Axillary treatment strategies for the young woman with early-stage, clinically node-negative breast cancer undergoing upfront surgery found to have 1–3 positive sentinel lymph nodes (SLNs) differ significantly after BCT and mastectomy. Here we compare axillary lymph node dissection (ALND) and regional nodal irradiation (NRI) rates between women electing breast-conservation therapy (BCT) versus mastectomy. From 2010 to 2016, women age < 50 years with clinical T1-T2N0 breast cancer having upfront surgery and found to have a positive SLN were identified. ALND and/or NRI receipt were compared between groups. 192 women undergoing BCT and 165 undergoing mastectomy were identified (median age: 44 years). 5.2% (10/192) of women undergoing BCT had an ALND versus 87% (144/165) of women undergoing mastectomy (p < 0.01). NRI was given to 48% (78/165) of mastectomy patients compared to 30% (57/192) of BCT patients (p < 0.01). Of the 75 mastectomy patients with 1–2 total positive lymph nodes after completion ALND, 44% received NRI. Women undergoing mastectomy were significantly more likely to receive both ALND and NRI than women undergoing BCS (45% vs 6%, p < 0.01). Young cT1-2N0 breast cancer patients found to have 1–3 SLN metastases received ALND, NRI, and combined ALND/NRI more frequently if they elected mastectomy over BCT. Use of both ALND and postmastectomy radiotherapy (PMRT) in this population could be reduced in the future by omitting ALND in patients for whom the need for PMRT is clear with the finding of 1–2 SLN metastases.

The following are corrections to the original article.

Nipple‐sparing mastectomy (NSM) is being performed increasingly for risk reduction in high‐risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis.

BACKGROUND:Young age at breast cancer diagnosis is associated with negative prognostic outcomes, and breast cancer in black women often manifests at a young age. This study evaluated the effect of age on breast cancer management and outcomes in black women.METHODS:This was a retrospective cohort study of all black women treated for invasive breast cancer between 2005 and 2010 at a specialized tertiary-care cancer centre. Clinical and treatment characteristics were compared by age. Kaplan-Meier methodology was used to estimate overall survival (OS) and disease-free survival (DFS).RESULTS:A total of 666 black women were identified. Median BMI was 30 (range 17-56) kg/m2 and median tumour size was 16 (1-155) mm. Most tumours were oestrogen receptor-positive (66·4 per cent). Women were stratified by age: less than 40 years (74, 11·1 per cent) versus 40 years or more (592, 88·9 per cent). Younger women were significantly more likely to have a mastectomy, axillary lymph node dissection and to receive chemotherapy, and were more likely to have lymphovascular invasion and positive lymph nodes, than older women. The 5-year OS rate was 88·0 (95 per cent c.i. 86·0 to 91·0) per cent and the 5-year DFS rate was 82·0 (79·0 to 85·0) per cent. There was no statistically significant difference in OS by age (P = 0·236). Although DFS was inferior in younger women on univariable analysis (71 versus 88 per cent; P < 0·001), no association was found with age on multivariable analysis.CONCLUSION:Young black women with breast cancer had more adverse pathological factors, received more aggressive treatment, and had worse DFS on univariable analysis. Young age at diagnosis was, however, not an independent predictor of outcome.

The following are corrections to the original article.

The Society of Surgical Oncology and American Society for Radiation Oncology consensus guidelines defined a negative margin for breast-conserving surgery (BCS) as no ink on tumor, and implementation has reduced rates of additional surgery for patients with invasive ductal cancer (IDC). The outcomes for invasive lobular cancer (ILC) patients are uncertain. This study identified patients who had stage 1 or 2 ILC treated with BCS from January 2010 to February 2018. The guidelines were adopted 1 January 2014. Clinicopathologic characteristics, margin status, and reexcisions were compared before and after adoption of the guidelines and with those of IDC patients treated from May 2013 to February 2015. Among 745 early-stage ILC patients undergoing BCT, 312 (42%) were treated before the guidelines and 433 (58%) after the guidelines. Most clinicopathologic characteristics were similar between the two groups, with differences in lobular carcinoma in situ, lymphovascular invasion, and node-positivity rates. The overall rates of additional surgery declined significantly after the guidelines (31.4 to 23.1%; p = 0.01), but the difference did not reach significance for reexcisions (19.9 to 15.2%; p = 0.12) or conversions to mastectomy (11.5 to 7.9%; p = 0.099) individually. Between eras, no difference in incidence or number of tumor on ink or ≤ 2 mm margins was observed (all p = 0.2). Larger tumors, younger age, and pre-guideline era were independently associated with additional surgery. Only younger age was predictive of mastectomy. Among 431 pre-guideline and 601 post-guideline IDC patients, reexcisions declined from 21.3 to 14.8% (p = 0.008), and conversion to mastectomy was rare (0.6%). The magnitude of reduction in any additional surgery (interaction, p = 0.92) and reexcisions (interaction, p = 0.56) was similar between ILC and IDC. Despite differences in growth pattern and conspicuity, guideline adoption significantly reduced additional surgery among ILC patients, with a magnitude of benefit similar to that among IDC patients.

Background Many factors influence decisions regarding choice of breast-conserving surgery (BCS) versus mastectomy with reconstruction for early invasive breast cancer. The purpose of this study was to compare patient satisfaction following BCS and mastectomy with implant reconstruction (M-iR) utilizing the BREAST-Q patient-reported outcome measure. Methods Women with stage I or II breast cancer undergoing BCS or M-iR who completed a BREAST-Q from 2010 to 2016 were identified by retrospective review of a prospective database. Baseline characteristics were compared, and linear mixed models were used to analyze associations with BREAST-Q scores over time. Results Our study group was composed of 3233 women; 2026 (63%) had BCS, 123 (3.8%) had nipple-sparing mastectomy, and 1084 (34%) had skin-sparing or total mastectomy. Median time from surgery to BREAST-Q was 205 days for BCS and 639 days for M-iR ( p < 0.001). Regardless of type of surgery, breast satisfaction scores decreased significantly over time ( p < 0.001), whereas psychosocial ( p = 0.001) and sexual ( p = 0.004) well-being scores increased significantly over time. BCS was associated with significantly higher scores over time compared with M-iR across all subscales (all p < 0.001). Radiation was significantly associated with decreased scores over time across all subscales (all p < 0.05). Conclusions Breast satisfaction and quality-of-life scores were higher for BCS compared with M-iR in early-stage invasive breast cancer. These findings may help in counseling women who have a choice for surgical treatment. Breast satisfaction scores decreased over time in all women, highlighting the need for further evaluation with longer follow-up.

Malignant/borderline phyllodes tumors (PTs) are rare, and little is known about their long-term prognosis. This study sought to evaluate recurrence rates and identify factors associated with local and distant failure.

Among patients with a core biopsy diagnosis of ductal carcinoma in situ (DCIS), approximately 10% have microinvasion (DCISM), which, like DCIS, is subject to upstaging by surgical excision, but for which the rates of T and N upstaging are unknown, as is the role of sentinel lymph node biopsy (SLNB), since current studies of SLNB for DCISM are based on the final pathologic report, not the core needle biopsy. In this study, we identified the rates of T and N upstaging following surgical excision in patients with a suspected versus definite core needle biopsy diagnosis of DCISM. Overall, 369 consecutive patients (2007–2017) with a core biopsy diagnosis of suspected versus definite DCISM and surgical excision were stratified by extent of DCISM on core biopsy: suspicious focus, single focus, multiple foci/single biopsy, and multiple foci/multiple biopsies. Within strata, we identified clinicopathologic features associated with T and N upstaging. Across core biopsy strata, there were no clear differences in imaging characteristics or median invasive tumor size (0.2 cm). Among 105 patients with a core biopsy suspicious for DCISM versus 264 with definite DCISM, 28% and 37%, respectively, were upstaged to at least pT1a, but only 1% and 6%, respectively, to pN1. Although 28% of patients with suspected DCISM on core biopsy were surgically upstaged to invasive cancer, the frequency of pN1 SLN metastasis (1%) was comparable with that of DCIS, and was insufficient to recommend SLNB at initial surgery. SLNB remains reasonable for patients with definite DCISM on core biopsy.

Background The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial demonstrated that axillary lymph node dissection (ALND) may be omitted for women with two or fewer positive sentinel nodes (SLNs) undergoing breast-conservation therapy (BCT). Lobular histology comprises a minority of patients, and applicability to these discohesive cancers has been questioned. Methods From August 2010 to March 2017, patients undergoing BCT for cT1-2N0 cancer with positive SLNs were prospectively managed with ALND for three or more positive SLNs or gross extracapsular extension (ECE). In this study, clinicopathologic characteristics and nodal burden were compared between pure/mixed invasive lobular cancer (ILC) and invasive ductal cancer (IDC) patients. Results Among 813 consecutive patients, 104 (12.8%) had ILC and 709 (87.2%) had IDC. ILC was more often multifocal and low grade, and less frequently had lymphovascular invasion (all p < 0.001). ILC more often had SLN macrometastases (81.7% ILC vs. 69.4% IDC; p = 0.01) and more than 2 mm of ECE (30.8% ILC vs. 19.5% IDC; p = 0.03), but the proportions of cases with three or more positive SLNs were similar in the two groups (14.4% ILC vs. 9.9% IDC; p = 0.2). The ALND procedure was performed for 20 ILC patients (19.2%) compared with 97 IDC patients (13.7%) (p = 0.2). Additional positive nodes were found in 80% of the ILC patients versus 56.7% of the IDC patients (p = 0.09). The ALND and nodal burden rates were similar in the estrogen receptor-positive (ER+) subset analysis. In the multivariable analysis, lobular histology (p = 0.03) and larger tumors (p = 0.03) were associated with additional positive nodes. During a median follow-up period of 42 months, there were no isolated axillary recurrences. Conclusions Despite a higher proportion of SLN macrometastases and association with more positive nodes at ALND, lobular histology does not predict the need for ALND. ALND is not indicated on the basis of histology among patients otherwise meeting Z0011 criteria.

BackgroundBlack women with breast cancer have lower survival rates and higher recurrence rates in comparison with white women. This study compared treatment and survival outcomes for black and white women at a highly specialized tertiary care cancer center.MethodsAn institutional review board–approved, retrospective institutional database review was performed to identify all black women treated for invasive breast cancer between 2005 and 2010. Women with a prior history of breast cancer, stage IV cancer, or bilateral breast cancer were excluded. White women had similar exclusion criteria applied and were then matched to black women 1:1 by age and diagnosis year. Clinicopathologic and treatment variables were compared by race. Kaplan‐Meier methodology was used to estimate overall survival (OS) and disease‐free survival (DFS); a multivariable analysis was conducted with Cox regression models.ResultsThe study group consisted of 1332 women (666 black). The median tumor size was larger in black women (1.6 vs 1.3 cm; P < .001). Black women had more nodal disease (41.1% vs 32%; P < .001) and had tumors that were more frequently an estrogen receptor–negative (32.9% vs 15%; P < .001), progesterone receptor–negative (47.1% vs 30.2%; P < .001), or triple‐negative (TN) subtype (24% vs 8.9%; P < .001) in comparison with white women. Black women also had inferior DFS and OS; race was not an independent prognostic indicator in the multivariable analysis.ConclusionsBlack women had more advanced disease and adverse prognostic indicators at diagnosis, but race was not an independent predictor of outcome. Black women were significantly more likely to have TN breast cancer. Further research is necessary to understand the differences in tumor biology associated with race.

Nipple-sparing mastectomy (NSM) is increasingly performed for invasive breast cancer. Growing evidence supporting the oncologic safety of NSM has led to its widespread use and broadened indications. In this study, we examine the indications, complications, and long-term outcomes of therapeutic NSM.

The efficacy of chemoprevention for breast cancer risk reduction has been demonstrated in randomized controlled trials; however, use remains low. We sought to determine whether uptake differed by risk factors, and to identify reasons for refusal and termination.

Background. The National Comprehensive Cancer Network (NCCN) endorses sentinel lymph node biopsy (SLNB) in patients with clinically positive axillary nodes who downstage after neoadjuvant chemotherapy (NAC). In this study, we compared the accuracy of post-NAC MRI to clinical exam alone in predicting pathologic status of sentinel lymph nodes in cN1 patients. Methods. We identified patients with T0-3, N1 breast cancer who underwent NAC and subsequent SLNB from March 2014 to July 2017. Patients were grouped based on whether a post-NAC MRI was done. MRI accuracy in predicting SLN status was assessed versus clinical exam alone. Results. A total of 450 patients met initial study criteria; 269 were analyzed after excluding patients without biopsy-confirmed nodal disease, palpable disease after NAC, and failed SLN mapping. Median age was 49 years. Post-NAC MRI was done in 68% (182/269). Patients undergoing lumpectomy vs mastectomy more frequently received a post-NAC MRI (88 vs 54%, p < 0.001). All other clinicopathologic parameters were comparable between those who did and did not have a post-NAC MRI. Thirty percent (55/182) had abnormal lymph nodes on MRI. Among these, 58% (32/55) had a positive SLN on final pathology versus 42% (53/127) of patients with no abnormal lymph nodes on MRI and 52% (45/87) of patients who had clinical exam alone (p = 0.09). MRI sensitivity was 38%, specificity was 76%, and overall SLN status prediction accuracy was 58%. Conclusions. Post-NAC MRI is no more accurate than clinical exam alone in predicting SLN pathology in patients presenting with cN1 disease. Abnormal lymph nodes on MRI should not preclude SLNB.

Women with dense breasts may have less-accurate preoperative evaluation of extent of disease, potentially affecting the achievement of negative margins. The goal of this study is to examine the association between breast density and re-excision rates in women having breast-conserving surgery for invasive breast cancer. Women with stage I/II invasive breast cancer treated with breast-conserving surgery between 1/1/2014 and 10/31/2014 were included. Breast density was assessed by two radiologists. The association between breast density and re-excision was examined using logistic regression. Seven hundred and one women were included. Overall, 106 (15.1%) women had at least one re-excision. Younger age at diagnosis was associated with increased breast density (p < 0.001). On univariable analysis, increased breast density was associated with significantly increased odds of re-excision (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.04–1.83), as was multifocal disease, human epidermal growth factor receptor 2 (HER2) positive status, and extensive intraductal component (EIC) (all p < 0.05). On multivariable analysis, breast density remained significantly associated with increased odds of re-excision (OR 1.37, 95% CI 1.00–1.86), as did multifocality and EIC. HER2 positive status was not significantly associated with re-excision on multivariable analysis. Women with dense breasts are more likely to need additional surgery (re-excision after breast-conserving surgery), but increased breast density did not adversely affect disease-free survival in our study. Our findings support the need for further study in developing techniques that can help decrease re-excisions for women with dense breasts who undergo breast-conserving surgery.