) had post‐operative radiation, 86 patients (61.9 %) had neoadjuvant chemotherapy, 41 and 58 patients (41.7 %) had adjuvant chemotherapy. There were no significant differences between the 2 groups in the above demographics and treatment variables, except those who underwent ALND alone had a significantly higher incidence of diabetes mellitus (25.7% patients with ALND alone vs 11.5% LYMPHA patients (p=0.043)). Based on patient reported symptoms and the need to initiate complete decongestive therapy, 57.1% (n=20) of patients who underwent ALND alone developed lymphedema compared to 26.9% (n=28 patients) of those who had ALND with LYMPHA (p=0.0011). When comparing the relative volume difference, 57.1% (n=8) of ALND alone patients developed lymphedema versus 20.3% (n=12) of LYMPHA patients (p=0.0055). Conclusions: Our data support the universal use of LYMPHA at the time of ALND as a means of preventing upper extremity lymphedema. Further studies are needed to evaluate quality of life and functional differences between those who had LYMPHA and those who did not

The effect of oncoplastic reduction on the incidence of post-operative lymphedema in breast cancer patients undergoing lumpectomy

Purpose: In breast cancer patients with macromastia, breast conservation surgery (BCS) followed by radiation therapy (RT) may be associated with a different complication profile than those without macromastia. Oncoplastic reduction mammoplasty (ORM) aims to reduce breast volume while excising the tumor bed and its margins. Since breast volume was found to be a risk factor for chronic breast lymphedema, this study was performed to determine the impact of ORM on chronic breast lymphedema as well as other complications compared to BCS without ORM. Material & Methods: We performed a retrospective chart review on patients who underwent lumpectomy with RT from 2014 to 2018. Chronic breast lymphedema (CBL) was defined as swelling that persisted \u3e1 year post-RT. Breast volumes (BV) were determined by contoured breast volumes or, if unavailable, estimated by the 95% isodose volumes from the RT treatment planning system. Univariate analysis was used to evaluate patient factors and treatment outcomes in women with BV ≥1300 cc compared to-Evaluate factors associated with ≥1 complication. Identify factors associated with the development of CBL. Results: The total population included 1173 patients: -1122 (95.7%) underwent BCS alone without ORM -51 (4.3%) underwent ORM -733 (62.5%) had a BVcc -440 (37.5%) had BV ≥1300 cc Multivariate regression analysis demonstrated that compared to patients with BV \u3c 1300 cc, patients with BV ≥1300 cc had: -Higher BMI (OR=1.200, P\u3c0.001) -Increased risk of CBL (OR=2.127, P=0.024) -Decreased risk of grade 2 radiation dermatitis (OR=0.457, P=0.002) Conclusion: Our data demonstrates that patients with breast volumes ≥1300 cc were two times more likely to develop CBL. Although patients with ORM had an increased risk for surgical site complications, the ORM procedure may have mitigated their risk for CBL. ORM should be considered at the time of BCS in women with macromastia to reduce their future risk of CBL as there is no cure for this disease.https://scholarlycommons.henryford.com/sarcd2021/1008/thumbnail.jp

Outcome of African-American compared to White-American patients with early-stage breast cancer, stratified by phenotype

BACKGROUND: Breast cancer mortality rates are 39% higher in the African-American (AA) women compared to White-American (WA) women despite the advances in overall breast cancer screening and treatments. Several studies have undertaken to identify the factors leading to this disparity in United States with possible effects of lower socioeconomic status and underlying aggressive biology. METHODS: A retrospective analysis was done using a prospectively maintained database of a metropolitan health system. Patients were selected based on diagnosis of early-stage breast cancer between 10/1998 and 02/2017, and included women over age of 18 with clinically node-negative disease. Patients were then stratified by phenotype confirmed by pathology and patient-identified race. RESULTS: A total of 2,298 women were identified in the cohort with 39% AA and 61% WA women. The overall mean age at the time of diagnosis for AA women was slightly younger at 60 years compared to 62 years for WA women (p = 0.003). Follow-up time was longer for the WA women at 95 months vs. 86 months in AA women. The overall 5-year survival was analyzed for the entire cohort, with the lowest survival occurring in patients with triple-negative breast cancer (TNBC). Phenotype distribution revealed a higher incidence of TNBC in AA women compared to WA women (AA 16% vs. WA 10%; p \u3c 0.0001). AA women also had higher incidence of HER2 positive cancers (AA 16.8% vs. WA 15.3%; p \u3c 0.0001). WA women had a significantly higher distribution of Non-TNBC/HER2-negative phenotype (AA 55% vs. WA 65%; p \u3c 0.0001). Furthermore, a subgroup analysis was done for a sentinel lymph node (SLN) negative cohort that showed higher rates of grade 3 tumors in AA (AA 35% vs. WA 23%; p \u3c 0.0001); and higher rates of grade 1 and grade 2 tumors in WA (30% vs. 21% and 44% vs. 40%). Despite higher grade tumors in AA women, five-year overall survival outcomes in SLN-negative cohort did not differ between AA and WA women when stratifying based on tumor subtype. CONCLUSION: Breast cancer survival disparities in AA and WA women with SLN-negative breast cancer are diminished when evaluated at early-stage cancers defined by SLN-negative tumors. Our evaluation suggests that when diagnosed early, phenotype does not contribute to racial survival outcomes. The lower survival rate in AA women with breast cancer may be attributed to later stage biology between the two races, or underlying socioeconomic disparities