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Background Chest wall perforator flaps are emerging in oncoplastic breast conservation, mostly as an alternative to mastectomy. However, standardization and consensus on patient selection, techniques, and outcomes have not yet been reached. The aim of this international multicentre collaborative study was to explore practice patterns and outcomes in high-volume centres from different countries. Methods Patients with both pre-invasive and invasive breast cancer treated at the Uppsala University Hospital in Uppsala, Sweden, the Royal Marsden Hospital in London, UK, and the Westmead Breast Cancer Institute in Sydney, Australia, were included in this study. The rationale for offering chest wall perforator flaps and surgical outcomes were prospectively documented. Results In total, 603 patients were analysed median age of 54 (interquartile range (i.q.r.) 48–63) years, median BMI of 25.0 (i.q.r. 22.5–28.1) kg/m2, median tumour extent of 30 (IQR 19–45) mm, median breast volume of 280 (i.q.r. 216–430) ml, and median calculated resection ratio of 16% (i.q.r. 9%–28%). In 67.7%, the treating surgeon had offered chest wall perforator flaps to avoid mastectomy. The procedure was performed as day surgery in 69.5% of patients, with an overall complication rate of 8.6% and the majority of complications being classified as Clavien–Dindo grade I (5.3% of patients). The re-excision rate was 15.9%, with only 1.5% of patients converting to a mastectomy. There were no flap losses. At a median follow-up of 22 (range 12 to 98) months, rates of local recurrence, distant recurrence, and breast cancer-related mortality were 1.9%, 4.9%, and 1.7% respectively. Conclusion Chest wall perforator flaps are a useful option to allow more women to avoid mastectomy. In experienced hands, the procedure is safe and should be offered to suitable patients.

Clinical trials have demonstrated conclusively the non-inferiority of breast-conserving surgery followed by breast radiation therapy (BCT) compared with mastectomy for the treatment of early-stage invasive breast cancer (BC). The definition of the required surgical margin to ensure adequate removal of the cancer by BCT to obtain an acceptable low local recurrence (LR) rate remains controversial. Meta-analyses published by Houssami et al. in 2010 and 2014 demonstrated significantly lower LR rates for patients with a negative margin compared with those with positive (ink on tumour) or close (defined as ≤1 mm or ≤2 mm) margins. Neither meta-analysis addressed whether ‘no ink on tumour’ was adequate to define a negative margin because of a lack of data. Nevertheless, in 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) with advice from pathologists reviewed these data together and published guidelines recommending that a margin of ‘no ink on tumour’ was sufficient to define a clear margin in BCT. Subsequently, clinical practice has varied with some national and international bodies endorsing ‘no ink on tumour’, whilst others have recommended a ≥1 mm margin as acceptable margins for BCT. A more recent meta-analysis conducted by Bundred and colleagues in 2022 did have sufficient data to compare ‘no ink on tumour’ and 1 mm and concluded that 1 mm rather than ‘no ink on tumour’, should be used as a minimum negative margin, and recommended that international guidelines be revised. The current review presents a balanced assessment of the evidence relating margin width and local recurrence after BCT. This review concludes that guidelines should consider re-defining a negative margin as ≥1 mm rather than ‘no ink on tumour’ in the context of BCT, recognising there will be variation to tailor therapy for any individual patient situation to ensure optimal patient care.

Clinical trials have demonstrated conclusively the non-inferiority of breast-conserving surgery followed by breast radiation therapy (BCT) compared with mastectomy for the treatment of early-stage invasive breast cancer (BC). The definition of the required surgical margin to ensure adequate removal of the cancer by BCT to obtain an acceptable low local recurrence (LR) rate remains controversial. Meta-analyses published by Houssami et al. in 2010 and 2014 demonstrated significantly lower LR rates for patients with a negative margin compared with those with positive (ink on tumour) or close (defined as ≤1 mm or ≤2 mm) margins. Neither meta-analysis addressed whether 'no ink on tumour' was adequate to define a negative margin because of a lack of data. Nevertheless, in 2014, the Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) with advice from pathologists reviewed these data together and published guidelines recommending that a margin of 'no ink on tumour' was sufficient to define a clear margin in BCT. Subsequently, clinical practice has varied with some national and international bodies endorsing 'no ink on tumour', whilst others have recommended a ≥1 mm margin as acceptable margins for BCT. A more recent meta-analysis conducted by Bundred and colleagues in 2022 did have sufficient data to compare 'no ink on tumour' and 1 mm and concluded that 1 mm rather than 'no ink on tumour', should be used as a minimum negative margin, and recommended that international guidelines be revised. The current review presents a balanced assessment of the evidence relating margin width and local recurrence after BCT. This review concludes that guidelines should consider re-defining a negative margin as ≥1 mm rather than 'no ink on tumour' in the context of BCT, recognising there will be variation to tailor therapy for any individual patient situation to ensure optimal patient care.

Background: Superparamagnetic iron nanoparticles perform comparably to radioisotope +/- blue dye for sentinel lymph node detection in breast cancer, even when injected up to 8 weeks before surgery. Using superparamagnetic iron nanoparticles for sentinel lymph node detection after primary systemic therapy, and the maximum time frame of superparamagnetic iron nanoparticle administration have not been investigated. Methods: This cohort study included cN0/1-to-ycN0 patients undergoing sentinel lymph node detection or targeted axillary dissection. All patients received superparamagnetic iron nanoparticles either before primary systemic therapy or before surgery, and radioisotope on the day of surgery. Results: For 113 patients analysed, superparamagnetic iron nanoparticles were injected a median of 3 (range 0-248) days before surgery, with a 97.4% detection rate compared with 91.2% for radioisotope (P = 0.057). Concordance for radioisotope was 97.1% and this was not affected by timing of superparamagnetic iron nanoparticle injection (Kendall's tau 0.027; P = 0.746). The median sentinel lymph node yield was 3 (interquartile range (i.q.r.) 2-3) for superparamagnetic iron nanoparticles and 2 (i.q.r. 2-3) for radioisotope (P < 0.001). In targeted axillary dissection, detection was 100% for superparamagnetic iron nanoparticles and 81.8% for radioisotope (P = 0.124). The index node was magnetic in 93.9% and radioactive in 66.7% (P = 0.007), an outcome that was not affected by any factors. For patients with metastases, superparamagnetic iron nanoparticle detection was 100% and radioisotope-based detection was 84.2% (P = 0.083), with superparamagnetic iron nanoparticles detecting more metastatic sentinel lymph nodes (median of 1 (i.q.r. 1-2) for superparamagnetic iron nanoparticles compared with a median of 1 (i.q.r. 0-1) for radioisotope; P = 0.005). Conclusion: Injection before primary systemic therapy is feasible and does not affect concordance with radioisotope. Superpara

Background: Patient reported outcomes (PROs) have an integral role on how to improve patients' overall experience. The optimal PROs delivery in patients with breast disease is an important issue since PROs are steadily integrated in routine care. Methods: An institutional phase 3 randomised controlled, open-label trial. Eligible candidates were adult women with perceived or confirmed breast disease. Computer generated randomization was used to allocate interventions: collection of PROs in electronic or paper form. Our objective was the effectiveness of electronic versus paper form of PROs. The main outcome measures were: response rate, reported experience, administrative resources, and carbon dioxide emissions. Results: Two hundred thirty-eight patients were randomised. After loss-to-follow-up and consent withdrawals, 218 participants (median age, IQR=55, 21; n=110/n=108) were included in the per-intention-to-treat analysis. Response rate was 61.8% for electronic patient reported outcomes (ePROs) and 63.9% for paper patient reported outcomes (pPROs) (difference=-2.1%, 95% CI: -15.8-11.7%). Only known breast cancer at recruitment was predictive for response in multivariable analysis. ePROs were associated with a 57% reduction in administrative time required, a 95% reduction in incremental costs, and 84% reduction in carbon dioxide emissions, all differences being significant. No difference was detected in perception of PRO significance or ease of completion, but participants experienced that they needed less time to complete ePROs [median, (IQR) 10 (9) respectively 15(10)]. Finally, respondents would prefer ePROs over pPROs (difference 48.1%, 95% CI: 32.8-63.4%). Conclusion: ePROs do not increase the response rate in patients with perceived or confirmed breast disease. However, they can enhance patient experience, reduce incremental costs, facilitate administrative logistics, and are more sustainable. On the basis of these findings, both modalities should continue to, De två första författarna delar förstaförfattarskapet.De två sista författarna delar sistaförfattarskapet.

To investigate the effects of heavy-load strength training during (neo-)adjuvant chemotherapy in women with breast cancer on muscle strength, body composition, muscle fiber size, satellite cells, and myonuclei. Women with stage I-III breast cancer were randomly assigned to a strength training group (ST, n = 23) performing supervised heavy-load strength training twice a week during chemotherapy, or a usual care control group (CON, n = 17). Muscle strength and body composition were measured and biopsies from m. vastus lateralis collected before the first cycle of chemotherapy (T0) and after chemotherapy and training (T1). Muscle strength increased significantly more in ST than in CON in chest-press (ST: +10 +/- 8%, p < .001, CON: -3 +/- 5%, p = .023) and leg-press (ST: +11 +/- 8%, p < .001, CON: +3 +/- 6%, p = .137). Both groups reduced fat-free mass (ST: -4.9 +/- 4.0%, p < .001, CON: -5.2 +/- 4.9%, p = .004), and increased fat mass (ST: +15.3 +/- 16.5%, p < .001, CON: +16.3 +/- 19.8%, p = .015) with no significant differences between groups. No significant changes from T0 to T1 and no significant differences between groups were observed in muscle fiber size. For myonuclei per fiber a non-statistically significant increase in CON and a non-statistically significant decrease in ST in type I fibers tended (p = .053) to be different between groups. Satellite cells tended to decrease in ST (type I: -14 +/- 36%, p = .097, type II: -9 +/- 55%, p = .084), with no changes in CON and no differences between groups. Strength training during chemotherapy improved muscle strength but did not significantly affect body composition, muscle fiber size, numbers of satellite cells, and myonuclei compared to usual care.

Background: Adjuvant radiotherapy (RT) after breast-conserving surgery for DCIS lowers the relative local recurrence risk by half. To identify a low-risk group with the minimal benefit of RT could avoid side effects and spare costs. In this study, the outcome was compared for different RT-strategies using data from the randomized SweDCIS trial. Material and methods: Five strategies were compared in a Swedish setting: RT-to-none or all, RT to high-risk women defined by DCISionRT, modified Radiation Therapy Oncology Group (RTOG) 9804 criteria, and Swedish Guidelines. Ten-year recurrence risks and cost including adjuvant RT and local recurrence treatment cost were calculated. Results: The mean age at recurrence was 64.4 years (36-90) and the mean cost for treating a recurrence was $21,104. In the SweDCIS cohort (n = 504), 59 women developed DCIS, and 31 invasive recurrence. Ten-year absolute local recurrence risk (invasive and DCIS) according to different strategies varied between 18.6% (12.5-23.6%) and 7.8% (5.0-12.6%) for RT-to-none or to-all, with an additional cost of $2614 US dollars per women and $24,201 per prevented recurrence for RT-to-all. The risk differences between other strategies were not statistically significant, but the larger proportion receiving RT, the fewer recurrences. DCISionRT spared 48% from RT with 8.1% less recurrences compared to RT-to-none, and a cost of $10,534 per prevented recurrence with additional cost depending on the price of the test. RTOG 9804 spared 39% from RT, with 9.7% less recurrences, $9525 per prevented recurrence and Swedish Guidelines spared 13% from RT, with 10.0% less recurrences, and $21,521 per prevented recurrence. Conclusion: It seems reasonable to omit RT in pre-specified low-risk groups with minimal effect on recurrence risk. Costs per prevented recurrence varied more than two-fold but which strategy that could be considered most cost-effective needs to be further evaluated, including the DCISionRT-test price.

Background: Superparamagnetic iron oxide nanoparticles (SPIO) have been used as a tracer for sentinel lymph node (SLN) localization in breast cancer, demonstrating comparable performance to the combination of radioisotope (RI) and blue dye (BD). Methods: A systematic literature search and meta-analysis with subgroup and meta-regression analysis were undertaken to update the available evidence, assess technique evolution, and define knowledge gaps. Recommendations were made using the GRADE approach. Results: In 20 comparative studies, the detection rate was 97.5 per cent for SPIO and 96.5 per cent for RI +/- BD (risk ratio 1.006, 95 per cent c.i. 0.992 to 1.019; P = 0.376, high-certainty evidence). Neoadjuvant therapy, injection site, injection volume or nodal metastasis burden did not affect the detection rate, but injection over 24 h before surgery increased the detection rate on meta-regression. Concordance was 99.0 per cent and reverse concordance 97.1 per cent (rate difference 0.003, 95 per cent c.i. -0.009 to 0.015; P = 0.656, high-certainty evidence). Use of SPIO led to retrieval of slightly more SLNs (pooled mean 1.96 versus 1.89) with a higher nodal detection rate (94.1 versus 83.5 per cent; RR 1.098, 1.058 to 1.140; P < 0.001; low-certainty evidence). In meta-regression, injection over 24 h before surgery increased the SPIO nodal yield over that of RI +/- BD. The skin-staining rate was 30.8 per cent (very low-certainty evidence), and possibly prevented with use of smaller doses and peritumoral injection. Conclusion: The performance of SPIO is comparable to that of RI +/- BD. Preoperative injection increases the detection rate and nodal yield, without affecting concordance. Whether skin staining and MRI artefacts are reduced by lower dose and peritumoral injection needs to be investigated.

Introduction: Books and papers are the most relevant source of theoretical knowledge for medical education. New technologies of artificial intelligence can be designed to assist in selected educational tasks, such as reading a corpus made up of multiple documents and extracting relevant information in a quantitative way. Methods: Thirty experts were selected transparently using an online public call on the website of the sponsor organization and on its social media. Six books edited or co-edited by members of this panel containing a general knowledge of breast cancer or specific surgical knowledge have been acquired. This collection was used by a team of computer scientists to train an artificial neural network based on a technique called Word2Vec. Results: The corpus of six books contained about 2.2 billion words for 300d vectors. A few tests were performed. We evaluated cosine similarity between different words. Discussion: This work represents an initial attempt to derive formal information from textual corpus. It can be used to perform an augmented reading of the corpus of knowledge available in books and papers as part of a discipline. This can generate new hypothesis and provide an actual estimate of their association within the expert opinions. Word embedding can also be a good tool when used in accruing narrative information from clinical notes, reports, etc., and produce prediction about outcomes. More work is expected in this promising field to generate "real-world evidence." (c) 2023 S. Karger AG, Basel

Background Volume replacement using chest wall perforator flaps (CWPFs) is a promising technique to reduce mastectomy rates without sacrificing function or aesthetics. Owing to limited availability of the technique, only a minority of patients currently have access to CWPF procedures. Methods An international web-based survey was disseminated through social media, dedicated webpages, and national and international societies for breast surgery. The survey explored surgeons' attitudes towards CWPFs and their perceived training needs. Results Of 619 respondents, 88.4 per cent agreed that CWPF surgery was desirable, with one-third offering it and performing a median of 10 (i.q.r. 5-15) procedures annually. They were more likely to be senior (OR 1.35, 95 per cent c.i. 1.18 to 1.55; P < 0.001), with formal oncoplastic training (OR 4.80, 3.09 to 7.48; P < 0.001), and working in larger units (OR 1.18, 1.03 to 1.35; P = 0.018) with a free-flap (OR 1.62, 1.06 to 2.48; P = 0.025) or CWPF (OR 3.02, 1.87 to 4.89; P < 0.001) service available. In cluster and latent class analysis, none showed high cohesion with performance of CWPF surgery. Conclusion There is a discrepancy between perceived importance and availability of CWPF surgery, indicating that optimal training is needed. Chest wall perforator flap reconstruction is an attractive oncoplastic technique that still needs to be standardized and disseminated. In an international survey of 620 respondents across the world, it was seen that, although most surgeons feel that the technique is important, very few are offering it and the results suggested that there is no clear profile of core skills that can lead to mastering it. The results of this survey highlight the knowledge gaps and the learning priorities, providing a basis for future standardization and consensus.

Importance Guidewires have been the standard for breast lesion localization but pose operative and logistic challenges. Paramagnetic seeds have shown promising results, but to the authors’ knowledge, no randomized comparison has been performed. Objective To determine whether the combination of a paramagnetic seed and superparamagnetic iron oxide (SPIO) is equivalent to guidewire and SPIO for breast cancer localization and sentinel lymph node detection (SLND). Design, Setting, and Participants This was a phase 3, pragmatic, equivalence, 2-arm, open-label, randomized clinical trial conducted at 3 university and/or community hospitals in Sweden from May 2018 to May 2022. Included in the study were patients with early breast cancer planned for breast conservation and SLND. Study data were analyzed July to November 2022. Interventions Participants were randomly assigned 1:1 to a paramagnetic seed or a guidewire. All patients underwent SLND with SPIO. Main Outcomes and Measures Re-excision rate and resection ratio (defined as actual resection volume / optimal resection volume). Results A total of 426 women (median [IQR] age, 65 [56-71] years; median [IQR] tumor size, 11 [8-15] mm) were included in the study. The re-excision rate was 2.90% (95% CI, 1.60%-4.80%), and the median (IQR) resection ratio was 1.96 (1.15-3.44). No differences were found between the guidewire and the seed in re-excisions (6 of 211 [2.84%] vs 6 of 209 [2.87%]; difference, −0.03%; 95% CI, −3.20% to 3.20%; P = .99) or resection ratio (median, 1.93; IQR, 1.18-3.43 vs median, 2.01; IQR, 1.11-3.47; P = .70). Overall SLN detection was 98.6% (95% CI, 97.1%-99.4%) with no differences between arms (203 of 207 [98.1%] vs 204 of 206 [99.0%]; difference, −0.9%; 95% CI, −3.6% to 1.8%; P = .72). More failed localizations occurred with the guidewire (21 of 208 [10.1%] vs 4 of 215 [1.9%]; difference, 8.2%; 95% CI, 3.3%-13.2%; P < .001). Median (IQR) time to specimen excision was shorter for the seed (15 [1

Background: Early detection along with improved locoregional and systemic therapies have decreased breast cancer mortality and allowed for the clinical implementation of breast conserving surgical options, in turn reducing the clinical and psychosocial impact of mastectomy. To what extend this has been successfully conveyed through social media for breast cancer awareness, has not been previously investigated. Methods: This study presents a content and social network cross-sectional descriptive study of Twitter and Google trends data worldwide from platform launch (2006 and 2004 respectively) until May 15th, 2022, in agreement with the STROBE guidelines. Tweets associated with the hashtags #Breastcancer, #Breastsurgery, #Oncoplasticsurgery, #Mastectomy, #Breastreconstruction, #Breastconservingsurgery were licensed and downloaded through the Vincitas and Tweetbinder online platforms. Associated available demographics, namely username, biography, location, date and language of post, were extracted from the Twitter dataset while interest percentage, location and language of search were extracted from the Google trends dataset. Results: A total of 390111 unique tweets were generated by 127284 unique users, with 2 users engaging with all six hashtags. Original tweets constituted on average 39.1% [Min 30.7% to max 47.2%] of the total. Hashtag frequency increased on Twitter for all six searches during October, the breast-cancer awareness month, but not on Google trends. Cancer survivors engaged much more often with the hashtag #Breastcancer and #Mastectomy, whereas #Breastsurgery, #Oncoplasticsurgery, #Breastconservingsurgery, #Breastreconstruction were mostly used by health professionals. Conclusion: In this large qualitative and quantitative dataset, geo-temporal oscillations on Twitter and Google trends for hashtags relevant with breast cancer provide preliminary insights on information flow and user engagement. Understanding the effective use of social media platforms

Background: Surgical excision of a non-palpable breast lesion requires a localization step. Among available techniques, wire-guided localization (WGL) is most commonly used. Other techniques (radioactive, magnetic, radar or radiofrequency-based, and intraoperative ultrasound) have been developed in the last two decades with the aim of improving outcomes and logistics. Methods: We performed a systematic review on localization techniques for non-palpable breast cancer. Results: For most techniques, oncological outcomes such as lesion identification and clear margin rate seem either comparable with or better than for WGL, but evidence is limited to small cohort studies for some of the devices. Intraoperative ultrasound is associated with significantly higher negative margin rates in meta-analyses of randomized clinical trials (RCTs). Radioactive techniques were studied in several RCTs and are non-inferior to WGL. Smaller studies show higher patient preference towards wire-free localization, but little is known about surgeons’ and radiologists’ attitudes towards these techniques. Conclusions: Large studies with an additional focus on patient, surgeon, and radiologist preference are necessary. This review aims to present the rationale for the MELODY (NCT05559411) study and to enable standardization of outcome measures for future studies. Simple summary Most breast cancers are small and can be treated using breast-conserving surgery. Since these tumors are non-palpable, they require a localization step that helps the surgeon to decide which tissue needs to be removed. The oldest localization technique is a guidewire placed into the tumor before surgery, usually using ultrasound or mammography. Afterwards, the surgeon removes the tissue around the wire tip. However, this technique has several disadvantages: It can cause the patient discomfort, requires a radiologist or another professional specialized in breast diagnostics to perform the procedure shortly before surgery, a