Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

REFERENCES

1. Ernster VL, Ballard-Barbash R, Barlow WE, et al. Detection of ductal carcinoma in situ in women undergoing screening mammography. J Natl Cancer Inst. 2002;94:1546-1554. http://www.ncbi.nlm.nih.gov/pubmed/12381707
2. Kuerer HM, Albarracin CT, Yang WT, et al. Ductal carcinoma in situ: state of the science and roadmap to advance the field. J Clin Oncol. 2009;27:279-288. http://www.ncbi.nlm.nih.gov/pubmed/19064970
3. NSABP B-43: Radiation therapy with or without trastuzumab in treating women with ductal carcinoma in situ who have undergone lumpectomy. https://clinicaltrials.gov/ct2/show/NCT00769379
4. Siziopikou KP, Anderson SJ, Cobleigh MA, et al. Preliminary results of centralized HER2 testing in ductal carcinoma in situ (DCIS): NSABP B-43. Breast Cancer Res Treat. 2013;142:415-421. doi: 10.1007/s10549-013-2755-z. Epub 2013 Nov 8. http://www.ncbi.nlm.nih.gov/pubmed/24202240

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉Magnetic resonance imaging is more sensitive than mammography in detecting breast cancers, especially in dense breasts, although it suffers from low specificity.

👉This results in additional biopsies of lesions seen on MRI that were not visualized by mammogram or ultrasound.

👉In one study of patients who underwent preoperative MRI, 12% of the subjects required additional biopsies, and 25% of these were malignant (the vastm majorty were benign lesions).

👉The prospective Comparative Effectiveness of MRI in Breast Cancer (COMICE) trial randomized 1623 women with breast cancer who were considered appropriate breast conservation candidates to either undergo preoperative MRI or to proceed to surgery with no further imaging.

👉The study showed that patients were more likely to undergo mastectomy as the first operation if they had a preoperative MRI (7%) versus those who did not (1%).

👉Re-excision rates following partial mastectomy were the same in the two groups (10% vs 11%).

👉These results have been replicated by the MR mammography of nonpalpable breast tumours (MONET) trial as well as several retrospective reviews.

👉Some single-institution trials have shown that MRI can identify contralateral cancers in patients with breast cancer.

👉However, many of these contralateral lesions are ductal carcinoma in situ or small, low-grade neoplasms.

👉The fact that the rate of contralateral cancers discovered by MRI is higher than the rate of development of a second contralateral cancer leads to the question of whether these cancers are clinically relevant or whether systemic chemotherapy and endocrine therapy given for the primary tumor may treat this occult neoplasm.

👉There are mixed data as to whether MRI decreases the rate of contralateral breast cancer after patients are treated for their primary cancer.

👉To date, no studies have shown that MRI improves survival.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉The results of the ACOSOG Z0011 clearly demonstrate that patients with one to two positive sentinel lymph nodes who undergo a breast-conserving operation followed by whole breast radiation can safely forego completion ALND.

👉Patients treated with mastectomy were not included in this trial, and applicability of the Z0011 results to these patients has not been established.

👉A retrospective review examined the outcomes in a series of patients with a positive SLNB undergoing mastectomy who received no further axillary treatment.

👉Axillary recurrence rates were compared in 210 patients treated with total mastectomy and 325 patients treated with breast conservation with a positive SLNB who did not undergo ALND between 1997 and 2009.

👉The patients treated with total mastectomy were on average younger and had larger tumors than the patients who underwent breast-conserving operations.

👉Ninety-four percent of the breast conservation group and 5% of the total mastectomy group underwent postmastectomy radiation.

👉At 4 years, three patients in the mastectomy group (1%) and three patients in the breast conservation group (1%) had an axillary recurrence.

👉The authors concluded that early-stage breast cancer patients with minimal nodal disease who undergo mastectomy experience excellent outcomes without ALND.

👉Another recent report followed 58 highly selected node-positive mastectomy patients who did not undergo ALND or nodal radiation.

👉At a median follow-up of 5.5 years, two of the 58 patients (3.4%) developed regional recurrence, with only one axillary recurrence.

👉The conclusions of both studies are limited by the small numbers of patients with macrometastatic lymph node disease.

👉A study in the Netherlands (BOOG 2013-07) seeks to determine whether completion axillary treatment can be safely omitted in sentinel lymph node–positive breast cancer patients treated with mastectomy.

👉T1-T2, clinically node-negative patients are randomized following mastectomy to no further axillary-specific treatment, radiation, or completion ALND.

👉The results should help clarify the role of ALND in these patients.

👉ASCO guidelines currently do not recommend SLNB alone for mastectomy patients with a positive SLNB.

👉Rodrigo Arrangoiz MS, MD, FACS cirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉Pathologic features taken into account in American Joint Committee on Cancer (AJCC) and the American Thyroid Association (ATA) systems include aggressive histologic variants of papillary thyroid cancer (PTC), gross extra thyroid extension (ETE), angioinvasion, lymph node metastasis, extra nodal extension (ENE), and genetics.

👉As most DTC is indolent, identification and reporting of key features may facilitate more aggressive treatment for patients at high risk, spare patients at lower risk, and provide more accurate risk expectations for patients.

Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello y cirugía endocrina de Sociedad Quirúrgica S.C. es experto en el manejo de nódulos tiroides y del cáncer de tiroides.

Articulo publicado por el Dr. Arrangoiz sobre el manejo de nódulos tiroides:

https://file.scirp.org/pdf/IJOHNS_2018072717023407.pdf

Es pionero en México:

• Cirugia tiroidea minimamente invasiva
• La cirugia minimamente invasiva radio-guiada de paratiroides

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

http://www.sociedadquirurgica.com

http://www.hiperparatiroidismo.info

http://www.cirugiatiroides.com

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

• In the last 10 years there has been a significant focus on the role of contralateral prophylactic mastectomy and the risk of contralateral breast cancer.
• Single-institution studies and SEER data:
  • Have found contralateral prophylactic mastectomy rates:
    • To be as high as 25%:
      • And continue to increase:
        • Further, this trend seems to be limited to the United States
• Nichols et al:
  • Reviewed the rates of contralateral breast cancer using the SEER database between 1976 and 2006:
    • Overall, they found the rate of contralateral breast cancer to be declining:
      • Approximately 3% per year since 1985
    • From 1990 forward:
      • They found this benefit to be restricted to those>
        • Presenting with an ER-positive breast cancer>
          • With annual incidence rates of contralateral breast cancer of 0.25% to 0.37% when the index cancer was diagnosed after age 30 years
      • The rates of contralateral breast cancer were higher in patients with ER-negative breast cancers:
        • But still remained reasonably low:
          • With annual incidence rates of contralateral breast cancer of:
            • 0.45% to 0.65% when the index cancer was diagnosed after age 40 years
• Contralateral prophylactic mastectomy is attributed with approximately a:
  • 90% to 94% overall reduction in the risk of contralateral breast cancer:
    • Not 100%
  • Contralateral prophylactic mastectomy does not improve overall survival:
    • Recent modeling suggests:
      • The added absolute benefit of contralateral prophylactic mastectomy to overall survival:
        • Is less than 1.45%

👉Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del patología de mama:

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

https://www.generalsurgerynews.com/In-the-News/Article/10-19/Surgeon-Reviews-Top-Breast-Cancer-Papers-of-2018/56184?sub=D05FEDE8A93BD6EED7F5E1777D724E7E32628044E96C5A21A5E3B0BFE3BD1AA2&enl=true&dgid=&utm_source=enl&utm_content=1&utm_campaign=20191107&utm_medium=button

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉JAMA Surg. Published online November 6, 2019. doi:10.1001/jamasurg.2019.4613

👉Although neoadjuvant chemotherapy (NAC) can decrease the size of a primary tumor to allow for breast conservation, eliminate nodal metastasis in some patients, and provide prognostic information, the optimal timing of SLNB for patients treated with NAC has been controversial.

👉Clinical staging of the axilla with SLNB is feasible both before and after chemotherapy.

👉SLNB prior to NAC may be a more accurate approach than after NAC.

👉Chemotherapy may alter lymphatic drainage through fibrosis of lymphatic channels and decreases the accuracy of SLNB.

👉SLNB before NAC has a lower false negative rate and provides more accurate staging, which could determine radiation fields.

👉Unfortunately, SLNB prior to NAC requires an additional operation, could delay the initiation of chemotherapy, and fails to decrease the rate of ALND.

👉It also eliminates prognostic information given by the effect of chemotherapy on axillary metastasis. Ç

👉These concerns have led to interest in performing SLNB after NAC.

👉Several recent prospective trials have examined the accuracy of SLNB after NAC.

👉The American College of Surgeons Oncology Group (ACOSOG) Z1071 enrolled women with cT0 to cT4, cN1 to cN2 clinical disease who underwent neoadjuvant chemotherapy.

👉 All patients underwent pre-NAC axillary needle biopsy.

👉41% of patients had a pathologic complete response (PCR) in the axilla.

👉After chemotherapy, patients underwent both SLNB and ALND.

👉A sentinel lymph node could not be identified in 7% of patients.

👉The overall false negative rate was 13%, which did not meet the preset target of 10%.

👉The false negative rate was 21% in patients with two or fewer sentinel lymph nodes identified but dropped to 9.1% when greater than three sentinel lymph nodes were sampled.

👉In the Sentinel Lymph Node Biopsy in Patients with Breast Cancer Before and After Neoadjuvant Chemotherapy (SENTINA) trial, 1,022 patients underwent SLNB before NAC, with a detection rate of 99%.

👉For patients who were evaluated after NAC and converted from cN+ to ycN0, the sentinel lymph node detection rate was only 80%, with a false negative rate of 14.2%.

👉As seen in ACOSOG Z1071, the false negative rate was much higher in patients with only one node removed (24%) than in those with three or more sentinel nodes removed (7%).

👉The false negative rate was also improved by the use of radiocolloid and blue dye together compared with blue dye alone (false negative rate of 9% versus 16%).

👉The Sentinel Node Biopsy following NeoAdjuvant Chemotherapy (SN FNAC) study enrolled patients with cT0 to cT3 with cN1 to cN2 biopsy-proven breast cancer treated with NAC.

👉Following chemotherapy, patients underwent clinical and ultrasound examination followed by SLNB and completion ALND.

👉The overall post-NAC SLNB false negative rate was 8% in 153 patients.

👉When only one sentinel lymph node was evaluated, the false negative rate was again unacceptably high at 20%.

👉On the basis of these three trials, resecting only one sentinel node is associated with an unacceptably high false negative rate (between 22% to 24%).

👉The false negative rate after NAC may be lowered with the use of dual tracers (from 16% to 9%) and resecting three or more sentinel nodes.

👉Placing clips in positive lymph nodes before chemotherapy decreases the false negative rate if the clipped node is then resected during SLNB.

👉The sentinel lymph node identification rate after NAC is significantly improved with increased surgeon experience, suggesting that a learning curve is needed to obtain accurate SLNB after NAC.

👉SLNB after NAC has the potential to decrease the number of women who receive ALND.

👉A study of 288 prospectively identified clinically node-positive patients reported that 132 became clinically node negative after NAC.

👉The clinically node-negative patients were then eligible for SLNB, and 48% had negative sentinel lymph nodes and were able to avoid an ALND.

👉Current ASCO recommendations state that SLNB should be offered to patients who have received preoperative neoadjuvant systemic therapy and have clinically negative lymph nodes.

👉However, no large studies have examined local recurrence rates or survival when ALND is omitted in patients who convert from node positive to node negative after NAC.

👉The safety of avoiding ALND in these patients has not been demonstrated.

👉The National Surgical Adjuvant Breast and Bowel Project (NSABP) B51 and Alliance A011202 are two sister studies examining the role of SLNB, ALND, and nodal radiation in patients who receive NAC.

👉The results of these trials will help identify patients who can safely avoid ALND after NAC.

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉Prophylactic mastectomy rates are rapidly rising in the United States.

👉Prophylactic mastectomy may be associated with a 3.5 to 5% occurrence of occult carcinoma depending on the indication for the operation.

👉 SLNB at the time of prophylactic mastectomy may eliminate the need for axillary lymph node dissection (ALND) if occult disease is identified.

👉A recent meta-analysis reviewed 14 studies where SLNB was routinely performed for prophylactic mastectomy in patients undergoing bilateral mastectomy for unilateral cancer.

👉This study found metastatic disease in the SLNB of the prophylactic mastectomy in 0% to 4% of patients with contralateral cancer.

👉The majority of metastatic disease was associated with contralateral axillary tumor spread from the primary tumor, not an occult primary tumor.

👉In patients who were found to have occult malignancy in the prophylactic mastectomy breast, less than 1% of sentinel lymph nodes were positive for metastatic disease.

👉Given the low rates of occult malignancy and axillary metastasis, SLNB is not indicated for patients undergoing prophylactic mastectomy.

Rodrigo Arrangoiz MS, MD, FACScirujano oncology y miembro de Sociedad Quirúrgica S.C en el America British Cowdray Medical Center en la ciudad de Mexico:

• Es experto en el manejo del cáncer de mama.

Training:

• General surgery:

• Michigan State University:

• 2004 al 2010

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• Fox Chase Cancer Center (Filadelfia):

• 2010 al 2012

• Masters in Science (Clinical research for health professionals):

• Drexel University (Filadelfia):

• 2010 al 2012

• Surgical Oncology / Head and Neck Surgery / Endocrine Surgery:

• IFHNOS / Memorial Sloan Kettering Cancer Center:

• 2014 al 2016

#Arrangoiz

#Surgeon

#Cirujano

#SurgicalOncologist

#CirujanoOncologo

#BreastSurgeon

#CirujanodeMama

#CancerSurgeon

#CirujanodeCancer

👉In this issue of JAMA Surgery, Benmiloud et provide evidence that the common and harmful complication of early postoperative hypocalcemia may be reduced with this new technique.

👉The primary aim of the study, was to see post operative hypocalcemia may be reduced by using the fluorescent properties of the parathyroid glands intraoperatively.

👉Although some important data are not reported in the study, particularly concerning how and by whom the patients were followed up, the completeness of follow-up, and biochemical data with blood levels of calcium and parathyroid hormone at 6 months, the results suggest that the concept of parathyroid autofluorescence can be used to reduce early postoperative hypocalcemia.

👉If these results are reproduced by other centers in randomized clinical trials with other devices, and for long-term hypoparathyroidism, this will represent a substantial improvement in the quality of thyroid surgery.

Commentary: New Technique to Reduce the Risk For Hypocalcemia in Thyroid Surgery https://ja.ma/2ClR5CO