Search

Background and Objectives: Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time., Methods: This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis., Results: In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%)., Conclusion: BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities., (© 2022 Wiley Periodicals LLC.)

Preoperative localization of nonpalpable breast lesions using a radar reflector surgical guidance system has become commonplace, but the clinical utility of this emerging technology in the musculoskeletal system has not yet been well established. The system components include a console, a handpiece, an implanted radiofrequency reflector that works as a lesion marker, and an infrared light-emitting probe to guide the surgeon. The reflector can be deployed to localize small nonpalpable nodules within the subcutaneous fat as well as lesions within the deeper soft tissues. It can also be used for lymph nodes and foreign bodies. Localization can be performed both before and after treatment. The objective of this article is to describe the potential applications and our technique and initial experience for radar reflector localization within the musculoskeletal system.

Significance: As many as 60% of patients with early stage breast cancer undergo breast-conserving surgery. Of those, 20% to 35% need a second surgery because of incomplete resection of the lesions. A technology allowing in situ detection of cancer could reduce re-excision procedure rates and improve patient survival., Aim: Raman spectroscopy was used to measure the spectral fingerprint of normal breast and cancer tissue ex-vivo . The aim was to build a machine learning model and to identify the biomolecular bands that allow one to detect invasive breast cancer., Approach: The system was used to interrogate specimens from 20 patients undergoing lumpectomy, mastectomy, or breast reduction surgery. This resulted in 238 ex-vivo measurements spatially registered with standard histology classifying tissue as cancer, normal, or fat. A technique based on support vector machines led to the development of predictive models, and their performance was quantified using a receiver-operating-characteristic analysis., Results: Raman spectroscopy combined with machine learning detected normal breast from ductal or lobular invasive cancer with a sensitivity of 93% and a specificity of 95%. This was achieved using a model based on only two spectral bands, including the peaks associated with C-C stretching of proteins around 940    cm - 1 and the symmetric ring breathing at 1004    cm - 1 associated with phenylalanine., Conclusions: Detection of cancer on the margins of surgically resected breast specimen is feasible with Raman spectroscopy., (© 2023 The Authors.)

Background and Objectives: This trial aimed to investigate the effects of circumferential shaving on reducing the reoperation rates during breast-conserving surgery (BCS)., Methods: In the study, before 2014, 404 (39.9%) breast cancers (BCs) out of a total of 1012 BCs underwent BCS without intraoperative cavity shaving (ICS) and constituted the no-ICS group. After this date, ICS was added to 608 (60.1%) BCSs (ICS group) and intraoperative margin analysis was not requested from pathologists during these second BCS procedures., Results: The patient and BC characteristics in the no-ICS and ICS groups were similar. Carcinoma detection at the margin and reoperation rates were 13.9% in the no-ICS group and 7.6% in the ICS group (p = 0.001). No significant difference was detected between patients who underwent BCS with intraoperative frozen section analysis (FSA) and patients who underwent BCS with additional ICS (5.6% vs. 7.6%, p = 0.383)., Conclusions: ICS decreased the rates of positive margins and reoperations among patients with BCS to an acceptable level compared with intraoperative FSA. It may be concluded that ICS is feasible to achieve BC margin control., (© 2022 Wiley Periodicals LLC.)

Background: Breast cancer is the most prevalent cancer in women. In the past few years, surgical interventions for breast cancer have experienced massive changes from radical excision to conserving approaches. In this study, we aim to compare the two breast surgery interventions, including conventional breast-conserving surgery (CBCS) versus oncoplastic breast-conserving surgery (OPBCS)., Methods: We searched on PubMed, Web of Science (WOS), Scopus, Embase, and Cochrane till 2 October 2021. All relevant randomized controlled trials (RCTs) and observational studies were included. The data were extracted and pooled using Review Manager software (RevMan 5.4)., Results: The pooled meta-analysis of the included studies showed that OPBCS was significantly superior to CBCS in most of the outcomes. Re-excision significantly favoured CBCS (RR = 0.49, 95% CI [0.37, 0.63], P < 0.00001). However, local recurrence (RR = 0.55, 95% CI [0.27, 1.09], P = 0.09), close surgical margins (RR = 0.37, 95% CI [0.14, 1.00], P = 0.05) and end up to the risk of mastectomy (RR = 0.73, 95% CI [0.54, 97], P = 0.06) showed no significant difference between both techniques. Notably, while performing a sensitivity analysis, other outcomes as local recurrence, significantly showed favourable results towards OPBCS. In terms of safety outcomes, there was no significant difference between OPBCS and CBCS., Conclusion: We recommend the oncoplastic approach rather than the conventional one in females with breast cancer. Re-excision rates showed better results following OPBCS., (© 2023. The Author(s).)

Radiotherapy with electrons is commonly applied to the tumor bed after whole-breast radiotherapy following breast conservation surgery for breast cancer patients. However, the radiation dose to adjacent organs-at-risk (OARs) and conformity of planning target volume (PTV) cannot be optimized. In this study, we examine the feasibility of using modulated electron bolus (MEB) to improve PTV conformity and reduce the dose to these OARs. Twenty-seven patients with left breast cancer were retrospectively selected in this study. For each patient, a tangential photon plan in RayStation treatment planning system with prescription of 26 Gy in 5 fractions was created as base plan. Two electron plans, one without bolus and one with MEB using Adaptiiv software based on the PTV were created. Various dosimetric parameters of OARs including left lung, heart, left anterior descending artery (LAD) and ribs and the conformity indices of PTV of these 2 electron plans together with the base plans were compared. Statistically significant decreases in the dosimetric parameters (V 5Gy , V 10Gy , V 20Gy , and mean dose) of the ipsilateral left lung and the heart were observed with MEB. The median maximum dose to the LAD and the ribs decreased by 6.2% and 4.5% respectively. The median conformity index was improved by 14.3% with median increases of monitor units by 1.7%. Our results show that MEB is feasible resulting in reduction of doses to the predefined OARs and an improved conformity of PTV. By using 3D printing, MEB might be considered as an alternative to conventional electron boost., Competing Interests: Conflict of interest There are no known conflicts of interest associated with this publication and this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2022 American Association of Medical Dosimetrists. Published by Elsevier Inc. All rights reserved.)

Background: Intraoperative radiotherapy (IORT) is a therapeutic de-escalation option in older women with low-risk early breast cancer (EBC). A qualitative study was implemented to describe EBC physicians' points of view on IORT as a de-escalation option., Methods: Recorded face-to-face and telephone semi-structured interviews were conducted among diverse physicians from seven French comprehensive cancer centers. Interview transcripts were grouped as corpus to construct a typology. Thematic analysis was performed., Results: Positions toward IORT were contrasted between the 16 participating physicians. Five fully supported IORT as a de-escalation option, four were not in favor, and seven had a more reserved or neutral opinion. Points of divergence concerned treatment efficacy, treatment duration, side effects and sequelae, psychological impact, compliance with adjuvant endocrine therapy, logistical constraints, financial cost, and availability of other techniques of partial breast irradiation. Physicians in favor of IORT emphasized direct benefits for the patient, and those against pointed the lack of specific guidelines, risk of lost opportunity in older women with long life expectancy, and challenges of shared decision making., Conclusions: Despite national policies to preserve cancer patients' quality of life and increase their participation in medical decision making, therapeutic de-escalation using IORT is not consensual among physicians. Further efforts are needed to promote patient-centered care.

Backgrounds: Traditionally, breast conserving surgery for non-palpable breast cancer is guided by wire or radioactive seed and radioactive tracer for sentinel lymph node biopsy (SLNB). Alternatively, a stain-less magnetic seed and superparamagnetic iron oxide tracer (SPIO) can be combined as a radioactive-free technique. The aim of this study was to define the pitfalls we encountered during implementation of this combined technique and provide solutions resulting in an instruction manual for a radio-active free procedure., Methods: Between January and March 2021, seventeen consecutive patients with cN0 non-palpable breast cancer were included. The magnetic seed was placed to localize the lesion and SPIO was used to identify the sentinel lymph node (SLN). A lymphoscintigraphy with Technetium-99m nano colloid was performed concomitantly in all patients as a control procedure for SPIO. Surgical outcomes are reported, including problems with placing and retrieval of the seed and SPIO and corresponding solutions., Results: Surgical excision was successful with invasive tumor-free margins in all patients. SLN detection was successful in 82% patients when compared to Technetium-99m. The most challenging issue was an overlapping magnetic signal of the seed and SPIO. Solutions are provided in detail., Conclusions: Combined use of magnetic seed and SPIO for wide local excision and SLNB patients with non-palpable breast lesions appeared challenging due to overlapping magnetic signals. After multiple adaptations, the protocol proved to be feasible with an added advantage of eliminating the use of radioisotopes. We described the pitfalls and solutions resulting in an instruction manual for a totally radioactive-free procedure., Competing Interests: Declaration of competing interest All authors declare that there are no conflicts of interest. The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: The purpose was to evaluate the effect of adjuvant radiation therapy on the survival prognosis of older women with early-stage breast cancer under different surgical treatments., Methods: We collected patients from the Surveillance, Epidemiology and End Results (SEER) database. Elderly female patients (≥ 70 years) with stage I-IIB diagnosed with invasive carcinoma in 1988-2017 were included. After propensity score matching (PSM), the prognosis of patients who underwent breast-conserving surgery or mastectomy was calculated separately. The effects of radiotherapy on the survival of three special population groups (breast-conserving surgery + T1N0M0 + ER positive, mastectomy + T3N0M0 and mastectomy + T1-2N1M0) were analyzed selectively., Results: Of 106,553 older women with early-stage breast cancer were identified. 48,630 patients had received radiotherapy, while 57,923 patients had not. After PSM, older women undergoing breast-conserving surgery benefited significantly from radiotherapy (both OS and BCSS p < 0.001), for patients with T1N0M0 and ER-positive breast cancer (both OS and BCSS p < 0.001). In the subgroup of T1-2N1M0 breast cancer treated by mastectomy, patients undergoing radiotherapy had a worse survival as well (OS p < 0.001; BCSS p = 0.0907). While in the subgroup of T3N0M0 breast cancer treated by mastectomy, survival analyses showed no statistical differences between patients receiving radiation or not (OS p = 0.1778, BCSS p = 0.6957)., Conclusions: This study indicated the clinical effects of radiation on older women who received different surgical treatments. Our study suggested that radiotherapy should be omitted in older women undergoing mastectomy + T3N0M0 or T1-2N1M0 and radiotherapy could be considered in women with T1N0M0 + ER-positive undergoing breast-conserving surgery., (© 2022. The Author(s).)

Breast-conserving surgery or lumpectomy requires localization of the lesion prior to surgery, which is traditionally accomplished by imaging-guided wire localization. Over the last decade, alternatives to wire localization have emerged. This work reviews the literature on one such wireless technology, SaviScout radar (SSR) system, and shares our experience with using this technology for presurgical tumor localization. The SSR surgical guidance system is non-radioactive. The radiologist implants a reflector device in the breast under mammography or ultrasound guidance at any time prior to surgery. The placement of this reflector can be confirmed from the cadence of a handheld percutaneous probe of a handpiece and console system. Results from several studies show that the surgical outcomes from SSR and wire-localization are similar. SSR provides operational advantages as the scheduling for reflector placement by radiologists is decoupled from surgery, but at an increased cost compared to wire-localization., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Iodine-125 (I-125) labelled radioactive seeds were the first published wireless pre-operative image-guided breast localization technique. Radioseeds offer benefit to radiologists as a relatively intuitive procedure with precise mammographic or sonographic-guided localization and improved patient experience. Localization and surgical dates can be uncoupled, which facilitates efficient scheduling for radiologists and surgeons. Surgeons can better tailor their surgery with intra-operative localization using a special probe to detect the emitted gamma energy. Due to radioactivity, implementation of a radioseed program requires compliance with the National Regulatory Commission and therefore multidisciplinary involvement. Seeds have a high placement success rate, and comparable surgical success and re-excision rate to wires., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Breast reirradiation (reRT) after breast conserving surgery (BCS) has emerged as a viable alternative to mastectomy for women presenting with recurrent or new primary breast cancer. There are limited data on safety of different fractionation regimens. This study reports safety and efficacy among women treated with repeat BCS and reRT., Methods and Materials: Patients who underwent repeat BCS followed by RT from 2015 to 2021 at 2 institutions were analyzed. Univariate logistic regression models were used to identify predictors of acute and late toxicities. Kaplan-Meier estimates were used to evaluate overall survival (OS), distant metastasis-free survival (DMFS) and locoregional recurrence-free survival (LR-RFS)., Results: Sixty-six patients were reviewed with median follow-up of 16 months (range: 3-60 months). At time of first recurrence, 41% had invasive carcinoma with a ductal carcinoma in situ (DCIS) component, 41% had invasive carcinoma alone and 18% had DCIS alone. All were clinically node negative. For the reirradiation course, 95% received partial breast irradiation (PBI) (57.5% with 1.5 Gy BID; 27% with 1.8 Gy daily; 10.5% with hypofractionation), and 5% received whole breast irradiation (1.8-2 Gy/fx), all of whom had received PBI for initial course. One patient experienced grade 3 fibrosis, and one patient experienced grade 3 telangiectasia. None had grade 4 or higher late adverse events. We found no association between the fractionation of the second course of RT or the cumulative dose (measured as EQD2) with acute or late toxicity. At 2 years, OS was 100%, DMFS was 91.6%, and LR-RFS was 100%., Conclusion: In this series of patients with recurrent or new primary breast cancer, a second breast conservation surgery followed by reirradiation was effective with no local recurrences and an acceptable toxicity profile across a range of available fractionation regimens at a median follow up of 16 months. Longer follow up is required., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Breast re-irradiation (reRT) after breast-conserving surgery (BCS) using external beam radiation is an increasingly used salvage approach for women presenting with recurrent or new primary breast cancer. However, radiation technique, dose and fractionation as well as eligibility criteria differ between studies. There is also limited data on efficacy and safety of external beam hypofractionation and accelerated partial-breast irradiation (APBI) regimens. This paper reviews existing retrospective and prospective data for breast reRT after BCS, APBI reRT outcomes and delivery at our institution and the need for a randomized controlled trial using shorter courses of radiation to better define patient selection for different reRT fractionation regimens.

Background: Multifocal (MFBC)/multicentric (MCBC) breast cancer is being more recognized due to the improved imaging modalities and the greater orientation with this form of breast cancer, however, optimal surgical treatment, still poses a challenge. The standard surgical treatment is mastectomy, however, breast-conserving surgeries (BCS) may be appropriate in certain situations., Methods: A total of 464 cases of MF/MCBC out of 4798 cases of breast cancer were retrospectively analyzed from the database of the Oncology Center, Mansoura University (OCMU), between January 2008 and December 2019., Results: Radiologic involvement of multiple quadrants was reported in 27.9% by ultrasonography, 19% by mammography, and 59.1% by magnetic resonance imaging. BCS was performed in 32 cases (6.9%) while 432 cases underwent a mastectomy. Postoperative pathology revealed infiltration of other quadrants grossly in 23.5%, and under the microscope in 63.6% of the examined cases. Mean disease-free and overall survival were 95.5 and 164.6 months, respectively. When compared with MFBC, MCBC showed higher pathologic tumor size (p < 0.001), higher stages (p < 0.001), higher recurrence rates (p = 0.006), and lower DFS (P = 0.009) but with similar OS (P = 0.8)., Conclusion: Mastectomy is still the primary treatment option for MCBC with higher recurrence rates compared with MFBC. However, BCS for properly selected MFBC is considered oncologically safe, following the same rules of breast conservation for unifocal disease.

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., Competing Interests: Declaration of competing interest All authors declare no competing interests within the scope of the present work. A.K. reports travel grants by ESSO, EUSOMA, UEMS and Endomag; institutional grants by Endomag; consultation for Resitu AB; honoraria by Elsevier., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Breast conservation therapy (BCT) has been shown to have comparable long-term survival outcomes when compared with mastectomy. Clearance of excision margin is one of the mainstays of the surgical treatment, which if not achieved at the first operation of BCT results in the need for subsequent surgery., Methods: This study evaluated the impact of routinely taken cavity shavings on re-excision rates. This retrospective two-centre study describes the use of routine four-quadrant cavity shaving in 449 patients with consecutively treated with wide local excision for invasive cancer or ductal carcinoma in situ., Results: The overall incomplete excision rate was 10.6%. Routine cavity shaving prevented the need for re-excision in 84 patients (18.7%) and identified the need for further re-excision in 33 patients (7.3%). Median time from surgery to radiotherapy was 50 days (range 13-209) for non-re-excised patients versus 78 days (range 47-260) for re-excised patients ( p <0.001). Median time to chemotherapy ( n =75) was 44 days (range 14-106) for non-re-excised patients versus 56 days (range 35-116) for re-excised patients ( p =0.017)., Conclusions: This study demonstrates that routine cavity shaving decreases re-excision rate in patients treated with wide local excision and prevents delays to adjuvant treatment due to incomplete excision.

Purpose: There is an unmet need to identify women diagnosed with ductal carcinoma in situ (DCIS) with a low risk of in-breast recurrence (IBR) after breast conserving surgery (BCS), which could omit radiation therapy (RT), and also to identify those with elevated IBR risk remaining after BCS plus RT. We evaluated a novel biosignature for a residual risk subtype (RRt) to help identify patients with elevated IBR risk after BCS plus RT., Methods and Materials: Women with DCIS treated with BCS with or without RT at centers in the US, Australia, and Sweden (n = 926) were evaluated. Patients were classified into 3 biosignature risk groups using the decision score (DS) and the RRt category: (1) Low Risk (DS ≤2.8 without RRt), (2) Elevated Risk (DS >2.8 without RRt), and (3) Residual Risk (DS >2.8 with RRt). Total and invasive IBR rates were assessed by risk group and treatment., Results: In patients at low risk, there was no significant difference in IBR rates with or without RT (total, P = .8; invasive IBR, P = .7), and there were low overall 10-year rates (total, 5.1%; invasive, 2.7%). In patients with elevated risk, IBR rates were decreased with RT (total: hazard ratio [HR], 0.25; P < .001; invasive: HR, 0.28; P = .005); 10-year rates were 20.6% versus 4.9% (total) and 10.9% versus 3.1% (invasive). In patients with residual risk, although IBR rates decreased with RT after BCS (total: HR, 0.21; P < .001; invasive: HR, 0.29; P = .028), IBR rates remained significantly higher after RT compared with patients with elevated risk (HR, 2.5; 95% CI, 1.2-5.4; P = .018), with 10-year rates of 42.1% versus 14.7% (total) and 18.3% versus 6.5% (invasive)., Conclusions: The novel biosignature identified patients with 3 distinct risk profiles: Low Risk patients with a low recurrence risk with or without adjuvant RT, Elevated Risk patients with excellent outcomes after BCS plus RT, and Residual Risk patients with an elevated recurrence risk remaining after BCS plus RT, warranting potential intensified or alternative treatment approaches., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Mammography breast cancer screening programs and continuing improvements in early diagnosis of the disease have led to more frequent detection of nonpalpable breast lesions. The commonly used technique in guiding the surgical removal of these lesions is hook wire-guided localization (WGL). However, the WGL procedure has been criticized for the last years. Key disadvantages of WGL are possible wire transection, wire migration before or during surgery, patient discomfort and pneumothorax. Over the last decade, alternatives to wire localization have emerged. In this study the authors present their initial experience with a wireless, nonradioactive, wave reflection implant system that enables surgeons to safely and accurately remove breast lesions (Tab. 2, Fig. 4, Ref. 20). Keywords: breast cancer, breast surgery, nonpalpable lesions, preoperative localization.

Objectives: The purpose of this study is to evaluate the utilization of intraoperative ultrasound (IOUS) for tumor localization in breast-conserving surgery and to examine its impact on margin positivity and re-excision rates. Additionally, the study seeks to identify factors contributing to surgeon utilization of IOUS., Methods: A retrospective chart review was conducted of patients with preoperative diagnosis of breast cancer undergoing breast-conserving surgery by breast surgeons at multiple centers within a single healthcare system. Characteristics such as lesion size, palpability, histology, receptor status, and use of neoadjuvant chemotherapy were recorded. Re-excision rates were determined based on localization technique and surgeons' status of breast ultrasound certification., Results: A total of 671 cases were performed, with 322 meeting study inclusion. 57 cases utilized IOUS, 250 utilized preoperative wire-guided localization (WGL), 10 used both methods and 5 cases used neither method. There was no significant difference in re-excision rates between IOUS and WGL or among the four surgeons. Ultrasound-certified surgeons were more likely to utilize IOUS, and re-excision rates trended higher for WGL, which may be clinically significant., Conclusion: Increasing familiarity with and utilization of IOUS during breast-conserving surgery may be clinically advantageous over traditional localization techniques. Ultrasound certification may lead to increased use of IOUS among surgeons., (Published by Elsevier Inc.)

Background: Autologous fat grafting (AFG) is often used to reconstruct defects after breast conservation therapy (BCT). However, concerns exist about the possibility of AFG-related recurrence or metastasis. This study aims to evaluate the literature to evaluate oncologic outcomes in patients undergoing AFG at the time of BCT., Methods: A systematic review of articles related to AFG based reconstruction at the time of BCT from 1970 to 2021 was performed via PubMed. Patients were grouped based on the presence or lack of AFG usage at the time of BCT, and oncologic outcomes and complications were compared., Results: Of the 146 articles identified, 15 were included. Nine hundred patients underwent BCT alone and 1063 patients underwent BCT with AFG patients. Similar average follow-up time was observed between the groups, 58.7 months (BCT only) and 55.2 months (BCT with AFG). On pooled analysis, no difference was identified in local recurrence 4.8% (43 patients) of the BCT group and 3% (32 patients) in the AFG group (P = 0.8), metastasis 4.8% (43 patients) of the BCT group and 6.9% (73 patients) in the AFG group (P = 0.3), or fat necrosis (P = 0.44). Meta-analysis additionally did not identify any statistically significant odds ratios between the BCT only group and BCT with AFG group when evaluated for total recurrence, local recurrence, metastasis or fat necrosis., Conclusions: The results show no significant difference in cancer recurrence or metastasis in the BCT only group versus BCT and AFG, showing that fat grafting has safe outcomes., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Conservative surgery and radiotherapy (CS + RT) have become the standard of care for early-stage breast cancer as an alternative to mastectomy. With the increasing rate of obesity and incidence of macromastia, surgeons increasingly encounter patients with a history of breast radiation desiring breast reduction. However, elective breast surgery after irradiation remains to be controversial due to known adverse effects of radiation, especially on wound healing, and unknown effects of lumpectomy on traditional pedicle choices. Herein, we present our experiences and outcomes of reduction mammaplasties and mastopexies in patients with breast cancer previously treated with CS + RT., Methods: Between 2009 and 2020, 13 patients undergoing reduction mammaplasty or mastopexy, who have previously underwent CS + RT with or without axillary surgery, were included in this study. Surgical techniques and complications, including delayed wound healing, infection, fat necrosis, and nipple-areolar necrosis, were recorded and analyzed based on the irradiated versus nonirradiated sides., Results: Of the 13 patients, delayed wound healing occurred in 7% on the irradiated side and 15% on the nonirradiated sides (P > 0.05). No significant correlation was observed between the number of complications and time of elective breast surgery from the last radiation therapy. Complications between irradiated and nonirradiated breasts did not significantly differ in both the reduction mammaplasty and mastopexy groups., Conclusions: Reduction mammaplasty and mastopexy in patients with a history of lumpectomy and breast irradiation can be safely performed and should be considered in those experiencing macromastia or asymmetry post-CS + RT., Competing Interests: Conflicts of interest and sources of funding: none declared., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: Our aim is to identify the subgroups of women undergoing breast conserving surgery (BCS) who are at high risk for positive surgical margins and who require a re-excision procedure and understand the characteristics of tumor and hormone receptors that will allow surgeons to remove larger margins., Material and Methods: One hundred twenty-nine patients with invasive carcinoma in breast who underwent BCS were included in the study. Women with a positive surgical margin (n = 61) required re-excision procedure., Results: Patients with high grade breast cancer, negative hormone receptor status, high Ki-67 status, upper outer quadrant tumor, and associated ductal carcinoma were more likely to undergo tumor removal and re-excision., Conclusion: The pathological and clinical predictors described above that meet these criteria require the removal of larger margins for safety in order to minimize the rate of positive surgical margins., Key Words: Estrogen Receptor, Hormone receptor status, Positive surgical margin.

Background: Surgical resection with clear surgical cut margins is the mainstay of managing malignant breast neoplasms. Multiple techniques have been suggested to enhance resection status during breast-conserving surgery (BCS), including intraoperative ultrasonography (IOUS). Herein, we conducted the current investigation to reveal the benefit of IOUS on the achievement of R0 resection. Patients and Methods . This retrospective investigation included 140 patients who underwent BCS. They were divided into two groups: the IOUS group (40 cases) and the control group (100 cases). Our primary objective was to determine the free resection margin status (R0)., Results: Both study groups expressed statistically comparable demographic and clinical data. Additionally, histopathological examination revealed no significant difference between the two groups regarding the tumor type, stage, or grade. Nonetheless, the R0 resection margin was more frequently encountered in association with IOUS application (97.5% compared to 79% in the control group), and that difference was statistically significant ( p =0.007)., Conclusion: The application of IOUS has a significant beneficial impact on the outcomes of BCS. It is associated with a marked decline in positive resection margins, and its application should be encouraged in the breast oncological practice., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Osama Almezaien et al.)

Aim: To evaluate outcome of intraoperative electron boost (IOERT) and hypofractionated whole breast irradiation (HWBI) for breast cancer (BC) in young women., Methods and Materials: Women aged ≤ 48 with pT1-2 N0-1 BC received 12 Gy IOERT boost during conservative surgery followed by 3-dimensional conformal HWBI in 13 fractions (2.85 Gy/die). Local relapses (LR) and survival (disease-free, DFS; specific, BCSS; overall, OS) were analyzed., Results: 481 consecutive BC patients, mostly node negative, with median age of 42 were treated between 2004 and 2014. Median tumor size was 1.48 cm and median IOERT collimator was 4 cm. After 25-day mean interval, HWBI was delivered. At a median follow-up of 9.6 years, there were 23 LRs (4.8 %, 9 of which were in the boost region). Ten-year LR cumulative incidence was 4.1 % (95 %CI, 2.5-6.3). Over time, local control rate decreased for Luminal A and HER2 positive with negative hormonal receptors, while remained steady for triple negative. At multivariate analysis, LR predictors included age < 40, extensive intraductal component and the use of 4-cm IOERT collimator size. Ten-year survival outcomes were as follows: DFS 80.0 % (95 % CI, 75.8-83.5), BCSS 97.5 % (95 % CI, 95.5-98.6 %), OS 96.5 % (95 % CI, 94.3-97.9). Luminal B HER2 negative had the worse survival outcomes. Perioperative complications were uncommon (16.4 %), acute toxicity was mild (<2% Grade 3), but moderate/severe fibrosis was described in 40.8 % of the cases. Cosmesis was scored as excellent/good in 86 % of the cases., Conclusions: ELIOT boost and HWBI achieved an excellent local control at the cost of tumor bed fibrosis. IOERT boost dose lower than 12 Gy is advisable., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Conflict of Interest Statement Maria Cristina Leonardi, Barbara Alicja Jereczek-Fossa and Samantha Dicuonzo received a speaker honorarium from Accuray Inc. outside the current work. Maria Alessia Zerella had research grant from AIRC under IG 2019 - ID. 23,118 project “Phase I/II clinical trial on single fraction ablative preoperative radiation treatment for early-stage breast cancer”. Mattia Zaffaroni received a research fellowship from AIRC entitled “Radioablation ± hormonotherapy for prostate cancer oligorecurrences (RADIOSA trial): potential of imaging and biology” outside the current study. Silvia Dellapasqua had travel/accommodations expenses paid by Lilly, Novartis, Pfizer, and an Advisory Role for Astra Zeneca. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The remaining authors declare no conflicts of interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: Pathologic examination of post-neoadjuvant chemotherapy (NAC) breast surgical specimens includes assessment of margins. It has been recommended that tumor bed (TB) changes extending to margins should be documented; however, its' incidence and clinical significance have not yet been established. The aim of our study was to gather prognostic data on this histological finding., Design: We retrospectively identified all cases where TB was reported at margin. Cases where margins were also positive for invasive carcinoma or DCIS were excluded., Results: From 2016 to 2019, 115 cases of NAC treated breast cancers were identified with 21 having at least one margin positive for TB after initial surgery (incidence of 18.3 %). Five cases were estrogen receptor (ER)-/HER2-, 9 were HER2+ and 7 were ER+/HER2-. Nineteen patients underwent partial mastectomy and 2 underwent total mastectomy. Nine patients had a pathological complete response (pCR).Ten cases had more than one positive margin for TB. None of the 21 patients underwent a second surgery for margin re-excision. Twenty patients received adjuvant therapy. With an average follow-up of 28.1 months, there has been one local recurrence. Four other patients developed metastatic disease, one of which died of the disease. The rates of locoregional and distant recurrence and mortality were statistically similar to those from patients whose margins were negative for TB., Conclusions: Our results suggest low risk of local recurrence when a positive margin for TB is not re-excised. Further data and follow-up will be needed to confirm the adequacy of conservative management in this setting., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There are several techniques for localization of non-palpable breast tumors, but comparisons of these techniques in terms of margin positivity and volume of tissue resected are lacking., Methods: Between 2011-2013 and 2016-2018, 2 randomized controlled trials involving 10 centers across the United States accrued 631 patients with stage 0-3 breast cancer, all of whom underwent breast conserving surgery. Of these, 522 had residual non-palpable tumors for which localization was required. The localization technique was left to the discretion of the individual surgeon. We compared margin positivity and volume of tissue resected between various localization techniques., Results: The majority of the patients (n = 465; 89.1%) had wire localization (WL), 50 (9.6%) had radioactive seed (RS) localization, and 7 (1.3%) had Savi Scout (SS) localization. On bivariate analysis, there was no difference in terms of margin positivity (37.8% vs. 28.0% vs. 28.6%, P = .339) nor re-excision rates (13.3% vs. 12.0% vs. 14.3%, P = .961) for the WL, RS, and SS groups, respectively. Further, the volume of tissue removed was not significantly different between the 3 groups (71.9 cm 3 vs. 55.8 cm 3 vs. 86.6 cm 3 for the WL, RS, and SS groups, respectively, P = .340). On multivariate analysis, margin status was affected by tumor size (OR = 1.336; 95% CI: 1.148-1.554, P <.001) but not by type of localization ( P = .670)., Conclusions: While there are a number of methods for tumor localization, choice of technique does not seem to influence volume of tissue resected nor margin status.

Purpose: To compare the effect of intraoperative radiotherapy (IORT) and no radiotherapy in early stage low-risk breast cancer patients undergoing breast-conserving surgery., Methods: According to the criteria recommended by ASTRO for patients eligible for IORT, we retrospectively selected women with early stage low-risk breast cancer who underwent breast-conserving surgery from 2010 to 2019 from the SEER database. Propensity score matching was used to balance the differences in baseline characteristics. The Kaplan-Meier method was used to calculate the overall survival (OS) and breast cancer-specific survival (BCSS) of patients, and the log-rank test was used to compare the differences., Results: A total of 20,245 patients were included in the analysis, including 1738 in the IORT group and 18,507 in the no radiotherapy group, with a median follow-up of 41 months. Before matching, the 5-year OS rates of the IORT group and the no radiotherapy group were 95.5% and 85.7% (p < 0.001), respectively, and the 5-year BCSS rates of the two groups were 99.6% and 98.3% (p < 0.001), respectively. After matching, the 5-year OS rates were 95.6% and 90.3% (p < 0.001) in the IORT group and the no radiotherapy group, respectively, and the 5-year BCSS rates were 99.5% and 99.1% (p = 0.028), respectively. Cox multivariate analysis of the original data showed that radiotherapy was an independent prognostic factor for both OS and BCSS (p < 0.05)., Conclusions: For patients aged 50 years or older with early stage low-risk breast cancer, IORT may be a better option, with improved BCSS compared to the elimination of radiotherapy. The study could not draw conclusions on OS, because underlying diseases may be unevenly distributed between the two groups., (© 2022. The Author(s), under exclusive licence to Federación de Sociedades Españolas de Oncología (FESEO).)

Introduction: Breast-conserving surgery (BCS) in case of breast cancer and/or in-situ-carcinoma lesions (DCIS) intends to completely remove breast cancer while saving healthy tissue as much as possible to achieve better aesthetic and psychological outcomes for the patient. Such modality should result in postoperative tumor-free margins of the surgical resection in order to carry on with the next therapeutical steps of the patient care. However, 10-40% of patients undergo more than one procedure to achieve acceptable cancer-negative margins. A 2nd operation or further operation (re-operation) has physical, psychological, and economic consequences. It also delays the administration of adjuvant therapy, and has been associated with an elevated risk of local and distant disease relapse. In addition, a high re-operation rate can have significant economic effects - both for the service provider and for the payer. A more efficient intraoperative assessment of the margin may address these issues. Recently, a large field-of-view confocal laser scanning microscope designed to allow real-time intraoperative margin assessment has arrived on the market - the Histolog Scanner. In this paper, we present the first evaluation of lumpectomy margins assessment with this new device., Materials and Methods: 40 consecutive patients undergoing BCS with invasive and/or DCIS were included. The whole surface of the surgical specimens was imaged right after the operation using the Histolog Scanner (HLS). The assessment of all the specimen margins was performed intraoperatively according to the standard-of-care of the center which consists of combined ultrasound (IOUS) and/or conventional specimen radiography (CSR), and gross surgical inspection. Margin assessment on HLS images was blindly performed after the surgery by 5 surgeons and one pathologist. The capabilities to correctly determine margin status in HLS images was compared to the final histopathological assessment. Furthermore, the potential reduction of positive-margin and re-operation rates by utilization of the HLS were extrapolated., Results: The study population included 7/40 patients with DCIS (17.5%), 17/40 patients with DCIS and invasive ductal cancer (IDC NST) (42.5%), 10/40 patients with IDC NST (25%), 4/40 with invasive lobular cancer (ILC) (10%), and 1/40 patients with a mix of IDC NST, DCIS, and ILC. Clinical routine resulted in 13 patients with positive margins identified by final histopathological assessment, resulting in 12 re-operations (30% re-operation rate). Amongst these 12 patients, 10 had DCIS components involved in their margin, confirming the importance of improving the detection accuracy of this specific lesion. Surgeons, who were given a short familiarization on HLS images, and a pathologist were able to detect positive margins in 4/12 and 7/12 patients (33% and 58%), respectively, that were missed by the intraoperative standard of care. In addition, a retrospective analysis of the HLS images revealed that cancer lesions can be identified in 9/12 (75%) patients with positive margins., Conclusion: The present study presents that breast cancer can be detected by surgeons and pathologists in HLS images of lumpectomy margins leading to a potential reduction of 30% and 75% of the re-operations. The Histolog Scanner is easily inserted into the clinical workflow and has the potential to improve the intraoperative standard-of-care for the assessment of breast conserving treatments. In addition, it has the potential to increase oncological safety and cosmetics by avoiding subsequent resections and can also have a significant positive economic effect for service providers and cost bearers. The data presented in this study will have to be further confirmed in a prospective phase-III-trial., Competing Interests: Declaration of competing interest M.P. Lux has received honoraria from AstraZeneca, Daiichi-Sankyo Eisai, Exact Sciences, Gilead, Grünenthal, Lilly, medac, MSD, Novartis, Pfizer, pfm, PharmaMar, Pierre-Fabre, Roche, Samantree and Sysmex for advisory boards, lectures, and travel support. M.F. Sandor received travel expenses by Samantree. Other authors have no conflicts of interest., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: For selected women diagnosed with breast cancer (BC), partial reconstructive techniques involve displacement or replacement procedures to improve cosmesis without compromising oncological safety. This study aims to evaluate the surgical outcomes of the round block (RB) compared with the subaxillary flap (SF) technique for patients with upper outer tumor., Patients and Methods: Thirty-three patients treated with oncoplastic conserving surgery (15 RB and 18 SF) were enrolled in this retrospective study. After carrying out a comparison of baseline characteristics, all cases were recruited for postoperative evaluation of oncological and cosmetic parameters. Moreover, we investigated several scoring combinations to check whether they could discriminate surgeon and patient satisfaction according to different functional results., Results: Median age ( p < 0.05), average tumor size ( p > 0.05), estimated resection volume ( p > 0.05), and nodal involvement ( p > 0.05) were slightly higher in the SF group. A greater frequency of DCIS ( p < 0.05) in the RB series correlated with reintervention for positive margins ( p > 0.001). At a mean follow-up of 19 months, no locoregional recurrences were recorded and early and late complications were comparable ( p > 0.05). The overall satisfaction with cosmesis was characterized by similar proportions of good results ( p > 0.05), with some details more related to each procedure., Conclusion: The proposed techniques represent effective solutions for reshaping that follows upper outer wide excision, achieving comparable complication rates, low reinterventions, and good aesthetic results in relation to technical and social functioning evaluations. However, it is crucial to establish a careful patient selection in order to manage correct surgical planning while predicting any potential sequelae or complication.

Background: Postoperative radiotherapy (PORT) could be useful for pN1 breast cancer patients who have undergone breast-conserving surgery (BCS) or mastectomy. However, the value of regional nodal irradiation (RNI) for BCS patients, and the indications for post-mastectomy radiotherapy (PMRT) for pN1 breast cancer mastectomy patients, have recently been challenged due to the absence of relevant trials in the era of modern systemic therapy. "PORT de-escalation" should be assessed in patients with pN1 breast cancer., Methods: The PORT-N1 trial is a multicenter, randomized, phase 3 clinical trial for patients with pN1 breast cancer that compares the outcomes of control [whole-breast irradiation (WBI) and RNI/PMRT] and experimental (WBI alone/no PMRT) groups. PORT-N1 aims to demonstrate non-inferiority of the experimental group by comparing 7-year disease-free survival rates with the control group. Female breast cancer patients with pT1-3 N1 status after BCS or mastectomy are eligible. Participants will be randomly assigned to the two groups in a 1:1 ratio. Randomization will be stratified by surgery type (BCS vs. mastectomy) and histologic subtype (triple-negative vs. non-triple-negative). In patients who receive mastectomy, dissection of ≥5 nodes is required when there is one positive node, and axillary lymph node dissection when there are two or three positive nodes. Patients receiving neoadjuvant chemotherapy are not eligible. RNI includes a "high-tangent" or wider irradiation field. This study will aim to recruit 1106 patients., Discussion: The PORT-N1 trial aims to verify that PORT de-escalation after BCS or mastectomy is safe for pN1 breast cancer patients in terms of oncologic outcomes and capable of reducing toxicity rates. This trial will provide information crucial for designing PORT de-escalation strategies for patients with pN1 breast cancer., Trial Registration: This trial was registered at ClinicalTrials.gov (NCT05440149) on June 30, 2022., (© 2022. The Author(s).)

Objective: To evaluate the feasibility and accuracy of near-infrared fluorescence imaging technology for assessing margins during breast-conserving surgery for breast cancer., Methods: Forty-three breast cancer patients who received surgical treatment at Yijishan Hospital of Wannan Medical College were selected. Before the operation, the patients were administered with an indocyanine green injection of 0.5 mg/kg intravenously 2 h before operation. During and after the operation, all patients underwent surgical margin monitoring with the near-infrared fluorescence imaging system for fluorescence imaging and acquisition of images and quantitative fluorescence intensity. During the operation, the patients' tissue specimens were collected on the upper, lower, inner, outer, apical, and basal sides of the fluorescence boundary of the isolated lesions for pathological examination., Results: Fluorescence was detected in the primary tumor in all patients. The average fluorescence intensities of tumor tissue, peritumoral tissue, and normal tissue were 219.41 ± 32.81, 143.35 ± 17.37, and 105.77 ± 17.79 arbitrary units, respectively (P < 0.05, t test). The signal-to-background ratio of tumor to peritumor tissue and normal tissue was 1.54 ± 0.20 and 2.14 ± 0.60, respectively (P < 0.05, t test). Abnormal indocyanine green fluorescence was detected in 11.6% patients (5/43), including 3 patients with residual infiltrating carcinoma and 2 patients with adenosis with ductal dilatation., Conclusion: This study confirms the high sensitivity and specificity of near-infrared fluorescence imaging technology for breast-conserving surgery margin assessment. Near-infrared fluorescence imaging technology can be used as an intraoperative diagnosis and treatment tool to accurately determine the surgical margin and is of important guiding value in breast-conserving surgery for breast cancer., (© 2022. The Author(s).)

Breast-conserving surgery (BCS) is commonly used for the treatment of early-stage breast cancer. Following BCS, approximately 20% to 30% of patients require reexcision because postoperative histopathology identifies cancer in the surgical margins of the excised specimen. Quantitative micro-elastography (QME) is an imaging technique that maps microscale tissue stiffness and has demonstrated a high diagnostic accuracy (96%) in detecting cancer in specimens excised during surgery. However, current QME methods, in common with most proposed intraoperative solutions, cannot image cancer directly in the patient, making their translation to clinical use challenging. In this proof-of-concept study, we aimed to determine whether a handheld QME probe, designed to interrogate the surgical cavity, can detect residual cancer directly in the breast cavity in vivo during BCS. In a first-in-human study, 21 BCS patients were scanned in vivo with the QME probe by five surgeons. For validation, protocols were developed to coregister in vivo QME with postoperative histopathology of the resected tissue to assess the capability of QME to identify residual cancer. In four cavity aspects presenting cancer and 21 cavity aspects presenting benign tissue, QME detected elevated stiffness in all four cancer cases, in contrast to low stiffness observed in 19 of the 21 benign cases. The results indicate that in vivo QME can identify residual cancer by directly imaging the surgical cavity, potentially providing a reliable intraoperative solution that can enable more complete cancer excision during BCS., Significance: Optical imaging of microscale tissue stiffness enables the detection of residual breast cancer directly in the surgical cavity during breast-conserving surgery, which could potentially contribute to more complete cancer excision., (©2022 The Authors; Published by the American Association for Cancer Research.)

Purpose: Elderly patients have different physical condition and tumor biology of breast cancer. Surgical choices for older patients are complicated and several studies have reported that breast conserving surgery (BCS) had better survival than mastectomy in different patient population. The major objective of this study was to compare the efficacy of BCS and mastectomy in the whole elderly cohort in SEER database., Methods: Female patients aged over 70 years old and diagnosed with breast cancer between 2010 and 2015 were included from SEER database. Propensity score matching (PSM) was used to establish a cohort composing of similar characteristics. We compared the overall survival (OS) among patients undergoing BCS and mastectomy. Kaplan-Meier analysis and Cox proportional regression model were used to evaluate the associated factors of survival outcome., Results: Of 44,755 eligible patients, 30,375 (67.9%) patients underwent BCS and 14,380 (32.1%) patients underwent mastectomy. After PSM, 7222 patients in each group were analyzed and there was no significant difference between BCS and mastectomy in terms of the OS rate (85.8% in BCS group and 85.0% in mastectomy group, p = 0.135). Multivariable analysis also indicated that no significant difference between two surgical procedures after adjusting for covariates in matched cohort (HR 1.062, 95% CI 0.997-1.132, p = 0.063). Subgroup analysis demonstrated that postoperative radiotherapy and chemotherapy contributed to the survival benefit of BCS compared to mastectomy (p < 0.05)., Conclusion: For elderly breast cancer patients, BCS and mastectomy appeared to be comparable in terms of OS after being matched by clinicopathologic features. While our findings suggested that there was statistically survival benefit of BCS in some subsets of patients, including radiotherapy, chemotherapy, and 80-84 year-old subgroups, these results were likely to be related to selection bias and should be interpreted with caution. Thus, for this elderly patient population, BCS should be considered as an equivalent and less aggressive alternative to mastectomy., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: A good cosmetic outcome has been defined as an important endpoint in breast-conserving therapy (BCT). Various evaluation methods have been studied, but the optimal method has yet to be identified. The present supplementary analysis of JCOG0906 focused on comparing evaluation methods for breast cosmetic outcomes following hypofractionated whole breast irradiation (HFWBI) to examine whether a computer-software (the Breast Cancer Conservative Treatment cosmetic results [BCCT. core])-based program evaluation (CE) can be used for Asian women in clinical trials of BCT., Methods: Of 306 women, 292 underwent institutional evaluation (IE) for breast cosmetic outcomes before (pre) and 3 years after (post) HFWBI using a 4-point scale (excellent/good/fair/poor), and they were evaluated by CE and a central panel evaluation (PE) on the same scale using 292 pairs of pre/post-HFWBI photographs. PE was performed twice by consensus of the same two experts with a 3-year interval. CE was assessed individually by two radiation oncologists, an expert and a non-expert. Intra-observer variability and inter-observer variability were calculated using the kappa (k) and weighted kappa (wk) statistics., Results: The agreement between the first and second PE using pre/post-HFWBI photographs was moderate (k = 0.60, wk = 0.64. k = 0.53, wk = 0.60). The agreement between the expert and non-expert on CE was substantial (k = 0.72, wk = 0.76. k = 0.72, wk = 0.77). The inter-observer variability of CE was smaller than the intra-observer variability of PE., Conclusion: CE with BCCT. core was considered a reproducible and an appropriate evaluation method for Asian women in clinical trials of BCT, when breast cosmetic changes were compared between pre/post therapy., (© 2022. The Author(s), under exclusive licence to The Japanese Breast Cancer Society.)

Background: There is little information on the risk factors for fat necrosis after breast-conserving surgery using an inframammary adipofascial flap (IAF)., Methods: We conducted a retrospective cohort study from a single institution evaluating the risk factors for fat necrosis after breast-conserving surgery using an IAF (n = 41) performed from 2005 to 2020 for newly diagnosed stage 0-2 breast cancer or phyllodes tumor., Results: Age (≥50 years of age vs. <50 years of age), mammographic density (fatty vs. other) and operation period (before vs. after revision of surgical procedure and patient indication) were significantly associated with fat necrosis (p = 0.006, p = 0.04 and p = 0.02, respectively)., Conclusion: Our study suggested that the use of an IAF with crescent dermis and selection of appropriate cases for IAF after breast-conserving surgery may be useful for the purpose of reducing fat necrosis. Further study is needed., (Copyright © 2022 Asian Surgical Association and Taiwan Robotic Surgery Association. Published by Elsevier B.V. All rights reserved.)

Purpose: In recent years, results with mature follow-up have been reported for several Phase III trials randomizing women to receive whole breast irradiation (WBI) versus varying modalities of partial breast irradiation (PBI). It is important to recognize that these methods vary in terms of volume of breast tissue treated, dose per fraction, and duration of therapy. As such, clinical and technical guidelines may vary among the various PBI techniques., Methods: Members of the American Brachytherapy Society with expertise in PBI performed an extensive literature review focusing on the highest quality data available for the numerous PBI options offered in the modern era. Data were evaluated for strength of evidence and published outcomes were assessed., Results: The majority of women enrolled on randomized trials of WBI versus PBI have been age >45 years with tumor size <3 cm, negative margins, and negative lymph nodes. The panel also concluded that PBI can be offered to selected women with estrogen receptor negative and/or Her2 amplified breast cancer, as well as ductal carcinoma in situ, and should generally be avoided in women with extensive lymphovascular space invasion., Conclusions: This updated guideline summarizes published clinical trials of PBI methods. The panel also highlights the role of PBI for women facing special circumstances, such as history of cosmetic breast augmentation or prior breast irradiation, and discusses promising novel modalities that are currently under study, such as ultrashort and preoperative PBI. Updated consensus guidelines are also provided to inform patient selection for PBI and to characterize the strength of evidence to support varying PBI modalities., (Copyright © 2022 American Brachytherapy Society. Published by Elsevier Inc. All rights reserved.)

Introduction: This study aimed to evaluate complication rates, patient satisfaction, and cosmetic outcomes after oncoplastic breast-conserving surgery (OPS). Furthermore, outcome differences between volume displacement and volume replacement techniques and the effect of postoperative complications on outcomes were evaluated., Methods: This was a prospective single-center study addressing patients who underwent OPS from 2017 to 2020. The BREAST-Q was used to measure patient satisfaction, and cosmetic outcomes were assessed by patient self-evaluation and panel evaluation based on medical photographs., Results: A total of 75 patients were included. The overall complication rate was 18.7%, of which 4% required invasive interventions. Median BREAST-Q scores ranged from 56 to 100 and cosmetic outcomes were scored good to excellent in 60-86%. No differences in complications were observed between volume replacement and volume displacement techniques. Following volume displacement techniques, patients-reported higher BREAST-Q scores for the domain "physical well-being of the chest" and lower cosmetic outcomes scores for "mammary symmetry." Patients with complications scored significantly lower on several domains of the BREAST-Q and in various cosmetic outcome categories., Conclusion: In this cohort, an overall complication rate of 18.7% was observed. Patients were generally satisfied, and most cosmetic outcomes were good to excellent. Volume displacement or replacement techniques were performed for different indications and generally showed comparable results. Expected differences in physical discomfort and symmetry between both techniques were observed. In addition, the occurrence of complications resulted in lower patient satisfaction and cosmetic outcomes. These findings emphasize the importance of thorough preoperative counselling., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Accelerated partial breast irradiation (APBI), including intraoperative radiation therapy (IORT), is an evidence-based treatment option in patients undergoing breast conserving surgery (BCS) for early-stage breast cancer. However, literature regarding reirradiation for patients with ipsilateral breast tumor recurrences (IBTR) is limited. This prospective study assessed the feasibility and efficacy of using APBI in patients who had prior whole breast irradiation., Methods and Materials: This was a single institution, prospective study of patients who were previously treated with BCS and adjuvant whole breast radiation. At the time of enrollment, all had unifocal IBTR, histologically confirmed invasive ductal carcinoma with negative margins after repeat BCS. Patients received either IORT in a single fraction at time of BCS or MammoSite brachytherapy twice daily over 5 days. Follow-up data and patient surveys were collected at 1, 3, 6, 9, and 12 months, then annually for at least a 5-year period., Results: From 2008 to 2014, 13 patients were enrolled. Median time to recurrence after initial course of radiation was 12.5 years. Median follow-up after retreatment was 7.8 years. One patient in the IORT group had a subsequent tumor bed recurrence, yielding a local control of 92%. One patient had distant recurrence. At baseline, 680 reported excellent-good cosmesis compared with 42% at 5 years. All patients indicated total satisfaction with overall treatment experience., Conclusions: APBI using IORT was well tolerated with excellent local control and may be a reasonable alternative to mastectomy for IBTR. Further study is needed to determine the most suitable candidates for this approach., (Copyright © 2022 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.)

Background: Many breast-conserving surgical options exist for patients with breast cancer. Surgical choices can have lasting effects on a patient's life, so patient satisfaction is important to assess. Patient-reported outcome measures provide important tools when evaluating surgical modalities. This systematic review aimed to evaluate how patients describe breast-conserving surgical choices in standard partial mastectomy and oncoplastic surgery options., Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses search was performed in PubMed for studies discussing standard partial mastectomy or oncoplastic surgery and measurement of preoperative and postoperative patient-reported outcomes using the BREAST-Q or other validated patient-reported outcome measures. Oncoplastic surgery was categorized as volume displacement or volume replacement. Articles in languages other than English, not involving partial mastectomy or oncoplastic surgery, or not measuring patient-reported outcomes were excluded. Weighted proportions were generated and analyzed with a Welch t test., Results: Of 390 articles, 43 met inclusion criteria, and 8784 patients were included in a pooled database. Although standard partial mastectomy scored well, oncoplastic surgery performed significantly better than partial mastectomy in all postoperative BREAST-Q categories: satisfaction with breasts (74.3 versus 65.7), psychosocial well-being (81.3 versus 78.0), sexual well-being (61.6 versus 54.9), and satisfaction with outcome (85.4 versus 62.2). Level 2 volume displacement surgery had the most favorable scores., Conclusions: Breast-conserving surgical choices that include a variety of oncoplastic surgery and partial mastectomy methods all score well in patient-reported outcome measures, with oncoplastic surgery significantly preferred over partial mastectomy. Oncoplastic surgery should be considered in all cases, and the appropriate breast-conserving surgical choice should depend on the patient's tumor presentation and anatomy., (Copyright © 2022 by the American Society of Plastic Surgeons.)

We looked at the usefulness of magnetic resonance imaging (MRI) in decision-making and surgical management of patients selected for intraoperative radiotherapy (IORT). We also compared lesion size measurements in different modalities (ultrasound (US), mammogram (MMG), MRI) against pathological size as the gold standard. 63 patients eligible for IORT based on clinical and imaging criteria over a 34-month period were enrolled. All had MMG and US, while 42 had additional preoperative MRI for locoregional preoperative staging. Imaging findings and pathological size concordances were analysed across the three modalities. MRI changed the surgical management of 5 patients (11.9%) whereby breast-conserving surgery (BCS) and IORT was cancelled due to detection of satellite lesion, tumor size exceeding 30mm and detection of axillary nodal metastases. Ten of 42 patients (23.8%) who underwent preoperative MRI were subjected to additional external beam radiotherapy (EBRT); 7 due to lymphovascular invasion (LVI), 2 due to involved margins, and 1 due to axillary lymph node metastatic carcinoma detected in the surgical specimen. Five of 21 (23.8%) patients without prior MRI were subjected to additional EBRT post-surgery; 3 had LVI and 2 had involved margins. The rest underwent BCS and IORT as planned. MRI and MMG show better imaging-pathological size correlation. Significant increase in the mean 'waiting time' were seen in the MRI group (34.1 days) compared to the conventional imaging group (24.4 days). MRI is a useful adjunct to conventional imaging and impacts decision making in IORT. It is also the best imaging modality to determine the actual tumour size., Competing Interests: The authors have declared that no competing interests exist.

Background: In the surgical treatment of breast cancer, the goal of surgeons is to continually create and improve minimally invasive surgical techniques to increase patients' quality of life. Currently, routine breast-conserving surgery is often performed using two obvious incisions. Here, we compare the clinical efficacy and aesthetic outcomes of a novel technique using one incision, called 'single-port insufflation endoscopic breast-conserving surgery' (SIE-BCS), vs. conventional breast-conserving surgery (C-BCS) in patients with early-stage breast cancer., Methods: A total of 180 patients with stage I or stage II breast cancer participated in this study, of whom 63 underwent SIE-BCS and 117 underwent C-BCS. Logistic regression analysis was conducted to assess the risk of local recurrence and metastasis. Aesthetic outcomes were evaluated using the BREAST-Q scale., Results: The mean operation time was significantly longer for SIE-BCS (194.9 ± 71.5 min) than for C-BCS (140.3 ± 56.9 min), but the mean incision length was significantly shorter for SIE-BCS than for C-BCS (3.4 ± 1.2 cm vs. 8.6 ± 2.3 cm). While both surgeries yielded similar BREAST-Q ratings for satisfaction with breasts and sexual well-being, SIE-BCS was associated with significantly better ratings for physical well-being (chest area) and psychological well-being. Additionally, SIE-BCS was associated with decreased rates of adverse effects of radiation. The preliminary analysis showed that SIE-BCS did not increase the risk of local recurrence or metastasis., Conclusion: The novel single-port insufflation endoscopic assisted BCS technique is feasible, safe, and improves patients' postoperative comfort and psychological well-being, as compared to the conventional technique., (© 2022. The Author(s).)

The adoption of innovation is essential to the evolution of patient care. Breast surgical oncology advances through incorporating new techniques, devices, and procedures. Historical changes in practice standards from radical to modified radical mastectomy or axillary node dissection to sentinel node biopsy reduced morbidity without sacrifice in oncologic outcome. Contemporary oncoplastic techniques afford broader consideration for breast conservation and the potential for improved cosmetic outcomes. At present, many breast surgeons face the decision of which wireless device to use for localization of nonpalpable lesions. Consideration for future changes, such as robotic mastectomy, are on the horizon. No guideline exists to assist breast surgeons in the adoption of innovation into practice. The Ethics Committee of the American Society of Breast Surgeons acknowledges that breast surgeons confront many questions associated with onboarding innovation. This paper aims to provide a framework for asking relevant questions along with the ethical principles to consider when integrating an innovation into practice., (© 2022. Society of Surgical Oncology.)

Background: There have been conflicting studies reporting on survival advantages between breast-conserving surgery with radiotherapy (BCS) in comparison with mastectomy. Our aim was to compare the efficacy of BCS and mastectomy in terms of overall survival (OS) comparing all past published studies., Methods: We performed a comprehensive review of literature through October 2021 in PubMed, Scopus, and EMBASE. The studies included were randomized controlled trials (RCTs) and cohorts that compare BCS versus mastectomy. We excluded studies that included male sex, stage 0, distant metastasis at diagnosis, bilateral synchronous cancer, neoadjuvant radiation/chemotherapy, and articles with incomplete data. We performed a meta-analysis following the random-effect model with the inverse variance method., Results: From 18,997 publications, a total of 30 studies were included in the final analysis: 6 studies were randomized trials, and 24 were retrospective cohorts. A total of 1,802,128 patients with a follow-up ranging from 4 to 20 years were included, and 1,075,563 and 744,565 underwent BCS and mastectomy, respectively. Among the population, BCS is associated with improved OS compared with mastectomy [relative risk (RR) 0.64, 95% confidence interval (CI) 0.55-0.74]. This effect was similar when analysis was performed in cohorts and multi-institutional databases (RR 0.57, 95% CI 0.49-0.67). Furthermore, the benefit of BCS was stronger in patients who had less than 10 years of follow-up (RR 0.54, 95% CI 0.46-0.64)., Conclusions: Patients who underwent BCS had better OS compared with mastectomy. Such results depicting survival advantage, especially using such a large sample of patients, may need to be included in the shared surgical decision making when discussing breast cancer treatment with patients., (© 2022. Society of Surgical Oncology.)

Introduction: Breast conserving surgery (BCS) is associated with unsatisfactory cosmetic outcomes in up to 30% of patients, carrying psychological and quality-of-life implications. This study compares long-term cosmetic outcomes after BCS for breast cancer with v without simple oncoplastic defect closure., Methods: A randomised controlled trial was performed, recruiting patients who underwent BCS over four years and randomising to the "reshaping" group (closure of excision defect with mobilised breast tissue; n = 124) and to the "control" group (no attempt at defect closure; n = 109). The estimated excision volume (EEV) was <20% of breast volume (BV) in both groups. Photography and breast retraction assessment (BRA) were recorded preoperatively. Cosmetic outcomes were blindly assessed annually for five years by BRA, panel assessment of patients, and body image questionnaire (BIQ)., Results: There were no significant differences between the reshaping and control groups in mean age (52.4 v 53.0; p = 0.63), body mass index (27.8 v 27.7; p = 0.80), margin re-excision (9 v 9; p = 0.78), mean BV (562.5 v 590.3 cc; p = 0.56), mean EEV (54.6 v 60.1 cc; p = 0.14), mean EEV/BV ratio (11.2 v 11.0; p = 0.84), or mean specimen weight (52.1 v 57.7 g; p = 0.24). Reshaping group patients had significantly better outcomes compared to control group patients in terms of mean BRA (0.9 v 2.8; p < 0.0001), achieving a score of "good" or "excellent" by panel assessment at 5 years (75.8% v 48%, p < 0.0001), body image questionnaire top score at 5 years (66.9% v 35.8%; p = 0.0001)., Conclusions: Simple oncoplastic closure of defects after breast-conserving surgery improves long-term objective and subjective cosmetic outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Background: Multifocal or complex breast lesions are a challenge for breast-conserving surgery, particularly surgery in small breasts or those located in the upper inner quadrant. The dual-layer rotation technique exploits the idea of manipulating the skin and glandular tissue in separate layers to fill the resection cavity via vertical mammoplasty if skin excision is not required, except in the central area., Methods: The authors performed a retrospective review of consecutive breast cancer patients who underwent DLR mammoplasty between 2017 and 2019 at a single institution. Clinical data, reoperations, surgical complications, delays in adjuvant treatments, and the need for late revisional surgery were evaluated. Aesthetic outcomes were evaluated objectively and subjectively from photographs., Results: The study included 46 breasts of 40 patients. Tumors were located in the UIQ (30%, 14/46) or in multiple quadrants (22%, 10/46). One third (33%, 13/40) of the patients had a small breast cup size (A-B). Negative margins were primarily achieved in 45 of the 46 breasts. Major complications occurred in three patients, who needed reoperation, and adjuvant therapy was delayed for one of these patients. Late refinement surgery was needed for two patients. The objective and subjective aesthetic outcomes were good or excellent regardless of the tumor position., Conclusion: As a novel oncoplastic approach, DLR mammoplasty offers a one-step procedure to treat selected breast cancer patients with challenging resection defects due to different breast sizes or lesion locations. The technique preserves the breast's natural appearance., (© 2022. The Author(s).)

Purpose: The purpose of this study was to evaluate the use of indocyanine green-guided nonpalpable breast cancer lesion localization (INBCL) and to compare it with ultrasound localization (US)., Methods: We retrospectively reviewed 78 consecutive patients undergoing breast-conserving surgery for nonpalpable breast cancer (NBC). Of all 78 excisions, 42 cases were guided by INBCL and 36 by US., Results: The rate of clear margins was 90.5% (38/42) in the INBCL group compared to the 83.3% (30/36) in the US ( P = .548). A comparison of the margins at first excision for both INBCL and US, in the INBCL series, 92.9% (39/42) of cases had a margin less than 5 mm, whereas for US series, it was 72.2% (26/36) ( P = .033). When results of the excised tissue are taken into account, the mean specimen volume for INBCL was 58 cm 3 , but for US it was 73 cm 3 , with difference in mean volume being 15 cm 3 ( P = .062)., Conclusions: INBCL for NBCs was more accurate than US because a smaller volume of the tissue may be excised by using the technique, without compromising margin status in nonpalpable lesions.

Background: Randomized, controlled trials comparing breast-conserving therapy (BCT) with mastectomy have demonstrated equivalent overall survival (OS), but recent observational studies have shown improved OS in patients undergoing BCT. These studies provide limited data on young patients who are traditionally offered mastectomy due to perceived higher disease risk. This study examines the OS in a contemporary series of young women with breast cancer undergoing upfront BCT compared with mastectomy., Methods: Women ≤40 years old with primary invasive T1-T2, N0-N1 breast cancer were identified from the National Cancer Database between 2006 and 2016. Patient cohorts were based according to locoregional treatment: BCT, mastectomy alone (Mx), and mastectomy with radiotherapy (Mx/RT). Kaplan-Meier method followed by Cox proportional-hazards regression with inverse probability of treatment weighting (IPTW) were performed to account for treatment selection bias effects in OS., Results: A total of 15,611 patients met the study criteria; 9,509 patients (60.9%) had BCT, 4,020 (25.8%) had Mx/RT, and 2,082 (13.3%) had Mx alone. The median follow-up was 4.6 years (interquartile range [IQR] 3.0-6.4). After IPTW-adjustment, the 5-year OS was similar for BCT (95%), Mx (95%), and Mx/RT (94%), and there was no significant difference in OS in Mx (hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.90-1.51) and Mx/RT (HR = 1.08, 95% CI 0.88-1.34) compared with BCT. Mx/RT was associated with decreased survival in patients with pT2N0 (HR = 1.78, 95% CI 1.12-2.84)., Conclusions: Among young patients with early-stage breast cancer, overall survival was equivalent regardless of surgical approach. Breast-conserving therapy remains a safe option in young women despite the clinical tendency to offer upfront mastectomy in young patients., (© 2022. Society of Surgical Oncology.)

Background: This study aimed to investigate the role of postoperative radiation therapy in a large population-based cohort of patients with stage I-III male breast cancer (MaBC)., Methods: Patients with stage I-III breast cancer treated with surgery were selected from the Surveillance, Epidemiology, and End Results cancer database from 2010 to 2015. Multivariate logistic regression identified the predictors of radiation therapy administration. Multivariate Cox regression model was used to evaluate the predictors of survival., Results: We identified 1321 patients. Age, stage, positive regional nodes, surgical procedure, and HER2 status were strong predictors of radiation therapy administration. There was no difference between patients who received radiation therapy and those who did not (P = 0.46); however, after propensity score matching, it was associated with improved OS (P = 0.04). In the multivariate analysis of the unmatched cohort, the factors associated with better OS were administration of radiation therapy and chemotherapy. In the subset analysis of the unmatched cohort, postoperative radiation therapy was associated with improved OS in men undergoing breast-conserving surgery (BCS), with four or more node-positive or larger primary tumours (T3/T4). Furthermore, we found no benefit of radiation therapy, regardless of the type of axillary surgery in mastectomy (MS). In older MaBC patients with T1-2N1 who underwent MS, radiation therapy showed no significant effects, regardless of chemotherapy., Conclusion: Postoperative radiation therapy could improve the survival of MaBC patients undergoing BCS, with four or more node-positive or larger primary tumours. Moreover, it should be carefully considered in patients undergoing MS and older T1-2N1 patients., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: We aimed to evaluate whether radiotherapy (RT) after breast-conserving surgery (BCS) can be omitted in elderly patients with early-stage, hormone receptor-negative breast cancer., Methods: Patients aged 65 years and older with T1-2N0-1, hormone receptor-negative breast cancer in 2010-2015 were extracted from the Surveillance, Epidemiology, and End Results program. Propensity score matching was used to balance the baseline of different groups. Survival analysis was performed using Kaplan-Meier plot and log-rank test. Independent risk factors were identified by multivariate Cox analysis. A nomogram predicting breast cancer-specific survival (BCSS) and a risk stratification model were constructed and validated., Results: A total of 4465 patients were included and 27.7% (1237/4465) patients did not receive postoperative RT. RT was significantly associated with improved overall survival (OS) (HR = 0.552 P < 0.001) and BCSS (HR = 0.559, P < 0.001) in the matched cohort. The same results were found after adjusting independent risk factors by multivariate analysis. On the basis of the nomogram predicting BCSS of patients without RT by incorporating independent risk factors (age, race, HER2 status, T stage, and N stage), we built a risk stratification model which indicated that RT improved OS (HR = 0.511, P < 0.001) and BCSS (HR = 0.517, P < 0.001) in the high-risk group (total score > 150), but not in the low-risk group (total score ≤ 120). The C-index and all calibration curves demonstrated sufficient accuracies and good predictive capabilities., Conclusions: RT is indeed beneficial for the whole cohort in this study. However, it may be omitted in the low-risk subgroup without significantly sacrificing survival. For patients in the high-risk group, RT following BCS remained beneficial. This study highlights the need for prospective randomized trials to study RT de-escalation strategies., (© 2022. The Author(s), under exclusive licence to Springer Healthcare Ltd., part of Springer Nature.)