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Background: Nipple-sparing mastectomy (NSM) is an oncologically safe approach for breast cancer treatment and prevention; however, there are little long-term data to guide management for patients whose nipple margins contain tumor or atypia. Methods: NSM patients with tumor or atypia in their nipple margin were identified from a prospectively maintained, single-institution database of consecutive NSMs. Patient and tumor characteristics, treatment, recurrence, and survival data were assessed. Results: A total of 3158 NSMs were performed from June 2007 to August 2019. Nipple margins contained tumor in 117 (3.7%) NSMs and atypia only in 164 (5.2%) NSMs. Among 117 nipple margins that contained tumor, 34 (29%) margins contained invasive cancer, 80 (68%) contained ductal carcinoma in situ only, and 3 (3%) contained lymphatic vessel invasion only. Management included nipple-only excision in 67 (57%) breasts, nipple-areola complex excision in 35 (30%) breasts, and no excision in 15 (13%) breasts. Only 23 (24%) excised nipples contained residual tumor. At 67 months median follow-up, there were 2 (1.8%) recurrences in areolar or peri-areolar skin, both in patients with nipple-only excision. Among 164 nipple margins containing only atypia, 154 (94%) nipples were retained. At 60 months median follow-up, no patient with atypia alone had a nipple or areola recurrence. Conclusions: Nipple excision is effective management for nipple margins containing tumor. No intervention is required for nipple margins containing only atypia. Our results support broad eligibility for NSM with careful nipple margin assessment. [ABSTRACT FROM AUTHOR]

Background: Retention of the nipple–areola complex with nipple-sparing mastectomy (NSM) techniques provides a more natural cosmetic result than procedures that sacrifice the nipple. While the oncologic safety of NSM is established by several studies, there is little long-term data on outcomes in BRCA mutation carriers with breast cancer. Patients and Methods: BRCA1/2 mutation carriers who underwent NSM and immediate reconstruction from 2008 to 2019 were reviewed and patients with breast cancer on biopsy or final pathology were included. Patient demographics and tumor characteristics, as well as treatment, recurrence, and survival data were collected. Results: A total of 114 therapeutic NSM were performed in 105 BRCA mutation carriers (56 BRCA1, 47 BRCA2, and two women with both mutations). Median age was 45 years. Cancers were 18% stage 0, 52% stage I, 27% stage II, and 3% stage III. Mean invasive tumor size was 1.6 cm and 33 (35%) invasive tumors were triple negative. There were five (4.4%) positive nipple margins on final pathology; all underwent nipple excision. Most patients (80, 76%) received systemic therapy: 65 (62%) received chemotherapy and 48 (46%) received endocrine therapy. At 70 months median follow-up (range 15–150 months), no patient had developed a recurrence in the retained nipple–areola complex or at the site of a nipple excised for a positive margin. The rate of locoregional recurrence outside the nipple was 2.6%, and the rate of distant recurrence was 3.8%. Overall survival was 96%. Conclusions: NSM is a safe option for BRCA1 and BRCA2 mutation carriers who undergo mastectomy for breast cancer. [ABSTRACT FROM AUTHOR]

Background: Reexcision following breast-conserving surgery (BCS) in women with ductal carcinoma in situ (DCIS) results in adjuvant treatment delays, higher health care costs, and undesirable cosmetic outcomes. The purpose of this study is to determine patient, imaging, pathological, and surgical predictors of reexcision following BCS for DCIS. Patients and Methods: A retrospective review of women with DCIS who had BCS from 2007 to 2016 was conducted. Patient, imaging, pathological, and surgical features, in addition to surgical outcomes, were collected from medical records. Standard statistical tests were used to compare features between patients who did and did not undergo at least one reexcision. A multivariable logistic regression model was fit to assess features associated with reexcision. Results: A total of 547 women (mean age 59 years; range 30–88 years) diagnosed with DCIS at core needle biopsy underwent BCS. Of all women, 31.6% (173/547) had at least one reexcision. With multivariable analysis, features associated with reexcision included younger patient age (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.97–1.0, p = 0.049), African-American race (aOR 2.66, 95% CI 1.13–6.26, p = 0.03), biopsy modality of ultrasound (aOR 2.35, 95% CI 1.22–4.53, p = 0.01), and earlier year of surgery (aOR 0.92, 95% CI 0.86–0.98, p = 0.01). No pathological features of DCIS were associated with reexcision risk. Conclusions: In our cohort of nearly 550 women with DCIS who underwent BCS, 31.6% had at least one reexcision. Features associated with reexcision include younger patient age, African-American race, biopsy modality of ultrasound, and earlier year of surgery. [ABSTRACT FROM AUTHOR]

Objectives: To compare upgrade rates of ductal carcinoma in situ (DCIS) on digital mammography (DM) versus digital breast tomosynthesis (DBT) and identify patient, imaging, and pathological features associated with upgrade risk. Methods: A retrospective review was performed of 318 women (mean 59 years, range 37–89) with screening-detected DCIS from 2007 to 2011 (DM group) and from 2013 to 2016 (DBT group). Comparisons made between DM and DBT groups using the unpaired t test and chi-square test include detection rates of DCIS, upgrade rates to invasive cancer, and pathological features of DCIS and upgraded cases. Patient, imaging, and pathological features associated with upgrade were also determined. P values < 0.05 were considered significant. Results: There was no significant difference in detection rates of DCIS between DM and DBT groups (0.9 versus 1.0 per 1000 examinations, p = 0.45). Upgrade rates of DCIS to invasive cancer in DM and DBT groups were similar (17.3% versus 16.8%, p = 0.90), despite significant differences in pathological features of DCIS between DM and DBT groups (including nuclear grade, comedonecrosis, and progesterone receptor status [p ≤ 0.01]). Among upgraded cases, a higher proportion were high-grade invasive cancers with DBT (36.7% versus 9.5%, p = 0.03). In both groups, ultrasound-guided (versus stereotactic) biopsy was associated with higher upgrade risk (p ≤ 0.03). Conclusions: There was no significant difference in detection rates or upgrade rates of DCIS on DM versus DBT; however, upgraded cases were more likely to be high grade with DBT, suggesting possible differences in tumor biology between cancers with DM and DBT. In both DM and DBT groups, biopsy modality was associated with upgrade risk. Key Points: • Detection rates and upgrade rates of ductal carcinoma in situ (DCIS) on digital mammography (DM) versus digital breast tomosynthesis (DBT) are similar. • A higher proportion of upgraded cases were high-grade invasive cancers with DBT than DM, suggesting possible differences in tumor biology between cancers that are detected with DM and DBT. • With both DM and DBT, ultrasound-guided biopsy (versus stereotactic biopsy) was associated with a higher risk of upgrade. [ABSTRACT FROM AUTHOR]

Background: Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials. Methods: A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials. Results: During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28–89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative. Conclusions: Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials. [ABSTRACT FROM AUTHOR]

Background: Increased use of contralateral prophylactic mastectomy (CPM) as treatment for ductal carcinoma in situ (DCIS) in the US was first noted in the early 2000s. Optimization of treatment guidelines for DCIS requires an understanding of current surgical treatment trends, particularly as they may differ by patient sociodemographic and community resource factors. Objective: The aim of this study was to evaluate surgical treatment trends among US women with DCIS and to assess the impact of sociodemographic and community resource factors on surgical treatment choice. Methods: The Surveillance, Epidemiology, and End Results dataset was queried for women aged 40 years and older who were diagnosed with unilateral DCIS between 2000 and 2014. Annual mastectomy rates were compared over time by age and race/ethnicity. Multivariable logistic regressions were performed to identify predictors of mastectomy use, with patient sociodemographics, tumor characteristics, and community resource factors (i.e. plastic surgeon density) as covariates. Results: A total of 130,731 women with DCIS met the inclusion criteria. Overall mastectomy rates remained relatively unchanged over the study period (25–30%). CPM use increased for all age and race/ethnic groups, with the greatest increase exhibited by women aged 40–49 years [relative to 2000; 2014 odds ratio (OR) 10.6]. With respect to community resource factors, CPM use, as opposed to unilateral mastectomy, was associated with counties of higher education level (OR 1.52), higher income level (OR 1.22), and lower plastic surgeon density (OR 1.26). Conclusion and Relevance: While the popularity of mastectomy in the management of DCIS has remained relatively unchanged since the turn of the century, the use of CPM has risen substantially. Younger women with DCIS have seen the greatest increase in CPM use, a choice that remains influenced by race/ethnicity as well as income, education, and health resource availability. Until clinical risk stratifiers of DCIS are identified, the surgical decision-making paradigm must be improved so that treatment choice remains sensitive to cultural differences but becomes independent of income, education, and health resource availability. [ABSTRACT FROM AUTHOR]

Background. African American women present with more aggressive breast tumors and at later stages than white women. Many factors have been proposed to explain these findings, including socioeconomic status, cultural beliefs, and access to medical care. The purpose of this project was to determine if stage at presentation would be equivalent in a system providing equal access to care and if screening was equivalent. Methods. The Naval Medical Center San Diego (NMCSD) tumor registry from 2007 to 2012 was queried for this cross-sectional study. Eligible women included all those diagnosed and treated for breast cancer at NMCSD. Distribution of tumor stage (early vs. advanced) between racial groups was compared by age, treatment, and receptor status. Results. A total of 624 women were eligible; 88 % were early stage (0-II) and 12 % presented with advanced stage (III or IV). Racial differences in distribution were significant among African American and Hispanic women for early versus advanced presentation (p = 0.011). No racial disparity was seen in screening patterns among women. Conclusions. In a military health system with equal access to care and standard screening recommendations, screening patterns did not vary with race but did vary with stage and active duty status. African American women present with breast cancer at later stages and with more hormone-receptor negative tumors, suggesting that biology rather than socioeconomic or access factors may be the most important determinant of stage at presentation of breast cancer for African American women. [ABSTRACT FROM AUTHOR]