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Body image concerns often arise during and after treatment and are a major concern in up to 67% of breast cancer survivors. Negative changes in body image are a predictor of worse satisfaction with appearance and poor quality of life outcomes. Opportunities to mitigate the negative impact of cancer treatment on a patient’s body image present during preoperative education or in the neoadjuvant setting, or during surgical management, adjuvant therapy delivery, and survivorship. The surgical management of breast cancer has evolved from breast amputations to procedures that provide improved cosmesis without compromising the oncologic outcome. The advent of the sentinel lymph node biopsy and lymphatic reconstruction techniques has led to decreased axillary morbidity. Modified radiation techniques and systemic therapies tailored to subtype limit unnecessary exposure to skin and systemic toxicities. Finally, incorporating prehabilitation and survivorship support optimizes the physical and psychosocial well-being of these patients. Setting expectations, treatment de-escalation when appropriate, morbidity risk reduction and improved screening and management of psychological sequelae during survivorship can decrease breast cancer treatment’s negative impact on body image. The following review synthesizes interventions during preoperative planning, local and systemic treatment, and survivorship to prevent poor body image outcomes without compromising oncologic success.

INTRODUCTION: Oncoplastic breast surgery permits tumours traditionally requiring total mastectomy to be excised with acceptable oncological and aesthetic outcomes. The purpose of this study was to evaluate outcomes following oncoplastic breast surgery in the breast unit at Inkosi Albert Luthuli Central Hospital in Durban. METHODS: This was a retrospective analysis of patient records. Patients who underwent oncoplastic breast surgery with curative intent from 2011 and 2012 were included in this study. Male patients, those with contraindications to breast conservation, and those with metastatic disease were excluded. Demographic and tumour-related data were collected and margin status, surgical site sepsis, recurrence and overall survival (OS) were recorded over a 5-year period starting from the date of presentation. RESULTS: Forty-five patients with 45 tumours were evaluated. The most prevalent tumour size at presentation was T2 (55.6%), and the most commonly performed procedure was a therapeutic mammoplasty. Twelve patients (27%) developed surgical site infection (SSI), eight of which were classified as deep SSI with wound breakdown. The resection margin was clear in 95.6%. Recurrence was noted in 8.9% of patients, with an OS of 91.1%. CONCLUSION: Breast-conserving surgery (BCS) using oncoplastic techniques results in favourable oncological outcomes in patients treated in a resource-constrained setting.

Inter-rater reliability between breast surgical oncologists and reconstructive surgeons using cosmesis scales, and the correlation between their observations and patients’ own subjective assessments, is poorly understood. Patients undergoing BCS in a prospective trial rated their cosmetic outcome on a Likert scale (poor/fair/good/excellent) at the postoperative and 1-year time points; photographs were also taken. Three breast surgical oncologists (not involved in these cases) and two reconstructive surgeons were asked to independently rate cosmesis using the Harvard/NSABP/RTOG scale. Overall, 55 and 17 patients had photographs and Likert self-evaluations at the postoperative and 1-year time points, respectively. There was poor agreement between surgeon and patient ratings postoperatively [kappas − 0.042 (p = 0.659), 0.069 (p = 0.226), and 0.076 (p = 0.090) for the breast surgical oncologists; and 0.018 (p = 0.689) and 0.112 (p = 0.145) for the reconstructive surgeons], and poor interobserver agreement between surgeons of the same specialty (kappa − 0.087, 95% confidence interval [CI] − 0.091 to − 0.082, p = 0.223 for breast surgical oncologists; and kappa − 0.150, 95% CI − 0.157 to − 0.144, p = 0.150, for reconstructive surgeons). At 1 year, the interobserver agreement between breast surgical oncologists was better (kappa 0.507, 95% CI 0.501–0.512, p < 0.001); however, there was still poor correlation between the reconstructive surgeons (kappa − 0.040, 95% CI − 0.049 to − 0.031, p = 0.772). Agreement between surgeon and patient ratings remained poor at this time point [kappas − 0.115 (p = 0.477), 0.177 (p = 0.245), and 0.101 (p = 0.475) for breast surgical oncologists; and 0.335 (p = 0.037) and −0.118 (p = 0.221) for reconstructive surgeons]. Despite gradation scales for measuring cosmesis after BCS, high levels of agreement between surgeons is lacking and these do not always reflect patients’ subjective assessments.

Introduction: Oncoplastic breast surgery combines oncologic partial mastectomy with ipsilateral defect repair using volume displacement and volume replacement techniques with contralateral symmetrising surgery as appropriate. Oncoplastic surgery aims to maintain quality of life by pre-empting and mitigating against breast asymmetry whilst not compromising oncological effectiveness. Although growing in popularity in North America, many patients still do not have access to these techniques which usually involve longer operation times and require a surgeon with specialized oncoplastic training. This study demonstrates the implementation of an effective oncoplastic surgical practice in a community hospital within Canada and shows low rates of peri-operative complications as well as high levels of patient-reported outcome measures. Methods:A retrospective chart review of consecutive patients diagnosed with Stage 0-3 breast cancer treated with level I and level II oncoplastic techniques by a single breast surgeon was undertaken. Patient demographics, tumor characteristics, procedure types, and clinical outcomes were collected. Patient satisfaction was assessed with the Breast-Q questionnaire administered pre-operatively as well as 3 months and 9 months post-operatively. Results:Oncoplastic breast conservation surgery was performed in 340 patients over a 31 month period from 2017-2019. The average size of breast lesion was 1.8 cm with 96 patients having lesions 2-5 cm in size, and 10 patients having tumours >5cm. Thirty (8.8%) patients experienced a complication requiring intervention. Margin revisions were required in 21.8% of patients which reduced to 18% after the implementation of the new margin consensus guidelines. The completion mastectomy rate was 4.7%. Contralateral symmetrizing procedures were performed in 31 (9.1%) of patients by the surgeon performing the patient's breast conservation surgery. Breast Q scores increased across breast satisfaction, process of care, psychosocial, physical, and sexual satisfaction domains post-operatively. Conclusion:This study demonstrates the feasibility of an oncoplastic breast surgery practice in a busy community hospital in Canada. This adds to the growing body of North American data on the clinical and oncological safety of these techniques and introduces the idea of collecting patient-reported outcome measures within a Canadian population. We hope that this will serve to aid in the recruitment of oncoplastic-trained surgeons to both teaching and community hospitals and enable these techniques to become the standard of care in North America. Citation Format: Ashley DiPasquale, Zofia Prus-Czarnecka, Lindsay Delmar, Lashan Peiris. Clinical and patient reported outcomes in oncoplastic breast conservation surgery from a single surgeon's practice in a busy community hospital in Canada [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-61.

Significant progress has been made in the treatment and outcome of breast cancer. Some of the most dramatic strides have been in the surgical management of breast cancer. Breast-conserving therapy (BCT), including wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. Large cooperative group trials have contributed to the paradigm shift from mastectomy to BCT. This review reports the landmark BCT trials that provided the data for current surgical practices. The review also describes the body of literature contributing to the increasing use of oncoplastic techniques for patients undergoing BCT.

Breast conservation therapy (BCT) is well established for the management of primary operable breast cancer, with oncologic outcomes comparable to those of mastectomy. It remains unclear whether re-conservation therapy (RCT) is suitable for those patients who develop ipsilateral breast tumor recurrence (IBTR), for whom mastectomy is generally recommended. We identified women who underwent BCT for invasive or ductal carcinoma in situ and developed IBTR as a first event, comparing the pattern of subsequent events and survival for those treated by RCT versus mastectomy. Of 16,968 patents who had BCT, 322 (1.9%) developed an isolated IBTR as a first event between 1999 and 2019. 130 (40%) had RCT and 192 (60%) mastectomy. Compared to mastectomy, the RCT patients were older (66 vs 53

Breast conservation surgery (BCS) and nipple-areola-sparing (NAS) mastectomy have been recognized as two milestones in this period. This study included 60 Egyptian female patients with breast cancer, all of them were subjected to modified radical mastectomy operation. Methods: This study included female patients > 18 years old who have breast cancer with healthy looking non invaded skin of nipple and areola and excluded patients 4 cm; 3) No multifocal/multicentric tumor; 4) Absence of lymph node invasion; 5) Tumor grade (grade I, II); 6) Peripheral not central tumor; 7) No sub-areolar lymphovascular invasion (LVI); 8) ER receptor positive; 9) PR receptor positive; 10) HER2 negative.

Objective: To explore the inverted T-shaped flap nursing after breast-conserving surgery combined with the reverse double V-shaped mastoconstriction suspension for breast cancer, and summarizes the nursing methods and experience. Method: 5 patients who underwent reverse double V-shaped mastoconstriction suspension and formed inverted T-shaped flap incision were selected from the same medical group in the Department of Breast Cancer of Sun Yat-sen University’s Cancer Center from February 1, 2019 to April 30, 2019, and they were evaluated for the recovery of blood supply of skin flap, sensory function of nipple and areola, breast satisfaction, etc. Results: Among the 5 patients in this group, the flaps of them all survived smoothly. The one-year follow-up after the operation showed that they were satisfied with the appearance of the breast after the operation, with normal sensory function, and no secondary sagging. Conclusion: The most important thing about the inverted T-shaped flap after the reverse double V-shaped mastoconstriction suspension for breast cancer is the blood supply. Close observation of the condition of the skin flap after the operation, strengthening the care of the skin flap, and preventing infection are the keys to the success of the operation.

Fibroadenomas are benign breast tumours consisting of epithelial and stromal components. Most of them are about 1 to 2cm in size. It is defined as “giant” when the fibroadenoma is larger than 5cm, weighs more than 500 g or occupies for at least 80% of breast volume. It is usually encountered in patients of less than 20 years of age. Progressively growing mass and its large size cause a suspicion of malignancy. It presents as unilateral macromastia that causes breast asymmetry. Excellent cosmetic results cannot be obtained with simple excision in this situation. We aimed to present a case of a 12-year-old patient with a diagnosis of giant juvenile fibroadenoma. In this case, we performed surgical excision with Batwing mastopexy of the breast to achieve optimal symmetry with contralateral breast.

BACKGROUND: Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer. METHODS: We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively. RESULTS: We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls. CONCLUSIONS: Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.

More women with unilateral early stage breast cancer are electing bilateral mastectomy (BM). Many cite anxiety, fear of recurrence, and certain aesthetic desires in their decision-making. Yet conflicting data exist regarding how these factors both inform and are modulated by medical decision-making, especially among women eligible for breast conservation (BCT). This study sought to assess the trajectories of women undergoing various surgical procedures for breast cancer. We performed a prospective longitudinal study of women with unilateral, non-hereditary breast cancer who underwent BCT, unilateral mastectomy (UM), or BM. Women completed surveys before surgery and at 1, 9, and 15 months postop. Surveys included questions about treatment preferences, decisional control, the HADS-A anxiety scale, the Fear of Relapse/Recurrence Scale (FRRS), and the BREAST-Q. The Kruskal–Wallis test was used to compare outcomes between BCT, UM, and BM groups at each time point. 203 women were recruited and 177 (87.2%) completed 15-month follow-up. Of these, 101 (57.0%) underwent BCT, 33 (18.6%) underwent UM, and 43 (24.2%) underwent BM. Generalized anxiety and FRRS scores were similar between BCT, UM, and BM groups and declined uniformly after surgery. Although baseline breast satisfaction was similar between groups, at 15 months, it was significantly lower in BM patients than in BCT patients. Women who felt “very” confident and “very” informed before surgery had lower anxiety, lower fear of recurrence, better psychosocial well-being (PSWB), and greater breast satisfaction at 15 months. While patients who undergo mastectomy have less long-term breast satisfaction, all patients can expect to experience similar improvements in anxiety and PSWB. Efforts should be made to ensure that patients are informed and confident regardless of which surgery is chosen, for this is the greatest predictor of better outcomes.

Breast conservation surgery and radiation therapy to the breast has revolutionized the treatment of breast cancer over the last few decades. Surgical direction had seen a heightened interest in the performance of cosmetically superior partial and segmental resections in breast conservation as well as increased demand by patients for breast preservation. The broadening of approaches to delivery of breast irradiation from whole breast to accelerated partial breast has allowed more patients to opt for breast conservation and allowed for what appears to be comparable measurable outcomes in emerging data. As well, the addition of state-of-the-art chemotherapeutic and hormonal therapies has allowed improved outcomes of patients from both local regional recurrence and overall survival standpoints. This paper will provide an overview of BCS including patients selection, prerequisit, indications, contraindications, procedures, complications and follow up. Faridpur Med. Coll. J. Jan 2020;15(1): 34-37

Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.

Aims Hypofractionated radiation treatment (HFRT) following breast conservation surgery (BCS) has similar efficacy to conventionally fractionated radiation treatment (CFRT). This study updates outcomes for patients treated with HFRT in Christchurch, New Zealand, and reports on the pattern, timing and method of detection of recurrences to inform follow-up practice. Methods Between 2004 and 2006, 273 women with early breast cancer were treated with HFRT (42.5 Gray (Gy) in 16 fractions). Details of demographics, tumour characteristics, treatments, any recurrence (local, nodal or distant), follow-ups and date of death were collected. The primary endpoint was local recurrence rate (LRR); secondary endpoints were local recurrence-free survival (LRFS) and overall survival (OS). Results With a median follow-up of 12.9 years, 17 women developed a local recurrence. LRR at 5 and 10 years were 3.1% and 5.3%, respectively. Five-year LRFS was 91.7% and ten-year LRFS was 83.5%. The OS at five years was 93.7% and at ten years was 87.7%. For the 41 patients with a first recurrence at any site, 75.6% were symptomatic, 22% were screen detected with radiology and 2.4% were incidental findings. None of the first recurrences were detected when asymptomatic on clinical examination in follow-up clinics. Conclusions The rate of local recurrence following HFRT for BCS is low. No asymptomatic recurrence was detected by routine clinic follow-up. The utility of regular clinical examination for the detection of recurrence is low and this should inform follow-up strategies.

Background We previously reported that breast conservation was feasible for women with large or irregularly shaped breast cancers when tumor resection was guided by multiple localizing wires. We now report long-term outcomes of multiple-wire versus single-wire localized lumpectomies for breast cancer. Patients and Methods We retrospectively reviewed wire-localized lumpectomies at our institution from May 2000 to November 2006. Rates of ipsilateral in-breast tumor recurrence, metastasis, and subsequent unplanned diagnostic imaging and biopsy were compared between multiple-wire and single-wire cohorts. Results We identified 112 multiple-wire and 160 single-wire breast cancer lumpectomies that achieved clear margins. Median age was 64 years in the multiple-wire cohort and 57 years in the single-wire cohort. Mean lumpectomy volume was 75 mL in multiple-wire patients and 49 mL in single-wire patients (P = .003). Invasive tumor size, axillary node status, and use of radiation and systemic therapy were similar, but the multiple-wire group had more patients with ductal carcinoma-in-situ only (38% vs. 28%). At 108 months’ median follow-up, there was no significant difference in local or distant recurrence rates between multiple-wire and single-wire cohorts. Six (5%) multiple-wire patients and 6 (4%) single-wire patients had local recurrences and 3 (3%) multiple-wire and 5 (3%) single-wire patients developed metastatic disease. Unplanned diagnostic imaging was required for 53 (47%) multiple-wire and 65 (41%) single-wire patients. Subsequent ipsilateral biopsy occurred in 15 (13%) multiple-wire and 19 (12%) single-wire patients. Conclusion Breast-conserving surgery with multiple localizing wires is a safe alternative to mastectomy for breast cancer patients with large mammographic lesions.

INTRODUCTION: Increasingly we are dealing with more and more impalpable breast lesions thanks to screening programmes, chemotherapy and in situ disease. There are various techniques already employed for assisting in surgery for impalpable lesions such as radioactive and magnetic markers. All of these have limitations and are only useful in surgery. Ultrasound can be used in clinic and theatre to locate tumours and sonographically visible markers. In our experience in the Cambridge breast unit we have found it is more satisfactory to use guidewires that are intraoperatively or preoperatively placed using ultrasound guidance. This allows for direct approach to the lesion at the same time limiting the dissection and volume of resection. The guidewire allows tactile feedback and helps with precision and accuracy of the excision as reflected in the specimen weights. In this study we look at the outcomes of intraoperatively and preoperatively placed guidewires using ultrasound for impalpable breast lesions between 2015 -2018 in the Cambridge Breast Unit. The primary outcomes are re-excision rate and average specimen weights. METHODS: Patients undergoing breast conservation surgery for impalpable lesions from 01/01/2015 to 30/07/2018 were included. Data was collected retrospectively from our electronic records system EPIC and analysed. RESULTS The results were divided into intraoperative localisations and preoperative localisations. A total of 441 lesions in 415 patients were included in this study. Preoperative localisationIntraoperative localisationNumber of patients193222Number of lesions210231*Re-excision rate per patient %19.2%14.0%Specimen weight per patient (grams)39.4g24.2g*Fishers exact 0.24 (NS) CONCLUSION: Impalpable lesions can be successfully localised using ultrasound guidance and a guidewire both intraoperatively and preoperatively with good outcomes. Intraoperative localisation has lower re-excision rates and specimen weights in our study as well as many other benefits for the patient and surgeon. We have looked into how easily and quickly we can train ultrasound naïve trainees in this technique and have achieved good results. Citation Format: Primeera Wignarajah, Vasiliki Papalouka, Parto Forouhi. The use of intraoperative ultrasound and guidewire placement to obtain low re-excision rates and increased accuracy of excision in impalpable breast lesions at the Cambridge Breast Unit [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-20-21.

Background Round block mammoplasty (RBM) is a type of Oncoplastic procedure to facilitate breast conservation surgery for breast cancer. Methods Retrospective study of 270 patients who underwent this surgery. The surgical and oncological outcomes of RBM were studied. Results The median age was 61 years and median follow-up 39 months. Most cancers (59%) were screen-detected. The location of the cancer was commonly in the upper outer quadrant followed by upper inner quadrant (20%). The average tumor size was 18 mm and in 48% of patients the whole tumor size increased to 23.5 mm due to associated DCIS. The median specimen weight was 41 gm. Forty patients (14.8%) had positive margins. Postoperative complications were seen in 18 patients (6.6%). There were 4 local and 1 axillary recurrences, and 8 distant metastasis. Contralateral symmetrising surgery was required in 13 patients (4.8%). Conclusion RBM is a robust and easily adaptable technique which provides good exposure for a safe oncological excision. The surgical and oncological outcomes are good and contralateral symmetrising surgery is rarely required.

Background: The role of oncoplastic breast conserving therapy (OPBCT) on physical function, morbidity and patient satisfaction has yet to be defined. Additionally, technique selection should be individualised and incorporate patient preference. The study aim was to investigate differences between "standard" (sBCT) and oncoplastic breast conservation (OPBCT) in patient-reported outcomes (PROs) when patients have been assessed in a standardised manner and technique selection has been reached through shared decision-making (SDM). Methods: This is a cross-sectional study of 215 women treated at a tertiary referral centre. Standardised surgical assessment included breast and lesion volumetry, definition of resection ratio, patient-related risk factors and patient preference. Postoperative morbidity and patient satisfaction were assessed by validated PROs tools (Diseases of the Arm, Shoulder and Hand-DASH and Breast-Q). Patient experience was assessed by semi-structured interviews. Results: There was no difference of the median values between OPBCT and sBCT in postoperative morbidity of the upper extremity (DASH 3.3 vs 5, p = 0.656) or the function of the chest wall (Breast-Q 82 vs 82, p = 0.758). Postoperative satisfaction with breasts did not differ either (Breast-Q 65 vs 61, p = 0.702). On the individual level, women that opted for OPBCT after SDM had improved satisfaction when compared to baseline (+3 vs -1, p = 0.001). Shared decision-making changed patient attitude in 69.8% of patients, leading most often to de-escalation from mastectomy. Conclusions: These findings support that a combination of standardised surgical assessment and SDM allows for tailored treatment and de-escalation of oncoplastic surgery without negatively affecting patient satisfaction and morbidity. De två första författarna delar förstaförfattarskapet.

Background: Surgical-site infections (SSIs) are the commonest cause of healthcare-related infections. Although a surgical care bundle (SCB), defined as a group of preventative measures, is effective in reducing SSIs, it has not been well documented in breast cancer surgery. We aimed to investigate the impact of SCB on SSI. Methods: A single-centre retrospective comparative cohort study between 2016 and 2020 was carried out. An SCB including eight different measures was implemented in October 2018 at Sahlgrenska University Hospital, Sweden. Patients who underwent non-reconstructive breast cancer surgery were included for analysis. The primary endpoint was SSI within 30 days after surgery. Results: Overall, 10.4% of patients (100/958) developed SSI. After SCB implementation, the overall SSI rate reduced from 11.8% to 8.9% (p = 0.15). The largest SSI rate reduction was seen in the subgroup that underwent breast conservation and sentinel lymph node biopsy (SLNB), from 18.8% to 9.8% (p = 0.01). In this multivariable analysis adjusting for patient and treatment factors, the implementation of SCB resulted in a statistically significant reduction in SSI risk (OR 0.63, 95% CI 0.40–0.99, p = 0.04). Conclusions: The implementation of a SCB could reduce the incidence of SSI in breast cancer surgery.

Background Inflammatory breast cancer (IBC), the most lethal form of breast cancer, constitutes 1–2% of all breast cancers in the United States. Multimodality therapy is the standard in management of non metastatic inflammatory breast cancer patients including neoadjuvant chemotherapy and endocrine therapy and mastectomy followed by post mastectomy radiation. A modified radical mastectomy has been the standard surgical procedure of choice. The objective of this systematic review and metanalysis is to estimate the pooled benefits and adverse effects of performing modified radical mastectomy versus breast conservation surgery in the management of non metastatic IBC. Objective To evaluate, review and analyze the outcome of non metastatic IBC patients treated with mastectomy or breast conservation surgery as an integral part of the multimodality treatment of the disease. To highlight the evidence and quality of the included studies. To share in modifying the current guidelines. Methods An electronic search was conducted from the inception till Jan 2020 in the following bibliographic databases: Medline via PubMed, SCOPUS, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and Google Scholar to identify relevant articles. We used different combinations of the following queries: ("Inflammatory Breast cancer" OR "breast cancer") AND ("Conservative Treatment" [Mesh] OR "conservative surgery" OR "breast conservative surgery" OR "partial mastectomy"). The search have been done with no limit regarding the year publication. Results After reviewing five studies we found that our results favors the use of modified radical mastectomy over breast conservation surgery in terms of the overall survival and breast cancer specific free survival, however, partial mastectomy could be an effective and safe option in selected group of patients with non metastatic IBC based on the response to NAC an patient’s preference. Conclusions Breast surgery is of great significance to the clinical outcomes of IBC. Standard mastectomy shouldn’t be the only recommended surgical treatment. Individualized surgical procedures can be safely performed in non-metastatic IBC patients based on the response of NAC and patient’s preference.

Background Breast cancer is the most common cancer in women all over the world representing 18% of all women reported cases of cancer. It represents the leading cause of women mortality as representing 23% of all women cancer deaths. The decision in any breast cancer patient is taken by MDT that includes breast surgery consultant, pathology consultant, plastic surgery consultant, radiology consultant and medical oncology consultant. Breast conserving surgeries are now the standard technique for management of breast cancer patient. Oncoplastic techniques are replacing SWLE for their better cosmetic outcomes and better exposure of the tumor. Objective The aim of this work was to assess the round block technique as regard oncological safety, surgical outcomes and patients' satisfaction comparing results with standard wide local excision. Methods This is a retrospective study to assess the round block technique as an oncological procedure for management of early breast cancer near to nipple-areola complex as regard oncological safety, surgical outcomes and patients' satisfaction comparing results with standard wide local excision. It was conducted at general surgery department, Ain Shams university hospitals. Approval of the Ethical Committee and written informed consent from all participants were obtained. In our study 40 breast cancer patients are subdivided into group (A) 20 females which underwent round block technique and group (B) 20 femaleswhich underwent standard wide local excision. Patient and tumor criteria including age, co morbidities, tumor size and distance between tumor and nipple-areola complex were considered to be nonsignificant between 2 groups so the only difference is the surgical technique. Results The study shows that the round block technique and SWLE have the same results regarding hospital stay, post operative complications and oncological recurrence with the advantage to RBT because of its better cosmetic outcomes. So, the round block technique is superior to SWLE in selected cases. Conclusion The round block technique has comparable post operative parameters with better cosmoses as it is scarless operation without nipple and areola shift suggesting that the round block technique is superior to SWLE in selected cases.

Aim We sought to compare breast conservation therapy & mastectomy as treatment of occult breast cancer in terms of recurrence. Methods It is a retrospective cross sectional study conducted on patients diagnosed to have occult breast cancer and going for either breast conservation therapy or mastectomy at The Aga Khan University Hospital Karachi between January 200o to December 2018, patients will be divided into two groups, first group will be consisting of patients who underwent breast conservation therapy and 2nd one will be of patients who had mastectomy. Patients will be included by consecutive sampling technique. Hospital database will be used to identify patients and data collected on a self designed tool using files and electronic patient records. Patients in both groups will be followed to see local recurrence from date of diagnosis to 2 years post operatively in hospital data base and their files, and then their data will be compared with the reference studies reported in this article. Results Awaited as the study is ongoing. Conclusions Awaited as study is ongoing.

Background: The improvement in the treatment of breast cancer is due to early diagnosis, better understanding of the natural history of this disease and therapeutic improvements over the years. There is a gradual shift away from radical surgery advocated by Halsted to the breast conservative surgery during the last few decades all over the world mainly influenced by the results of several large trials of lesser surgical procedures. Methods: Hospital based descriptive study was conducted on patients with Early Breast Cancer presenting to the Department of General Surgery in Guru Gobind Singh Medical College & Hospital, Faridkot. Results: Mean blood loss of the subjects of the BCS group was observed to be 44.07±15.76 ml as compared to 94.36 ± 31.50 ml in the subjects of the MRM. Mean operative time of the subjects of the BCS group was observed to be 46.03±8.68 minutes as compared to the mean operative time of 64.03±16.56 minutes in the subjects of the MRM group. Mean VAS score on day-1 in BCS group and in MRM group was 5.3±1.98 and 6.73±1.70 respecively. Mean VAS score on day-3 in BCS group and in MRM group was 4.46±1.50 and 5.1±1.56 respectively. Mean VAS score on day-5 in BCS group and in MRM group was 2.96±0.76 and 2.96±1.06 respectively. Seroma Formation was observed in 3.33 % cases in BCS group and 16.67 % in MRM group. Flap necrosis was observed in 0 % in BCS group whereas 10.00 % of the patients had flap necrosis in MRM group. Positive margins were absent in both BCS group and MRM group. Wound infection was observed in 6.67% of the patients in the BCS group and 20.00% in the MRM group. Quality of life score for BCS and MRM was 108.53±14.62 and 95.26±14.70 respectively. Conclusion: Breast conservation surgery should be the preferred treatment for Stage-I and Stage-II Breast cancer disease due to its lesser post-operative pain, shorter duration of surgery, lesser blood loss and short hospital stay thus helping in early returning to normal activity. Breast conservation surgery has better outcomes compared with Modified radical mastectomy. Keywords: BCS, MRM, Breast surgery

The rates of BCS in the Indian subcontinent vary between 11% and 34%, as compared to the management of breast cancer in the west where the rates of BCS are as high as 70% in early breast cancer. All this has brought to light the need for evaluation of the best and the most functional and cosmetic surgeries that are available in the management of breast cancer especially when detected in the ver early stages.With all this in mind we decided to study the demographic evaluation and outcome of the early breast cancer patients undergoing breast conservation surgery as the primary modality of management at a medical teaching hospital. Materials and Methods: The study was done at the department of general surgery, oncosurgery, radiation oncology and medical oncology at Father Muller Medical College Hospital. All breast cancer patients underwent the following treatment regimen:- Surgery that included BCS with Axillary Dissection followed by neo adjuvant chemotherapy CFU regimen and then after completion of systemic chemotherapy 50-55 Gy of radiotherapy to the remaining breast with a tumor bed boost of 9-12 Gy in daily 2 Gy fractions for 5 days in a week over 5-6 weeks was given. Results: In the present study new-found that the most common site in the breast for breast cancer was the superior - lateral quadrant of the 70 cases 56 cases 80% were in the superior - lateral quadrant. Common in this area. The most common histology seen in 67 cases 95.71% was infiltrating duct carcinoma. The median age was 45 years. 65 cases 92.86% had node-negative disease and 54 cases 77.14% tumors were hormone receptor-positive. One case developed isolated local recurrences which were managed surgically. None of the rest 69 cases of them had recurrence during follow up. The mean age was 44.75 with SD 8.8 years. The youngest was 28 years and the eldest was 63 years of age. In the 295 cases, we had 3 male cases, among those who had BCS all were females. Conclusion: We would like to conclude that

With the advent of breast conservation options in the 1970s, as well as wider acceptance of breast reconstruction in cancer patients in 1980/1990, ending up with evolution of oncoplastic concepts in the early 2000s, detailed surgical anatomy of the breast became important. This short article reviews surgical anatomy of breast with particular emphasis on innervation and blood supply to the skin and nipple-areolar complex, as well as points out the concept of compartmental breast cancer anatomy. Meticulous dissection and avoidance of transection of major vessels and nerves constitutes the crucial factor for satisfactory results of surgery in terms of preservation of sensation as well as appropriate vitality of skin.

BACKGROUND Patients with an in-breast tumor recurrence (IBTR) after breast-conserving therapy have a high risk of distant metastasis and disease-related mortality. Classifying clinical parameters that increase risk for recurrence after IBTR remains a challenge. AIM To describe primary and recurrent tumor characteristics in patients who experience an IBTR and understand the relationship between these characteristics and disease outcomes. METHODS Patients with stage 0-II breast cancer treated with lumpectomy and adjuvant radiation were identified from institutional databases of patients treated from 2003-2017 at our institution. Overall survival (OS), disease-free survival, and local recurrence-free survival (LRFS) were estimated using the Kaplan Meier method. We identified patients who experienced an isolated IBTR. Concordance of hormone receptor status and location of tumor from primary to recurrence was evaluated. The effect of clinical and treatment parameters on disease outcomes was also evaluated. RESULTS We identified 2164 patients who met the eligibility criteria. The median follow-up for all patients was 3.73 [interquartile range (IQR) 2.27-6.07] years. Five-year OS was 97.7% (95%CI: 96.8%-98.6%) with 28 deaths; 5-year LRFS was 98.0% (97.2-98.8) with 31 IBTRs. We identified 37 patients with isolated IBTR, 19 (51.4%) as ductal carcinoma in situ and 18 (48.6%) as invasive disease, of whom 83.3% had an in situ component. Median time from initial diagnosis to IBTR was 1.97 (IQR: 1.03-3.5) years. Radiotherapy information was available for 30 of 37 patients. Median whole-breast dose was 40.5 Gy and 23 patients received a boost to the tumor bed. Twenty-five of thirty-two (78.1%) patients had concordant hormone receptor status, HER-2 receptor status, and estrogen receptor (ER) (P = 0.006) and progesterone receptor (PR) (P = 0.001) status from primary to IBTR were significantly associated. There were no observed changes in HER-2 status from primary to IBTR. The concordance between quadrant of primary to IBTR was 10/19 [(62.2%), P = 0.008]. Tumor size greater than 1.5 cm (HR = 0.44, 95%CI: 0.22-0.90, P = 0.02) and use of endocrine therapy upfront (HR = 0.36, 95%CI: 0.18-0.73, P = 0.004) decreased the risk of IBTR. CONCLUSION Among patients with early stage breast cancer who had breast conserving surgery treated with adjuvant RT, ER/PR status and quadrant were highly concordant from primary to IBTR. Tumor size greater than 1.5 cm and use of adjuvant endocrine therapy were significantly associated with decreased risk of IBTR.

Purpose: To assess the cosmetic impact of breast conserving surgery (BCS), whole breast irradiation (WBI) fractionation and tumour bed boost (TBB) use in a phase III trial for women with ductal carcinoma in situ (DCIS) of the breast. Materials and methods: Baseline and 3-year cosmesis were assessed using the European Organization for Research and Treatment of Cancer (EORTC) Cosmetic Rating System and digital images in a randomised trial of non-low risk DCIS treated with postoperative WBI +/− TBB. Baseline cosmesis was assessed for four geographic clusters of treating centres. Cosmetic failure was a global score of fair or poor. Cosmetic deterioration was a score change from excellent or good at baseline to fair or poor at three years. Odds ratios for cosmetic deterioration by WBI dose-fractionation and TBB use were calculated for both scoring systems. Results: 1608 women were enrolled from 11 countries between 2007 and 2014. 85–90% had excellent or good baseline cosmesis independent of geography or assessment method. TBB (16 Gy in 8 fractions) was associated with a >2-fold risk of cosmetic deterioration (p < 0.001). Hypofractionated WBI (42.5 Gy in 16 fractions) achieved statistically similar 3-year cosmesis compared to conventional WBI (50 Gy in 25 fractions) (p ≥ 0.18). The adverse impact of a TBB was not significantly associated with WBI fractionation (interaction p ≥ 0.30). Conclusions: Cosmetic failure from BCS was similar across international jurisdictions. A TBB of 16 Gy increased the rate of cosmetic deterioration. Hypofractionated WBI achieved similar 3-year cosmesis as conventional WBI in women treated with BCS for DCIS.

Objectives Extreme oncoplastic breast conserving surgery (eOPBCS) allows breast conservation for tumours ≥ 50 mm, but long-term outcomes are unclear. We investigated early complications and the longer-term clinical and oncological outcomes following eOPBCS to assess the clinical utility and safety of this technique. Materials and methods A prospectively collected database of all eOPBCS procedures (1993–2016) using LD miniflaps (LDm) and therapeutic mammoplasties (TM) was interrogated and cross-checked with hospital records to establish length of follow up (FU), clinical outcomes (complications, revisions), local recurrence (LR) and survival. Results Ninety eOPBCS procedures (62 LDm, 28 TM) performed for large tumours (mean 67 [50–177] mm) were identified, overall FU 80 (10–308) months (LDm 91 [13–308], TM 54 [10–120] months). Forty two per cent were node positive, and 2 were benign (benign cases excluded from LR and FU analysis). Eleven patients required surgery for involved excision margins (LDm 3 re-excisions and 2 mastectomies, TM 6 mastectomies). Surgery for complications and subsequent revision was required in 6% and 37% of LDm and 18% and 7% of TM patients, respectively. Seven patients developed LR (LDm 5 versus TM 2) giving a predicted 5 and 10 year LR rate of 1.1% and 16%. Conclusion Long-term FU of this unique series has confirmed that eOPBCS is a safe procedure for patients with bulky tumours normally treated by mastectomy, without risking local control. TM patients experienced more early complications but LDm patients required more revisions over a more prolonged period of FU.

Ductal carcinoma in situ (DCIS) is a non-invasive malignancy confined within the basement membrane of the breast ductal system. There is a lot of disparity in the natural history of DCIS with an estimated incidence of progression to invasive ductal carcinoma between 20% to 53% over ten or more years after initial diagnosis. The surgical and adjuvant management of DCIS has advanced significantly in the last couple of decades. Nonetheless, surgeons, medical oncologists, and radiation oncologists, along with their patients, still depend on conventional clinical and pathologic risk factors to make management decisions. Irrespective of the management strategy, long-term survival is excellent. The debate around DCIS relates to preventing either under-treatment or over-treatment. In this paper, we will review the incidence and management options of DCIS. Additionally, we will focus on several current disputes related to the management of DCIS, including breast conserving surgery, the role of radiation in breast conservation surgery, sentinel node biopsy in DCIS, hormonal therapy, various risk stratification schemes, and the option of active surveillance for low-risk DCIS.

Background: Breast cancer is one of the most common cancers in Bangladeshi women. Breast sacrificing treatment is still now the common practice in our country. Now a day’s breast conservative treatment is the standard treatment of breast cancer without compromising the survival. Objective: To observe local recurrence and distant metastasis free survival and overall survival of patients with breast cancer. Methods: Between January 1996 and December 2010, breast conserving treatment was carried out in 237 female patients with breast cancer in different Institutions of Bangladesh. Clinical staging was recorded by physical examination, relevant investigations as well as surgical records. Revised breast conserving surgery was carried out in those who had positive surgical margins or palpable disease. The patients with large but operable cancer or locally advanced cancer were treated by neoadjuvant chemotherapy followed by breast conserving surgery. Systemic adjuvant therapy (chemotherapy and or hormone therapy) and adjuvant radiotherapy were given in all patients. After completion of treatment, the patients were followed up with a standard protocol and data were compiled and analysed. Results: Among 237 patients who underwent breast conserving therapy 13 patients were excluded from the study for various reasons. Total 224 female patients with breast cancer who followed all the treatment schedules and attended for regular follow up were included in the study. They were between 22- 74 years of age, mean age 42.35 years; premenopausal 152 (68%). Sixty five percent (146 patients) was localized cancer (T1-2N0M0), 31.6% was regional cancer (T1-3N1M0), five cases were locally advanced stage (T4bN12M0) and two metastastatic cancer (T2-3N1M1). All most all (98%) were Infiltrating duct cell carcinoma except four which were Intraductal carcinoma in situ (IDIS). Estrogen and progesterone receptors were positive in 57% , HER2 positive (+++) in 24% of Patients. Lumpectomy/quandrentectomy with/without axillary clearance was done in 158 patients, revised breast conserving surgery in 53 cases, mastectomy in 8 cases and only biopsy done but no surgical treatment in five cases.Chemotherapy was given in 192 patients (86%); adjuvant 122 cases and neoadjuvant 70 cases. Hormone therapy in 182 patients. Radiotherapy: in 222 cases. Follow up period was 4 years to 19 years, median 10 years. Overall survival (OS) and disease free survival (DFS) was 84% and 70% respectively. Local recurrence occurred in 14(6%) cases and distant metastasis in 54 cases (24%). Conclusion: Breast conserving treatment was satisfactory for appropriate case selection and optimized therapy. Survival was no way worse than breast sacrificing treatment. Journal of Surgical Sciences (2015) Vol. 19 (2) : 55-60

We queried the National Cancer Database for nonmetastatic breast angiosarcoma, yielding 808 patients (202 de novo, 606 secondary). The median survival was 53.7 months. Secondary tumors were more likely to undergo mastectomy than de novo lesions (OR = 3.99, P 0.001). Treatments included lumpectomy (10%), lumpectomy/radiation (3%), mastectomy alone (73%), or mastectomy/radiation (14%), with no difference in survival (P = 0.68). Lumpectomy correlated with positive margin rate (OR 3.29), which was a predictor for death (HR = 2.37, P 0.01), along with older age, higher comorbidity scores, size5 cm, and high-grade disease (P 0.05). While breast angiosarcoma is usually treated with mastectomy, lumpectomy may be feasible for well-selected tumors.

Background: Data from recently published trials have provided practice-changing recommendations for the surgical approach to the axilla in breast cancer. Patients with T1-2 lesions, treated with breast conservation, who have not received neoadjuvant chemotherapy and have 1-2 positive sentinel nodes (Z0011-criteria) may avoid axillary lymph node dissection (ALND). We aim to describe the dissemination of this practice in Europe over an extended period of time. Methods: Our source of data was the eusomaDB, a central data warehouse of prospectively collected information of the European Society of Breast Cancer Specialists (EUSOMA). We identified cases fulfilling Z0011-criteria from 2005 to 2016 from 34 European breast centers and report trends in ALND. Data derived from Germany, Italy, Belgium, Switzerland, Austria, and Netherlands. Results: 6671 patients fulfilled Z0011-criteria. Rates of ALND showed a statistically significant decrease from 2010 (89%) to 2011 (73%), reaching 46% in 2016 (p < 0.001). After multivariable analysis, factors associated with higher probability of ALND were earlier year of surgery, younger age, increasing tumor size and grade, and being operated in Italy (p < 0.001). The minimum and maximal rates of ALND in the most recent two-year period (2015-2016) were 0% and 83% in two centers located in different countries (p < 0.001). Conclusion: Our study demonstrates, a decrease in rates of ALND that started after year 2010 through the end of the study period. Wide differences were observed among centers and countries indicating the need to spread unified clinical guidelines in Europe to allow for homogeneous evidence-based practice patterns. (C) 2019 Elsevier Ltd. All rights reserved.

Abstract: Introduction: Breast conserving surgery for breast cancer requires the analysis of surgical margins. If the tumor is not removed completely, additional treatments (reoperation, boost irradiation) are generally recommended. Aim: To analyze the information content of histopathology reports on surgical margins in consecutive cases of breast conservation for invasive female breast cancer, to evaluate the frequency of incompletely removed tumors and to estimate the rate of further treatments after incomplete removal. Method: Analysis of margin related data of consecutive histopathology reports from 8 Hungarian pathology units with locoregional treatment related data in case of unsafe margins. Results: 386 reports were analyzed after exclusions. 200 and 32 cases were identified as having unsafe margins according to the previous (0 mm margin distance. Conclusions: Some pathology reports lack information on surgical margins. Unsafe margin rates decreased with the new definition. Residual cancer may be left behind in case of clear margins with no ink on tumor. Neither reoperation, nor boost radiotherapy is given to some patients with unclear surgical margins. Orv Hetil. 2019; 160(26): 1036–1044.

For clinically low-volume breast cancer patients subjected to BCS, there is a concern regarding achieving microscopically negative margins and avoiding inadvertent resection of excessive volume of breast tissue. In this study, we utilized intraoperative ultrasound to guide resection in patients subjected to BCS. This was compared with palpation-guided resection. A total of 80 patients of invasive breast carcinoma (T1-2, N0-1, M0) (39 patients in USG-guided BCS (group A) and 41 patients in palpation-guided BCS (group B)) were enrolled. In group A, intraoperative localization was performed using a multifrequency 10-MHz linear array ultrasound probe and tumors were excised under USG guidance. In group B, tumor excision was guided by the palpation skills of the surgeon with the aim of achieving grossly negative margin circumferentially. Specimen volume was measured using water displacement technique. One out of 39 patients (2.56%) in group A and 5 out of 41(12.19%) in group B had positive margin in histopathology report. Mean of specimen volume in groups A and B was 42.67 and 57.97 ml respectively (P = 0.011). Mean of excess volume removed in study group was 4.19 ml and in control group, it was 24.11 ml (P =

Oncoplastic surgery is a form of breast conservation surgery that involves volume displacement and replacement techniques to reconstruct the breast after a partial mastectomy. We aimed to report our clinical experiences with support from the literature as to the optimal application of oncoplastic surgery with regard to patient and disease selection and presentation, and discuss common technical considerations. Based on clinical experience and recent literature, oncoplastic surgery has several oncologic and reconstructive strengths including a decreased positive margin rate, high patient satisfaction, and additional benefit when applied to patients with both breast cancer and symptomatic macromastia. Oncoplastic surgery constitutes an additional breast conservation option that is safe, well tolerated, and can provide autologous reconstruction after a large oncologic resection in a one-staged surgical effort that adds value for the appropriate breast cancer patient.

Several definitions of oncoplastic surgery have been reported in the literature. In an effort to facilitate communication regarding oncoplastic surgery to patients, trainees, and among colleagues, the American Society of Breast Surgeons (ASBrS) aimed to create a consensus definition and classification system for oncoplastic surgery. We performed a comprehensive literature search for oncoplastic surgery definitions using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Following this, a consensus definition and classification system was created by the ASBrS. Overall, 30 articles defining oncoplastic surgery were identified, with several articles contradicting each other. The ASBrS definition for oncoplastic surgery defines this set of breast-conserving operations using volume displacement and volume replacement principles as: “Breast conservation surgery incorporating an oncologic partial mastectomy with ipsilateral defect repair using volume displacement or volume replacement techniques with contralateral symmetry surgery as appropriate”. Volume displacement is defined as closing the lumpectomy defect and redistributing the resection volume over the preserved breast, and is divided into two levels: level 1 (

INTRODUCTION: Breast conservation is the standard of care for early breast cancer. Several oncoplastic approaches have been described for the reconstruction of partial breast defects. The multiplicity of techniques indicates that the ideal reconstructive technique is yet to be identified. There has been a recent emphasis on minimizing the magnitude of surgery. In this report, we describe our experience using the pectoralis major muscle to fill relatively large post-tumorectomy breast defects. PATIENTS AND TECHNIQUE: Nine patients were operated on for malignant breast lesions. Tumorectomy resection with surgical margin rendered a 40–50% breast defect. The parenchymal defect was repaired with an advancement muscle flap of the ipsilateral pectoralis major muscle. RESULTS: All patients experienced a non-eventful postoperative course. The early cosmetic outcome was excellent in four patients, good in another four, and fair in one patient. CONCLUSION: The pectoralis major flap is useful for local repair of upper half partial breast defects in non-ptosed, cup A–B breasts.

Mastectomy has long been the preferred approach for local salvage of recurrent breast cancer following breast-conservation therapy (BCT). Growing interest in avoiding mastectomy prompted RTOG 1014, a landmark phase two study demonstrating the feasibility of repeat BCT using a novel radiotherapy (RT) regimen (i.e., 45 Gy administered in 30 fractions of 1.5 Gy twice-daily to the partial breast, “rePBI”). We adopted this regimen as our institutional standard and report our observations regarding the safety and efficacy of rePBI as salvage therapy. All patients at our institution who underwent repeat BCT and subsequently received rePBI from 2011 to 2019 were identified. Clinicopathologic features and treatment characteristics for both primary breast cancers and recurrences were collected, as were rates of subsequent recurrence and treatment-associated toxicities. The cohort included 34 patients with a median age of 65.8 (46.2–78.2) at the time of rePBI. At a median follow-up of 23.5 months, there were two subsequent locoregional recurrences (2-year local control rate 97%). There was no grade ≥ 3 toxicity. The most common acute toxicity ( 3 months) included fibrosis in 14 (41%), breast asymmetry in 12 (35%), and chest wall pain in 11 (32%). Repeat breast conservation using the hyperfractionated partial breast RT regimen defined by RTOG 1014 (45 Gy administered in 30 1.5 Gy twice-daily fractions) appears effective and well tolerated. No grade 3 or higher toxicities were observed and local control was excellent. Longer term follow-up among larger cohorts will define whether salvage mastectomy should remain the preferred standard.

Purpose Guidelines for early-stage breast cancer allow for radiotherapy (RT) omission following breast conserving surgery (BCS) among older women, though high utilization of RT persists. This study explores surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance (QA) review. Methods We evaluated patients ≥ 70 years of age treated with BCS for ER + pT1N0 breast cancer at a single institution between 2015–2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics, and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables. Results Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post- productivity metric implementation was observed (p = 0.57). RT receipt was associated with younger patient age (70–74 years, OR 2.66, 95% CI 1.54–4.57) and higher grade (grade 3, OR 7.75, 95% CI 3.33–18.07). Initial referral was associated with younger age (70–74, OR 5.64, 95% CI 3.37–0.45) and higher performance status (KPS ≥90, OR 5.34, 95% CI 2.63–10.83). Conclusion Non-referral to radiation oncology accounted for half of RT omission, but was based on age and KPS, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting centralized QA review. Multi-institutional studies are needed to confirm these findings.

Oncoplastic breast surgery (OBS) with local tissue rearrangement, flap reconstruction, or mammoplasty techniques is a highly valuable tool in the comprehensive management of breast cancer, and it should be offered to all patients when indicated. A thorough understanding of the various OBS procedures and careful assessment of the patients and their tumor size and location will allow the proper selection of patients and surgical techniques. OBS has achieved better oncologic and cosmetic results compared to breast conservation surgery (BCS) alone, and its complications are equivalent to partial mastectomy and will rarely cause any delay in adjuvant treatment.

Breast conservation rate is being increasingly used nowadays as a marker of breast cancer care among hospitals. Searching for the ideal technique to predict the feasibility of BCS is ongoing. For this matter, the preoperative MRIs of 169 patients operated with radical or conservative surgery were reviewed. We estimated the tumor volume (TV) and breast volume (BV) on enhanced 3D-MRI and compared the tumor-to-breast volume ratio (TV/BV) in both groups. The mean ratio was 9.5% in the mastectomy group and 1.7% in the BCS group. A tumor-to-breast volume ratio less than 4% seemed to favor the adoption of a conservative option. Our data suggest that preoperative 3D-MRI can orient the surgical approach by assessing the TV/BV ratio, increasing lumpectomy rates with clear margins and good cosmetic outcome.

Surgery for early breast cancer has evolved from the mutilating radical mastectomies to breast conservation surgery (BCS) aimed to reduce the disfigurement associated with surgery. In breast conservation surgery, where the surgeon has to excise >20% of the breast volume, the cosmetic outcomes are less than optimal. Oncoplastic surgery (OPS) combines techniques used in plastic surgery with the oncology principle of resecting the tumour with adequate margins and aims to reconstruct the breast defect taking into consideration both oncologic safety and preservation of breast form. In this chapter, a review of the rationale behind oncoplastic surgery, indications and techniques and the emerging clinical data on outcomes are discussed.

This chapter focuses on the techniques of radiation treatment delivery both in post-mastectomy and breast conservation scenarios.

Tremendous progress has been made over the past several decades in the treatment of breast cancer. Mortality and recurrence rates continue to decline. Our ability to tailor patient- and tumor-specific treatments has rapidly advanced. The vast majority of our patients can safely have breast conservation. Unfortunately, for many patients, survivorship is burdened by ongoing quality-of-life issues. Most breast cancer patients are asymptomatic at presentation, and the onus is on us to preserve this. Surgery, radiation, and systemic therapy can result in long-term toxicities that can be amplified with multimodality approaches. We must strive to apply minimally effective therapies rather than a maximally tolerated approach. Breast cancer-related lymphedema (BCRL) is a particularly dreaded chronic complication. This review strives to give the reader a better understanding of BCRL and shed light on wisely choosing an integration of treatment modalities that minimizes BCRL risk. Key literature on emerging concepts is highlighted.

With early detection, breast conservation surgery with adequate surgical margins is the standard of care. The aim of this study was to evaluate the use of pre-operative duct endoscopy (DE) to target surgical resection, improve adequate margins and reduce re-excision operations. Women with DCIS, stage I and II breast cancer suitable for breast conservation were randomized to DE-assisted wide local excision versus standard wide local excision (without DE). The primary endpoint was margin re-excision rates between the two groups. Secondary end points were: (i) volume differences of the surgical specimen; (ii) whether an extensive in situ component (EIC) influenced successful DE-guided resection. 78 women were randomized: 44 patients to no-DE and 34 patients to the DE group. The median age was 59 (49–65) and 56 (48–64) years in the two groups respectively with mean follow-up of 9.1 (4.2–11.1) years. There were 23 positive findings in 17 women in 30 successful DE procedures (17/30 = 56.7%). The surgical specimen volume, no-DE (17 [IQR 10–29] cm3) and DE 20 [IQR 12–28] cm3), did not differ, p = 0.377. The overall re-excision rate was 20/78 (26%), 9 (20%) and 11 (32% in the no-DE and DE groups, respectively, p = 0.233. This randomized clinical trial was limited by incomplete accrual. DE did not contribute to improved margin excision rates whether a target lesion was visualized or not. The presence of EIC did not improve efficacy of DE.

Purpose Deep inspiration breath hold (DIBH) reduces heart and pulmonary doses during left-sided breast radiation therapy (RT); however, there is limited information whether the reduction in doses is similar in patients with modified radical MRM (MRM) and breast conservation surgery (BCS). The primary objective was to determine whether DIBH offers greater dosimetric reduction in cardiac doses in patients with MRM as compared to BCS with secondary objectives of documenting time consumed in counseling, simulation and planning such techniques. Methods Thirty patients with diagnosis of left sided breast cancer underwent CT simulation both free breathing (FB) and DIBH. Patients were grouped into two cohorts: MRM (n = 20) and BCS (n = 10). 3D-conformal plans were developed and FB was compared to DIBH for entire group (n = 30) and each cohort using Wilcoxon signed-rank tests for continuous variables and McNemar's test for discrete variables. The percent relative reduction conferred by DIBH in mean heart (Dmean heart) and left anterior descending artery dose (LADmean and LADmax), heart V25,V10, V2 and ipsilateral DmeanLung,V20, V12 were compared between the two cohorts using Wilcox rank-sum testing. A two-tailed p-value ≤ 0.05 was considered statistically significant. Time consumed during FB and DIBH from patient counseling to planning was documented. Results Patients undergoing BCS had comparable boost target coverage on DIBH and FB. For the overall group (n = 30), DIBH reduced Dmean heart and LAD dose, V25, V10 and V2 doses for the heart and Ipsilateral DmeanLung, V20, V12 which was statistically significant. For individual cohorts DIBH did not significantly reduce the lung (Ipsilateral DmeanLung, V20, V12) and LAD (LADmean and LADmax) doses for BCS while significant reduction in all cardiopulmonary doses was seen in MRM cohort. Despite significant reductions with DIBH in MRM, ipsilateral lung constraint of V12 Conclusion DIBH led to significant reduction of cardiac doses in both MRM and BCS. Reduction of lung and LAD doses were significant in MRM cohort. All cardiac constraints were met with DIBH in both cohorts, lung constraints were less frequently met in MRM cohort requiring nodal radiation.

The aim of a breast conservation surgery (BCS) is to achieve complete excision of the tumor with clear surgical margins while preserving the normal breast as much as possible. Intra-operative margin assessment helps to achieve negative margins, decreasing the need for re-excision. Intra-operative gross margin evaluation is a cost-effective and easy technique; however, data available regarding its adequacy are limited. We aim to find the minimum adequate gross margin required to achieve microscopic tumor-free margins and assess the relation if any of margin status with the tumor type, grade, nodal status and immunohistochemical (IHC) markers. A total of 178 patients who underwent BCS from the years 2013–2018 in our tertiary care center were selected, excluding the ones who underwent prior neoadjuvant chemotherapy and excision biopsy. A retrospective chart review was done, and the minimum adequate cutoff of gross margins required to achieve negative margins, without any positive or close margins, was evaluated. Ten exceptional cases were excluded. Among the 168 cases, 147 (87.5%) had negative and 21 (12.5%) had close or positive margins. On evaluation, maintaining an average gross margin of 5.5 mm gave a positive predictive value of 95.45%. The sensitivity and specificity were 71.43% and 76.19%, respectively, with an accuracy of 72%. No correlation was obtained between gross margin status and tumor characteristics. Gross margin evaluation is a fast and cost-effective method which can be easily set up in any hospital setting with limited resources to ensure negative margins during BCS.