Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

• NSABP B-04:
  • A Protocol for the Evaluation of Radical Mastectomy and Total Mastectomy with and without Radiation in the Primary Treatment of Cancer of the Female Breast
  • Enrolled 1,079 patients:
    • With clinically node-negative disease
  • Randomized patients to:
    • Radical mastectomy (RM)
    • Total mastectomy (TM) plus local-regional axillary irradiation, or 
    • TM alone
  • An additional 586 patients:
    • With clinically node-positive disease
    • Were randomized to:
      • RM or 
      • TM plus radiation
  • An important point of this trial:
    • Is that none of these patients received systemic therapy
  • After 25 years of follow-up:
    • The study showed no significant difference in long-term outcome:
      • Between clinically node-negative patients:
        • Who received RM and those who received TM with or without radiation
      • Between clinically node-positive patients:
        • Who received RM vs.TM with nodal irradiation
    • When comparing the hazard ratio for death within the two arms:
      • The results show no survival advantage from RM

• In patients with clinically node-negative disease:
  • Pathologic examination of the mastectomy specimen in patients treated with radical mastectomy:
    • Revealed that 40% of the patients had pathologically positive nodes
    • However, only 19% of patients treated with TM alone and no axillary surgeryhad an axillary recurrence:
      • Suggesting that not all occult axillary disease will progress into clinically meaningful disease:
        • Even in the absence of systemic therapy

• NSABP B-06:
  • Phase III Total Mastectomy / Axillary Dissection vs Segmental Mastectomy / Axillary Dissection with or without Radiotherapy for Potentially Curable Breast Carcinoma
  • Compared lumpectomy and axillary node dissection with or without breast irradiation with modified radical mastectomy (MRM):
    • In patients with tumors 4 cm or less in greatest diameter
  • The results of this trial:
    • Demonstrating equivalent survival between the two surgical options:
      • Establish BCS as a viable surgical option for most patients with invasive breast cancer

• The Milan I trial:
  • Compared 701 patients with invasive breast cancer up to 2 cm in size without clinically positive axillary lymph nodes
  • Randomized them into those who:
    • Received radical mastectomy and those who received quadrantectomy plus axillary dissection and radiotherapy
  • A recent analysis of the trial:
    • Showed no differences in OS between the two study groups

• The NSABP B-17:
  • Phase III Randomized Study of Postoperative Radiotherapy Following Segmental Mastectomy and Axillary Dissection in Patients with Noninvasive Intraductal Adenocarcinoma of the Breast:
    • Compared lumpectomy alone to lumpectomy plus breast irradiation:
      • In 818 patients with localized ductal carcinoma in situ
  • This trial concluded that:
    • Radiotherapy did not improve OS but that it did significantly decrease the rate of invasive or in situ in breast tumor recurrence in the ipsilateral breast

• The EORTC Trial 10801:
  • Was a randomized multicenter trial:
    • That compared breast-conserving therapy with MRM for patients with invasive breast cancer less than 5 cm in diameter
  • At 10 years:
    • There was no difference between the two groups in:
      • OS or in distant metastasis-free rates
  • Locoregional recurrence at 10 years was:
    • 12% for the mastectomy group and 20% for the breast-conserving therapy group

• References:
  • Fisher B, Montague E, Redmond C, Barton B, Borland D, Fisher ER, et al. Comparison of radical mastectomy with alternative treatments for primary breast cancer: a first report of results from a prospective randomized clinical trial. Cancer. 1977;39(6 Suppl):2827-2839.
  • Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233-1241.
  • Mamounas EP, Wickerham DL, Fisher B, Geyer CE, Julian TB, Wolmark N. The NSABP experience. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill Companies; 2010:475-508.
  • Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232.
  • Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998;16(2):441-452.
  • Curran D, van Dongen JP, Aaronson NK, Kiebert G, Fentiman IS, Mignolet F, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. The European Organization for Research and Treatment of Cancer (EORTC), Breast Cancer Co-operative Group (BCCG

• Obtaining a chest radiograph:
  • Is reasonable if acute cardiopulmonary disease is suspected
  • If there is a history of chronic stable cardiopulmonary diseases:
    • In patients older than age 70 years who have not had chest radiography within 6 months
• The American Society of Clinical Oncology and the National Comprehensive Cancer Network:
  • Do not recommend routine preoperative chest imaging:
    • In asymptomatic patients with normal clinical examinations undergoing surgery for breast neoplasms:
      • Routine systemic imaging leads to unnecessary cost and risk of false-positive findings
• In 1979, the Royal College of Radiologists published a multicenter study:
  • That retrospectively examined 10,619 preoperative chest x-rays in patients undergoing elective non-cardiopulmonary surgery and concluded that:
    • Preoperative chest x-rays did not influence the decision to operate or choice of anesthetic
• Since then, studies have confirmed that preoperative chest x-rays did not influence postoperative outcome
• Therefore, the low benefit does not justify their cost for the general population undergoing ambulatory procedures:
  • As only 2% of such images lead to a change in management
• References:
  • The American Society of Breast Surgeons Releases List of Five Things Clinicians and Patients Should Question. http://www.choosingwisely.org/the-american-society-of-breast-surgeons-releases-list-of-five-things-clinicians-and-patients-should-question/. Accessed January 7, 2020.
  • NCCN Breast Cancer Guidelines 2018. National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed October 17, 2019.
  • Mohammed TL, Kirsch J, Amorosa JK, et al. ACR Appropriateness Criteria routine admission and preoperative chest radiography. Updated 2015. https://acsearch.acr.org/docs/69451/Narrative. Accessed October 21, 2019.
  • Munro J, Booth A, Nicholl J. Routine preoperative testing: a systematic review of the evidence. Health Technol Assess. 1997;1(12):1-62.
  • Preoperative chest radiology. National study by the Royal College of Radiologists. Lancet. 1979;2(8133):83-86.
  • Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth. 1993;40(11):1022-1027.

#Arrangoiz #BreastSurgeon #BreastCancer #CancerSurgeon #Surgeon #Teacher

• The risk of DVT or pulmonary embolism (PE):
  • Is very low with most breast operations
  • The exception is breast operations:
    • Having long duration of general anesthesia and autologous reconstruction with flaps
• No specific prophylaxis for DVT / PE is necessary for breast operations:
  • Performed with local or regional anesthesia
• Ambulation and leg compression stockings:
  • Are adequate for prophylaxis of DVT / PE in the vast majority of patients undergoing breast surgery in a report from MD Anderson Cancer Center
• Aspirin:
  • Is not considered sufficient prophylaxis for any patient at moderate to high risk for DVT / PE
• Vena cava filters decrease the risk of PE but do not prevent DVT
• The most effective method to decrease a repeat DVT in a patient at moderate risk:
  • Is with chemoprophylaxis with:
    • Low molecular weight heparin or low dose unfractionated heparin given preoperatively, then continued
• References
  • The American Society of Breast Surgeons. Consensus statement on venous thromboembolism prophylaxis for patients undergoing breast operations. https://www.breastsurgeons.org/docs/statements/Consensus-Guideline-on-Venous-Thromboembolism-VTE-Prophylaxis-for-Patients-Undergoing-Breast-Operations.pdf. Accessed October 14, 2019.
  • Andtbacka RH, Babiera G, Singletary SE, Hunt KK, Meric-Bernstam F, Feig BW, et al. Incidence and prevention of venous thromboembolism in patients undergoing breast cancer surgery and treated according to clinical pathways. Ann Surg. 2006;243(1):96-101.
  • El-Tamer MB, Ward BM, Schifftner T, Neumayer L, Khuri S, Henderson W. Morbidity and mortality following breast cancer surgery in women: national benchmarks for standards of care. Ann Surg. 2007;245(5):665-671.
  • Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ; American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl);7S-47S.
  • Neumayer L, Schifftner TL, Henderson WG, Khuri SF, El-Tamer M. Breast cancer surgery in Veterans Affairs and selected university medical centers: results of the patient safety in surgery study. J Am Coll Surg. 2007;204(6):1235-1241.

Breast Cancer Screening in Women Over 74 Years of Age

• Women over age 74:
  • Should be educated on the possible harms of screening mammogram:
    • Such as:
      • Overdiagnosis and false positives vs. the potential benefits
  • They should be offered the choice to stop or continue mammogram screening in the context of:
    • Their life expectancy
    • Comorbidities
    • Personal beliefs
• Controversy exists and data are limited for using screening mammogram in women over age 74:
  • Healthy women in this age group of women are likely to have a lifespan of 15 years or more
  • Using Medicare claims and Surveillance, Epidemiology, and End Results (SEER) program data:
    • Patients age between 69 to 84 who elected for annual mammograms in the four years prior to breast cancer diagnosis:
      • Had lower 5- and 10-year death rates compared to those who elect for irregular or no mammograms during that interval
• “Framing cancer screening conversations in terms of increasing harms in relation to decreasing benefits has been found to be most acceptable to older patients and may maintain or promote trust more than citing national guideline recommendations to stop screening based on age cutoffs for women with less than a 5 to 10 year life expectancy, recommendations to stop screening mammography should be framed around how a woman’s health problems increase the harms of screening (e.g., overdiagnosis) and shift the focus to interventions likely to be beneficial over a shorter time frame (e.g., falls prevention, depression screening).”
• No screening breast imaging:
  • Is required for asymptomatic patients with a normal breast exam who have a life expectancy less than 5 years
• Conversations regarding cessation of mammogram should be focused on risk of harm such as false positives and the significance of this in relation to the patient’s medical condition
  • Interestingly, the number of false positives actually decreases with age^:
    • However, the number of lives saved is 2 / 1000, compared to 39% of women harmed by overdiagnosis or false positives
• References
• Walter LC, Schonberg MA. Screening mammography in older women: a review. JAMA. 2014;311(13): 1336-1347.
• Sanderson M, Levine RS, Fadden MK, Kilbourne B, Pisu M, Cain V, et al. Mammography screening among the elderly: a research challenge. Am J Med. 2015;128(12):1362.e7-1362.e14
• Sharpe RE Jr, Levin DC, Parker L, Rao VM. The Effect of the Controversial US Preventive Services Task Force Recommendations on the Use of Screening Mammography.J Am Coll Radiol. 2016 Nov;13(11S):e58-e61.
• Oeffinger KC, Fontham ET, Etzioni R, Herzig A, Michaelson JS, Shih YC, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614.

#Arrangoiz #BreastSurgeon #BreastCancer #CancerSurgeon #SurgicalOncologist #Teacher

• Recurrent laryngeal nerve (RLN) injury:
  • Is one of the most serious complications in endocrine surgery:
    • It is related to significant morbidity and frequent malpractice litigation
• The recurrent laryngeal nerve:
  • Originates from the:
    • Trunk of the vagus nerve
  • Upon reaching the larynx:
    • It is renamed the inferior laryngeal nerve
  • It innervates all the intrinsic muscles of the same side:
    • With the exception of the cricothyroid muscles
  • It supplies sensory innervation to the laryngeal mucosa:
    • Below the true vocal folds
  • While ascending:
    • The nerve on the right and on the left side:
      • Delivers branches that supply the trachea and the esophagus
  • The morphologic appearance and course of the recurrent laryngeal nerve:
    • Are subject to great anatomic variability
  • In addition, it may often be overlooked:
    • That the nerve most frequently does not consist only of a single trunk but exhibits a network of smaller branches
  • On the right side:
    • It usually loops around and behind the subclavian artery and then ascends into the neck in the tracheoesophageal groove:
      • To enter the larynx distal to the inferior cornu of the thyroid cartilage
    • In instances of embryologic malformation of the aortic arch:
      • In terms of retroesophageal right subclavian artery:
        • The nerve passes with a more median course directly to the larynx (non-recurrent laryngeal nerve):
          • Although the reported incidence of non-recurrent laryngeal nerve is less than 1%:
            • The surgeon has to be aware of the existence of this rare anatomic condition
  • The left recurent laryngeal nerve:
    • Courses upward around the ligamentum arteriosum and the aortic arch and runs vertically toward the tracheoesophageal groove:
      • On their way to the cricothyroid muscle where they enter the larynx
  • Both nerves run close to the capsule of the lateral aspect of the thyroid and cross the inferior thyroid artery:
    • Several variations of the relationship between the nerve and the artery, particularly on the right side, can be observed:
      • The nerve may pass superficially to the artery, deep to it, or between the branches of the vessel
  • After running into the laryngeal wall:
    • The nerve separates into two branches that supply the innervation of various laryngeal muscles:
      • A third branch that serves as a connection with the superior laryngeal nerve
  • During cervical exploration the recurrent laryngeal nerve can be exposed at different levels:
    • Caudally:
      • At the crossing with the common carotid artery
      • In the neighborhood of the inferior thyroid artery
    • Cranially:
      • At Berry’s ligament:
        • A dense condensation of the posterior thyroid capsule near the cricoid cartilage and upper tracheal rings
  • In addition to visual identification:
    • The nerve can be located by direct palpation of the tracheal wall below the lower thyroid pole
    • Considerable debate has long existed concerning the necessity of deliberate exposure of the recurrent laryngeal nerve during thyroid surgery:
      • Kocher commented on postoperative hoarseness and stated that:
        • Following his technique of thyroid dissection, injury to the nerve can with certainty be avoided without the direct exposure
      • The first surgeon who advocated routine dissection and demonstration of the nerves in 1911 was:
        • August Bier of Berlin
      • He was followed by Frank Lahey of Boston in 1938
      • Others advocated that exposure itself:
        • Is a risk due to potential induction of local edema by dissection of adjacent tissues and hemorrhage
      • Following these initial experiences, several studies revealed that depending upon the skill of an individual surgeon principal identification of the nerve reduces the risk of permanent laryngeal nerve injuries from over 5% to less than 1%
      • Nowadays, the practice of visual identification of the nerve represents the gold standard
      • To alleviate the visual identification of the nerve and to provide an intraoperative tool to prove its functional integrity, diverse monitoring methods, i.e., intramuscular vocal cord electrodes inserted either through the cricothyroid membrane or placed endoscopically, endotracheal tube surface electrodes, endoscopic visualization of the vocal cords in combination with nerve stimulation, and palpation of the cricoarytenoid muscle with simultaneous neural stimulation, have been developed
      • Although intraoperative neuromonitoring might be of use in the presence of extended thyroid surgery, particularly in a patient with a preoperatively documented vocal cord paralysis or in difficult anatomic situations:
        • It does not further reduce the low risk of permanent recurrent nerve lesions and it fails to reliably predict the outcome:
          • This experience has been found not only in primary but also in reoperative thyroid and parathyroid procedures
    • Damage to the recurrent laryngeal nerve may be caused by different mechanisms:
      • Cutting
      • Clamping
      • Stretching of the nerve
      • Nerve skeletonization
      • Local compression of the nerve:
        • Due to edema or hematoma
      • Thermal injury by electrocoagulation
  • Transient cord paresis:
    • Which is often caused by edema or axon damage by excessive nerve stretching:
      • Seldom lasts more than 4 to 6 weeks
  • When no restitution of function is notable within 6 to 12 months postoperatively:
    • Permanent damage should be assumed
  • Accidental injury to the recurrent laryngeal nerve is not recognized during surgery in most of the cases:
    • If the surgeon is aware of this complication intraoperatively:
      • Primarily repair of the nerve using microsurgical techniques and epineural sutures or a cable graftfrom the greater auricular nerve can be attempted
      • Even if the nerve is reanastomosed, the dysfunctioning vocal cord will probably never completely recover
      • Delayed nerve repairs are virtually always ineffective in restoring cord function
    • When a paralyzed vocal cord stays in the paramedian position:
      • The patients frequently remain asymptomatic:
        • This phenomenon is due to compensatory overadduction of the intact cord and consecutive constriction of the glottic chink
      • The majority of asymptomatic patients need no special treatment but close observation
    • Unless routine indirect laryngoscopy or videostroboscopy is performed:
      • Many cases of vocal cord paresis will remain unrecognized
    • The some authors recommend preoperative and postoperative laryngoscopic examination of the vocal cord function:
      • Not only for medicolegal reasons but also to document potential preexisting pathologies and consecutively adapt the surgical approach
    • If the paretic cord moves to the lateralized position:
      • Hoarseness or aspiration can occur
        • The prognosis considering gain of normal function is favorable in cases of delayed onset of symptoms:
          • In symptomatic patients either treatment by a speech and language pathologist or invasive interventions such as injection laryngoplasty or medialization laryngoplasty are necessary
• References:
  • Beldi G, Kinsbergen T, Schlumpf R (2004) Evaluation of intraoperative recurrent nerve monitoring in thyroid surgery. World J Surg 28:589–591 
  • Hermann M, Hellebart C, Freissmuth M (2004) Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg 240:9–17
  • Dralle H, et al (2004) Risk factors of paralysis and func- tional outcome after recurrent laryngeal nerve monitoring in thyroid surgery. Surgery 136:1310–1322 

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #ParathyroidSurgeon #HeadandNeckSurgeon #CancerSurgeon #RecurrentLaryngealNerveInjury

Bleeding Post Thyroidectomy

• The incidence of symptomatic hemorrhage:
  • Requiring reintervention amounts to 0.1% to 1.5%
• Post-operative bleeding will characteristically be prefaced by:
  • Respiratory distress
  • Pain
  • Cervical pressure
  • Dysphagia
  • Increased blood drainage
• No specific perioperative risk factors:
  • That would allow identification of the high-risk patient population for this potentially lethal complication are known
• High surgical volume:
  • Does not reduce the incidence of hematoma formation:
    • Consequently, the key issue of prevention is:
      • Attention to anatomic detail and careful hemostasis during surgery
• If the surgeon is uncertain about the dryness of the operative field:
  • A Valsalva maneuver:
    • Which elevates the intrapulmonary pressure to 40 cm H20:
      • Facilitates recognition of bleeding vessels:
        • Can be performed prior to wound closure
• Routine use of suction drains:
  • Does not prevent postoperative cervical bleeding
• In the majority of patients, symptomatic hemorrhage:
  • Occurs between 6 and 12 hours after the initial operation
• Since in approximately 20% of cases the onset of hematoma symptoms:
  • Is reported beyond 24 hours postoperatively:
    • Ambulatory surgery with a 4- to 8-hour observation period might harbor risk of delayed intervention
• Once recognized:
  • The wound should be deliberately re-opened, and the hematoma evacuated
• In case of significant respiratory distress:
  • Emergency bedside hematoma evacuation, if necessary, in combination with endotracheal intubation, is required
  • The requirement for tracheotomy either in the emergency setting or due to persisting airway obstruction after hematoma removal is generally a rare event
• Reference:
  • Burkey SH, et al (2001) Reexploration for symptomatic he- matomas after cervical exploration. Surgery 130:914–920 

Neck Edema Following Thyroidectomy

• Laryngotracheal edema:
  • Can be a cause of respiratory obstruction after extensive thyroid surgery
• After bilateral lymphadenectomy:
  • Disturbances of lymphatic flow may be the cause of edema
• Pharyngolaryngeal edema:
  • Is a well-recognized complication caused by the endotracheal tube or laryngeal mask and can also occur in association with an anaphylactoid reaction
    • Steroid therapy, occasionally in combination with temporary reintubation:
      • Leads to rapid relief
• References:
  • Lacoste L, et al (1993) Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 102:441–446 

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #ThyroidComplications #HeadandNeckSurgeon #CancerSurgeon

• Wound infections, usually caused by Staphylococcus or Streptococcus species are considered to be rare events in thyroid surgery:
  • Occurring in 0.3% to 0.8% of cases
• Antibiotic prophylaxis:
  • Is recommended only in immunocompromised patients or in those with valvular cardiac disorders
• While mild neck cellulitis frequently regresses under conservative treatment:
  • Abscesses require rapid incision and evacuation:
    • Delay of invasive treatment can result in devastating mediastinitis
• Clinically evident seromas:
  • Respond well to percutaneous aspiration
• References:
  • Sosa JA, et al (1998) The importance of surgeon experience for clinical and economic outcomes from thyroidectomy. Ann Surg 228:320–330
  • Rosato L, et al (2004) Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients oper- ated on in Italy over 5 years. World J Surg 28:271–276

#Arrangoiz #ThyroidSurgeon #HeadandNeckSurgeon #CancerSurgeon #SurgicalOncologist #ThyroidCancer #ThyroidInfection #SurgicalSiteInfection

• Factors associated with increased contralateral breast cancer risks include:
  • Genetic mutations:
    • Such as:
      • BRCA1 mutations
      • BRCA 2 mutations
      • Chek2 mutations
      • Atm mutations
      • Palb2 mutations
  • History of mantle radiation
  • First-degree relative with breast cancer
  • Young age at diagnosis
  • Hormone negative disease
• To consider contralateral prophylactic mastectomy (CPM):
  • The disease burden of the primary tumor needs to be lower than the risk of contralateral breast cancer
• For an average risk patient:
  • Contralateral cancer risk ranges from 1% to 5%
• Markov models for stage 1 and 2 breast cancer patients:
  • Showed overall survival benefit of less than 1% in patients who had CPM
• CPM may offer a survival advantage for:
  • Women less than 50 years of age who are diagnosed with triple negative breast cancer

• References
  • Deshmukh AA, Cantor SB, Crosby MA, Dong W, Shen Y, Bedrosian I, et al. Cost of contralateral prophylactic mastectomy. Ann Surg Oncol. 2014;21(9):2823-2830.
  • Roberts A, Habibi M, Frick KD. Cost-effectiveness of contralateral prophylactic mastectomy for prevention of contralateral breast cancer. Ann Surg Oncol. 2014;21(7):2209-2217.
  • Frost MH, Hoskin TL, Hartmann LC, Degnim AC, Johnson JL, Boughey JC. Contralateral prophylactic mastectomy: long-term consistency of satisfaction and adverse effects and the significance of informed decision-making, quality of life, and personality traits. Ann Surg Oncol. 2011;18(11):3110-3116.
  • Barton MB, West CN, Liu IL, Harris EL, Rolnick SJ, Elmore JG, et al. Complications following bilateral prophylactic mastectomy. J Natl Cancer Inst Monogr. 2005;(35):61-66.
  • Grann VR, Jacobson JS, Whang W, Hershman D, Heitjan DF, Antman KH, et al. Prevention with tamoxifen or other hormones versus prophylactic surgery in BRCA1/2-positive women: a decision analysis. Cancer J Sci Am. 2000;6(1):13-20.
  • Portschy PR, Kuntz KM, Tuttle TM. Survival outcomes after contralateral prophylactic mastectomy: a decision analysis. J Natl Cancer Inst. 2014;106(8).

• Once a patient undergoes breast-conserving surgery:
  • The pathology report is reviewed to determine any need for additional surgery
  • If the sentinel node biopsy was negative:
    • No additional axillary surgery is warranted
  • Margins assessed next:
    • Historically, the definition of what was considered an adequate margin in patients undergoing breast-conserving surgery was left to the interpretation of the treating physicians
    • In 2013, the Society of Surgical Oncology and the American Society for Radiation Oncology released consensus guidelines to assist physicians and patients in decisions regarding margins:
      • These guidelines were based on:
        • A meta-analysis of 33 studies evaluating in-breast tumor recurrence (IBTR) in relation to margin width
      • The results of the meta-analysis reported:
        • Positive margins were associated with 2-fold risk of IBTR:
          • Routine re-excision is recommended for those patients
        • For those with negative margins (defined as “no ink on tumor”), the meta-analysis reported that:
          • Increasing margin widths were not associated with a reduction in IBTR.
  • Is the patient a candidate for adjuvant therapy?
    • The 21-gene recurrence assay:
      • Has been shown to accurately predict risk of distant recurrence and benefit of adjuvant chemotherapy:
        • In women with ER positive tumors
    • Adjuvant chemotherapy is a category 1 recommendation for women with:
      • ER negative tumors greater than 1 cm
  • Does this patient need genetic studies?
    • The incidence of BRCA mutations in women with triple negative breast cancers:
      • Ranges in the literature from 10% to 31%
    • Current guidelines state that women who present with triple negative histology prior to age 60 should be considered for testing

• References
  • Moran MS, Schnitt SJ, Giuliano AE, Harris JR, Khan SA, Horton J, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole breast irradiation in Stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88(3):553–564.
  • Breast Cancer (version 1.2018). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed October 18, 2019.
  • Greenup R, Buchanan A, Lorizio W, Rhoads K, Chan S, Leedom T, et al. Prevalence of BRCA mutations among women with triple negative breast cancer in a genetic counseling cohort. Ann Surg Oncol. 2013;20:3254-3258.
  • Genetic/Familial High Risk Assessment: Breast and Ovarian (version 2.2019). National Comprehensive Cancer Network website. https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf. Accessed October 18, 2019.

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