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Advances in Surgical Treatment of Breast Cancer

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A special issue of Current Oncology (ISSN 1718-7729). This special issue belongs to the section "Surgical Oncology".

Deadline for manuscript submissions: closed (1 March 2023) | Viewed by 27449

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Special Issue Editors

Dr. Rona Cheifetz

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Guest Editor

Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
Interests: hereditary breast cancer; breast cancer surgery

Dr. Elaine McKevitt

E-Mail Website
Guest Editor

Department of Surgery, Faculty of Medicine, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
Interests: optimizing breast cancer surgery; breast cancer care journey

Special Issue Information

Dear Colleagues,

Breast cancer is the most commonly occurring cancer in women; in 2020 alone, 2.3 million women were diagnosed with breast cancer globally. Whereas multimodality therapy including combinations of chemotherapy, hormonal blockade, immunotherapy, and surgery is used for the management of breast cancer, surgery remains the mainstay of treatment and is a component of care of almost all patients diagnosed with nonmetastatic disease.

Yet, it has been more than three decades since Fisher published a paper validating lumpectomy for the management of breast cancer, and more than two decades since Giuliano published a paper on sentinel lymph node biopsy for axillary staging. Surgical innovation tends to be a slower process than what is observed in other areas of cancer care. Nonetheless, innovation does occur, and the dissemination and adoption of new surgical approaches to the management of breast cancer are essential for optimizing patient outcomes.

This Special Issue will focus on the advances in the surgical management of breast cancer. Suggested manuscript topics include, but are not limited to:

Oncoplastics;
Breast conserving surgery vs. mastectomy;
Sensation preserving mastectomy;
Sequelae of breast cancer surgery;
Contralateral prophylactic mastectomy (roles, trends, and controversies);
Breast reconstruction and oncoplastic reductions;
Nonoperative management of advanced breast cancer (post-NAT);
Nonoperative management of early breast cancer (ablation techniques);
Surgical management of lymphedema;
Genetic testing by surgeons;
Patient-reported outcomes of breast cancer surgery;
Operative and nonoperative management of the axilla.

Dr. Rona Cheifetz
Dr. Elaine McKevitt
Guest Editors

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Keywords

breast cancer
breast surgery
breast reconstruction
breast ablation
oncoplastics
genetic screening
mastectomy
prophylactic mastectomy
lymphedema
genetic testing
patient-reported outcomes
axillary surgery
neoadjuvant chemotherapy

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Published Papers (10 papers)

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Editorial

Jump to: Research, Review, Other

3 pages, 160 KiB

Open AccessEditorial

Advances in the Surgical Treatment of Breast Cancer

by Rona Cheifetz and Elaine McKevitt

Curr. Oncol. 2023, 30(11), 9584-9586; https://doi.org/10.3390/curroncol30110693 - 31 Oct 2023

Cited by 1 | Viewed by 1841

Abstract

Breast cancer is the most commonly occurring cancer in women and has become the most common cancer diagnosed worldwide [...] Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

Research

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11 pages, 914 KiB

Open AccessArticle

Incorporating Lymphovenous Anastomosis in Clinically Node-Positive Women Receiving Neoadjuvant Chemotherapy: A Shared Decision-Making Model and Nuanced Approached to the Axilla

by Daniel Ben Lustig, Claire Temple-Oberle, Antoine Bouchard-Fortier and May Lynn Quan

Curr. Oncol. 2023, 30(4), 4041-4051; https://doi.org/10.3390/curroncol30040306 - 3 Apr 2023

Cited by 2 | Viewed by 2374

Abstract

Introduction: Lymphedema remains a risk for 13–34% of breast cancer patients who require an axillary dissection (ALND) and radiation. Immediate lymphovenous anastomosis (LVA) may mitigate lymphedema by up to 30% by restoring the physiologic lymphatic drainage immediately after ALND. Currently, completion of ALND (cALND) versus radiation after neoadjuvant therapy (NAC) is being addressed by the Alliance A11202 trial, leaving a paucity of data to guide practice. Our study describes the implementation process of LVA into clinical practice after NAC for node-positive breast cancer in the current clinical context. Methods: We reviewed a prospective database of LVA in node-positive patients (cT1-4,Nany) who received NAC followed by axillary surgery ± immediate LVA from October 2021 to 2022. The evolution of the surgical approach is described. Specifically, patients who downstaged to clinically negative nodes post-NAC were offered targeted SLNB with dual-tracer and intraoperative frozen section (FS). Patients were reminded that the standard of care for any node positive is cALND. Immediate cALND with LVA was performed for grossly positive nodes or all positive SLNs; cALND was omitted for those with negative SLNs. For a microscopic disease on a frozen section, a shared decision was made pre-operatively, given each patient’s differing valuations of the benefit and risks of cALND ± LVA versus no cALND with planned regional radiation postoperatively. LVA was offered as an option as part of our institutional evaluation of the procedure. Results: A total of 15 patients were included; the mean age was 49.9 (range 32–75) with stage IIA to IIIB breast cancer. Of these, 6 (40%) were triple negative, 5 (33.3%) HER-2 positive, and 4 (26.7%) ER/PR+ HER-2 negative. There were 13 women (86.7%) who had persistent axillary adenopathy based on clinical and/or ultrasound assessment, with 8 patients proceeding directly to ALND with LVA. Among these patients, 3 (37.5%) had pathologic nodal disease, and 5 (62.5%) were node negative, confirming the limitations of pre-operative imaging. As a result, the subsequent 7 (46.7%) underwent targeted SLNB with FS, with 3 patients (42.9%) avoiding an ALND as a result of a negative FS. A total of 4 patients (57.1%) had 1 or more positive lymph nodes on FS: 3 proceeded with a cALND and LVA, and 1 patient (14.2%) opted for no cALND based on a pre-operative discussion and received adjuvant radiation and chemotherapy. Of the 11 patients who underwent ALND and LVA, 1 patient (9.1%) developed lymphedema at 6.9 months following their surgery. The accuracy, sensitivity, and specificity of pre-operative US were 46.7%, 85.7%, and 12.5% and intraoperative FS were 88.0%, 72.7%, and 100%, respectively. Conclusions: As adjuvant nodal radiation and systemic therapy continue to improve, the benefit of a cALND in patients with the limited residual disease remains unclear as we await the outcomes from clinical trials. In the era of clinical uncertainty, we propose a nuanced approach to the axilla by utilizing a shared decision model with patients, incorporating targeted SLNB with FS and completion node dissection when required and desired by the patient, coupled with LVA in a simple stepwise treatment pathway. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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14 pages, 2451 KiB

Open AccessArticle

Mitigating Breast-Cancer-Related Lymphedema—A Calgary Program for Immediate Lymphatic Reconstruction (ILR)

by Melina Deban, J. Gregory McKinnon and Claire Temple-Oberle

Curr. Oncol. 2023, 30(2), 1546-1559; https://doi.org/10.3390/curroncol30020119 - 24 Jan 2023

Cited by 5 | Viewed by 2336

Abstract

With increasing breast cancer survival rates, one of our contemporary challenges is to improve the quality of life of survivors. Lymphedema affects quality of life on physical, psychological, social and economic levels; however, prevention of lymphedema lags behind the progress seen in other areas of survivorship such as breast reconstruction and fertility preservation. Immediate lymphatic reconstruction (ILR) is a proactive approach to try to prevent lymphedema. We describe in this article essential aspects of the elaboration of an ILR program. The Calgary experience is reviewed with specific focus on team building, technique, operating room logistics and patient follow-up, all viewed through research and education lenses. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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12 pages, 607 KiB

Open AccessArticle

Differences in Preoperative Health-Related Quality of Life between Women Receiving Mastectomy or Breast Conserving Surgery in a Prospectively Recruited Cohort of Breast Cancer Patients

by Elaine McKevitt, Maria Saleeb, Guiping Liu, Rebecca Warburton, Jin-Si Pao, Carol Dingee, Amy Bazzarelli, Katelynn Tang, Trafford Crump and Jason M. Sutherland

Curr. Oncol. 2023, 30(1), 118-129; https://doi.org/10.3390/curroncol30010010 - 22 Dec 2022

Cited by 5 | Viewed by 2333

Abstract

As rates of total mastectomy rise, the relationships between surgery modality with domains of health-related quality of life is not well understood. This study reports differences in depression, anxiety, pain, and health status among a cohort of women scheduled to receive total mastectomy or breast-conserving surgery. Patient-reported outcomes measured preoperative differences between patients receiving total mastectomy or breast-conserving surgery in a cross-sectional design. Regression analyses was used to model health outcomes and adjust for patient demographics on patient measures. Participants scheduled for total mastectomy were more likely to report more severe symptoms of depression and anxiety. This association was non-significant after adjusting for demographic differences. Younger participants were more likely to be scheduled for total mastectomy. Age was negatively associated with symptoms of depression and anxiety. Screening patients for mental health symptoms may be particularly important among younger patients who were more likely to report depression and anxiety before their surgery and were more likely to receive total mastectomy. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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8 pages, 1083 KiB

Open AccessArticle

Complete Surgical Excision Is Necessary following Vacuum-Assisted Biopsy for Breast Cancer

by Jung Ho Park, So Eun Ahn, Sanghwa Kim, Mi Jung Kwon, Yong Joon Suh and Doyil Kim

Curr. Oncol. 2022, 29(12), 9357-9364; https://doi.org/10.3390/curroncol29120734 - 30 Nov 2022

Cited by 5 | Viewed by 3487

Abstract

Vacuum-assisted breast biopsy (VABB) has been replacing excisional biopsy in the treatment of benign breast lesions. Complete surgical excision is still needed for the lesions occasionally diagnosed with breast cancer after VABB. We aimed to characterize residual tumors after VABB and define a subset of patients who do not need surgical excision after VABB. From a retrospective database, we identified patients diagnosed with breast cancer after VABB guided with ultrasonography. Patients who underwent stereotactic biopsies were excluded. We reviewed clinicopathologic data and radiologic findings of the sample. We identified 48 patients with 49 lesions. After surgical excision, the residual tumors were identified in 40 (81.6%) lesions, and there was no residual tumor in nine (18.3%) patients. Imaging studies could not accurately locate residual tumors after VABB. A small tumor size on a VABB specimen was associated with no residual tumor on final pathology. However, residual tumors were identified in four (40%) of 10 lesions with a pathologic tumor size less than 0.5 cm. In conclusion, complete surgical excision remains the primary option for most of the patients diagnosed with breast cancer after VABB. Imaging surveillance without surgery should be carefully applied for selected low-risk patients. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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16 pages, 1954 KiB

Open AccessArticle

Donor-Site Morbidity and Quality of Life after Autologous Breast Reconstruction with PAP versus TMG Flap

by Angela Augustin, Petra Pülzl, Evi M. Morandi, Selina Winkelmann, Ines Schoberleitner, Christine Brunner, Magdalena Ritter, Thomas Bauer, Tanja Wachter and Dolores Wolfram

Curr. Oncol. 2022, 29(8), 5682-5697; https://doi.org/10.3390/curroncol29080448 - 11 Aug 2022

Cited by 7 | Viewed by 2296

Abstract

The transverse myocutaneous gracilis (TMG) and the profunda artery perforator (PAP) flap are both safe choices for autologous breast reconstruction originating from the same donor region in the upper thigh. We aimed to compare the post-operative outcome regarding donor-site morbidity and quality of life. We included 18 patients who had undergone autologous breast reconstruction with a PAP flap (n = 27 flaps). Prospective evaluation of donor-site morbidity was performed by applying the same questionnaire that had already been established in a previous study evaluating TMG flap (n = 25 flaps) outcome, and results were compared. Comparison of the two patient groups showed equivalent results concerning patient-reported visibility of the donor-site scar and thigh symmetry. Still, the TMG group was significantly more satisfied with the scar (p = 0.015) and its position (p = 0.001). No difference was found regarding the ability to sit for prolonged periods. Donor-site wound complications were seen more frequently in the PAP group (29.6%) than in the TMG group (4.0%). Both groups expressed rather high satisfaction with their quality of life. Both flaps show minimal functional donor-site morbidity and high patient satisfaction. To minimize wound healing problems in PAP patients, thorough planning of the skin paddle is necessary. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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Review

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11 pages, 555 KiB

Open AccessReview

The Role of the Surgeon in the Germline Testing of the Newly Diagnosed Breast Cancer Patient

by Stephanie Schick, Joshua Manghelli and Kandice K. Ludwig

Curr. Oncol. 2023, 30(5), 4677-4687; https://doi.org/10.3390/curroncol30050353 - 1 May 2023

Viewed by 2411

Abstract

For patients with newly diagnosed breast cancer, information regarding hereditary predisposition can influence treatment decisions. From a surgical standpoint, patients with known germline mutations may alter decisions of local therapy to reduce the risk of second breast primaries. This information may also be considered in the choice of adjuvant therapies or eligibility for clinical trials. In recent years, the criteria for the consideration of germline testing in patients with breast cancer has expanded. Additionally, studies have shown a similar prevalence of pathogenic mutations in those patients outside of these traditional criteria, prompting calls for genetic testing for all patients with a history of breast cancer. While data confirms the benefit of counseling by certified genetics professionals, the capacity of genetic counselors may no longer meet the needs of these growing numbers of patients. National societies assert that counseling and testing can be performed by providers with training and experience in genetics. Breast surgeons are well positioned to offer this service, as they receive formal genetics training during their fellowship, manage these patients daily in their practices, and are often the first providers to see patients after their cancer diagnosis. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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46 pages, 12212 KiB

Open AccessReview

Mesenchymal Tumors of the Breast: Fibroblastic/Myofibroblastic Lesions and Other Lesions

by Riordan Azam, Miralem Mrkonjic, Abha Gupta, Rebecca Gladdy and Andrea M. Covelli

Curr. Oncol. 2023, 30(5), 4437-4482; https://doi.org/10.3390/curroncol30050338 - 24 Apr 2023

Cited by 6 | Viewed by 3748

Abstract

Mesenchymal breast tumors are a rare and diverse group of tumors that present some of the most challenging cases for multidisciplinary breast cancer teams. As a result of overlapping morphologies and a lack of large-scale studies on these tumors, practices are often heterogeneous and slow to evolve. Herein, we present a non-systematic review that focuses on progress, or lack thereof, in the field of mesenchymal breast tumors. We focus on tumors originating from fibroblastic/myofibroblastic cells and tumors originating from less common cellular origins (smooth muscle, neural tissue, adipose tissue, vascular tissue, etc.). Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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Other

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16 pages, 459 KiB

Open AccessSystematic Review

Breast Reconstruction Use and Impact on Surgical and Oncologic Outcomes Amongst Inflammatory Breast Cancer Patients—A Systematic Review

by Ananya Gopika Nair, Gary Tsun Yin Ko, John Laurie Semple and David Wai Lim

Curr. Oncol. 2023, 30(7), 6666-6681; https://doi.org/10.3390/curroncol30070489 - 13 Jul 2023

Viewed by 2211

Abstract

Breast reconstruction is generally discouraged in women with inflammatory breast cancer (IBC) due to concerns with recurrence and poor long-term survival. We aim to determine contemporary trends and predictors of breast reconstruction and its impact on oncologic outcomes among women with IBC. A systematic literature review for all studies published up to 15 September 2022 was conducted via MEDLINE, Embase, and the Cochrane Library. Studies comparing women diagnosed with IBC undergoing a mastectomy with or without breast reconstruction were evaluated. The initial search yielded 225 studies, of which nine retrospective cohort studies, reporting 2781 cases of breast reconstruction in 29,058 women with IBC, were included. In the past two decades, immediate reconstruction rates have doubled. Younger age, higher income (>USD 25,000), private insurance, metropolitan residence, and bilateral mastectomy were associated with immediate reconstruction. No significant difference was found in overall survival, breast cancer-specific survival or recurrence rates between women undergoing versus not undergoing (immediate or delayed) reconstruction. There is a paucity of data on delayed breast reconstruction following IBC. Immediate breast reconstruction may be a consideration for select patients with IBC, although prospective data is needed to clarify its safety. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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9 pages, 491 KiB

Open AccessSystematic Review

Safety and Accuracy of Sentinel Lymph Node Biopsy Alone in Clinically Node-Positive Patients Undergoing Upfront Surgery for Invasive Breast Cancer: A Systematic Review

by Olivia Lovrics, Brendan Tao and Elena Parvez

Curr. Oncol. 2023, 30(3), 3102-3110; https://doi.org/10.3390/curroncol30030235 - 7 Mar 2023

Cited by 2 | Viewed by 2449

Abstract

Landmark trials (Z0011 and AMAROS) have demonstrated that axillary lymph node dissection (ALND) can be safely omitted in patients with breast cancer and 1–2 positive sentinel nodes. Extrapolating from these and other cardinal studies such as NSABP B-04, guidelines state that patients with 1–2 needle biopsy-proven positive lymph nodes undergoing upfront surgery can have sentinel lymph node biopsy (SLNB) alone. The purpose of this study is to systematically review the literature to identify studies examining the direct application of SLNB in such patients. EMBASE and Ovid MEDLINE were searched from inception to 3 May 2022. Studies including patients with nodal involvement confirmed on pre-operative biopsy and undergoing SLNB were identified. Studies with neoadjuvant chemotherapy were excluded. Search resulted in 2518 records, of which 68 full-text studies were reviewed, ultimately yielding only 2 studies meeting inclusion criteria. Both studies used targeted axillary surgery (TAS) with pre-operative localization of the biopsy-proven positive node in addition to standard SLNB techniques. In a non-randomized single-center prospective study, Lee et al. report no regional recurrences in patients undergoing TAS or ALND, and no difference in distant recurrence or mortality at 5 years. In the prospective multicenter TAXIS trial by Webber et al., the median number of positive nodes retrieved with TAS in patients undergoing upfront surgery was 2 (1, 4 IQR). Within the subset of patients who underwent subsequent ALND, 61 (70.9%) had additional positive nodes, with 26 (30.2%) patients having ≥4 additional positive nodes. Our review demonstrates that there is limited direct evidence for SLNB alone in clinically node-positive patients undergoing upfront surgery. Available data suggest a high proportion of patients with residual disease in this setting. While the totality of the data, mostly indirect evidence, suggests SLNB alone may be safe, we call on clinicians and researchers to prospectively collect data on this patient population to better inform decision-making. Full article

(This article belongs to the Special Issue Advances in Surgical Treatment of Breast Cancer)

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