Faculty Bibliography

Introduction: Ductal carcinoma in situ (DCIS) and invasive breast cancer have long been viewed as representing two points on the spectrum of one disease. A recent study published by Narod et al. found that women diagnosed with DCIS who developed an invasive recurrence were 18.1 times more likely to die of breast cancer than women who did not. In light of this controversial topic, we investigated DCIS in a contemporary cohort of newly diagnosed women at our institution spanning a five year period. Methods: The institutional Breast Cancer Database was queried for all women with newly diagnosed breast cancer from 2010-2015. Variables included age, race, body mass index (BMI), risk factors, tumor characteristics and outcomes. Statistical analyses included Pearson's Chi Square and Fisher's Exact Tests. Results: Out of a total of 2190 patients, 475 (22%) had pure DCIS while 1715 (78%) had invasive cancer. The median follow up was 3 years. The median age was 59 years (range 22-95). Of the patients with invasive cancer, 36 (2%) had any recurrence. Similarly, of the patients with DCIS, 9 (2%) developed recurrent disease (ipsilateral or contralateral), with 4 patients diagnosed with invasive recurrence (44%). Of the 36 recurrences in patients with invasive cancer, 33% presented with chest wall or distant metastasis. Patients with pure DCIS had a slightly higher proportion of African Americans and Hispanics (11% v. 8%) and higher proportion of women with BMI>30 who developed an invasive recurrence (78% v. 50%). All recurrences in the pure DCIS cohort were detected by routine screening surveillance, with a majority detected by mammography (89%). Conclusions: Within a relatively short follow up period, we found that the rates of in-breast recurrences were the same in women with pure DCIS compared to women with invasive breast cancer. Also, 44% of women developed invasive breast cancer recurrence after an initial DCIS diagnosis, potentially altering their long term survival. These findings suggest that women with all breast cancers, including DCIS, requires intensive surveillance after initial treatment, as consequences of delayed diagnosis may impact on their long term survival

BACKGROUND: Despite current advances in cancer treatment, many breast cancer survivors still face long-term post-operative challenges as a result of suffering from daily pain and other distressing symptoms related to lymphedema, ie, abnormal accumulation of lymph fluid in the ipsilateral upper limb or body. Grounded in research-driven behavioral strategies, The-Optimal-Lymph-Flow is a unique Web- and mobile-based system focusing on self-care strategies to empower, rather than inhibit, how breast cancer survivors manage daily pain and symptoms. It features a set of safe, feasible, and easily-integrated-into-daily-routine exercises to promote lymph flow and drainage, as well as guidance to maintain an optimal body mass index (BMI). OBJECTIVE: To conduct a randomized clinical trial (RCT) to evaluate the efficacy of the Web- and mobile-based The-Optimal-Lymph-Flow system for managing chronic pain and symptoms related to lymphedema. The primary outcome includes pain reduction, and the secondary outcomes focus on symptom relief, limb volume difference by infra-red perometer, BMI, and quality of life (QOL) related to pain. We hypothesize that participants in the intervention group will have improved pain and symptom experiences, limb volume difference, body mass index, and QOL. METHODS: A parallel RCT with a control-experimental, pre- and post-test, repeated-measures design is used in this study. A total of 120 patients will be randomized according to the occurrence of pain. Participants will be recruited face-to-face at the point of care during clinical visits. Participants in the intervention group will receive the Web- and mobile-based The-Optimal-Lymph-Flow intervention and will have access to and learn about the program during the first in-person research visit. Participants in the control group will receive the Web- and mobile-based Arm Precaution program and will have access to and learn about the program during the first in-person research visit. Participants will be encouraged to enhance their learning by accessing the program and following the daily exercises during the study period. Participants will have monthly online self-report of pain and symptoms at 4 and 8 weeks post-intervention. During the two in-person research visits prior to and 12 weeks post-intervention, participants will be measured for limb volume difference, BMI, and complete self-report of pain, symptoms, self-care behaviors, and QOL. RESULTS: This trial is currently open for recruitment. The anticipated completion date for the study is July 2017. The primary endpoint for the study is absence or reduction of pain reported by the participants at week 12 post-intervention. CONCLUSIONS: The-Optimal-Lymph-Flow is a unique Web- and mobile-based self-care and patient-reported outcome system designed to effectively help women treated for breast cancer manage daily pain and symptoms related to lymphedema. Patients learn self-care strategies from a Web- and mobile-based program and track their symptoms. The RCT will directly benefit all women treated for breast cancer who suffer from or at risk for pain and symptoms related to lymph fluid accumulation. TRIAL REGISTRATION: Clinicaltrials.gov NCT02462226; https://clinicaltrials.gov/ct2/show/NCT02462226 (Archived by WebCite at http://www.webcitation.org/6du4IupG5).

INTRODUCTION: Long-term oncologic outcomes in nipple-sparing mastectomy (NSM) continue to be defined. Rates of locoregional recurrence for skin-sparing mastectomy (SSM) and NSM in the literature range from 0% to 14.3%. We investigated the outcomes of NSM at our institution. METHODS: Patients undergoing NSM at our institution from 2006 to 2014 were identified and outcomes were analyzed. RESULTS: From 2006 to 2014, 319 patients (555 breasts) underwent NSM. One-hundered and fourty-one patients (237 breasts) had long-term follow-up available. Average patient age and BMI were 47.78 and 24.63. Eighty-four percent of patients underwent mastectomy primarily for a therapeutic indication. Average tumor size was 1.50 cm with the most common histologic type being invasive ductal carcinoma (62.7%) followed by DCIS (23.7%). Average patient follow-up was 30.73 months. There was one (0.8%) incidence of ipsilateral chest-wall recurrence. There were 0.37 complications per patient. CONCLUSIONS: We examined our institutional outcomes with NSM and found a locoregional recurrence rate of 0.8% with no nipple-areolar complex recurrence. This rate is lower than published rates for both NSM and SSM. J. Surg. Oncol. (c) 2015 Wiley Periodicals, Inc.

Use of nipple-sparing mastectomy (NSM) for risk-reduction and therapeutic breast cancer resection is growing. The role for intraoperative frozen section of the nipple-areolar complex remains controversial. Records of patients undergoing NSM at our institution from 2006 to 2013 were reviewed. Records from 501 nipple-sparing mastectomies were reviewed (216 therapeutic, 285 prophylactic). Of the 480 breasts with sub-areolar biopsies, 307 had intraoperative frozen sections and 173 were evaluated with permanent paraffin section only. Among the 307 intraoperative frozen sections, 12 biopsies were positive on permanent paraffin section (3.9% or 12/307). Of the 12 positive permanent biopsies, five were false negative and the remaining seven concordant intraoperatively. Sensitivity and specificity of sub-areolar frozen section were 0.58 and 1, respectively. Positive sub-areolar biopsies consisted primarily of ductal carcinoma in situ (62% or 13/21). The nipples or nipple-areolar complex were resected in a separate procedure following mastectomy (10/21), intraoperatively following frozen section results (7/21) or during second-stage breast reconstruction (3/21; 1 additional scheduled). Only 30% (6/20) of resected specimens had abnormal residual pathology. Intraoperative frozen section is highly specific and moderately sensitive for the detection of positive sub-areolar biopsies in NSM. Its use can help guide intraoperative reconstructive planning. The presence of positive sub-areolar biopsies in both contralateral and high-risk prophylactic mastectomy specimens emphasizes the need to perform sub-areolar biopsies in all nipple-sparing mastectomies.

Background: Current methods for intraoperative assessment of lumpectomy margins are limited, and a meaningful proportion of patients require re-excision to achieve acceptable margins. There is little available information regarding the relationship of mammographic breast density (BD) and positive margin rate. Methods: The MarginProbe device uses radiofrequency spectroscopy to evaluate the margins of lumpectomy specimens. The current study utilized data from the MarginProbe Pivotal Trial (Dune Medical Devices, Israel, NCT00749931 ). This randomized clinical trial compared adjunctive intraoperative use of the MarginProbe device with surgeons' standard approach to lumpectomy surgery. For the current analysis, data was compiled from the period prior to patient randomization and device use. Variables of interest included BD, patient and tumor characteristics, and the margin status of the main lumpectomy specimen (prior to device use in the device arm). For the purpose of this analysis, a positive margin was considered tumor on ink. Statistical analysis was performed with univariate and multivariate analysis, and linear/logistic regression. Results: A total of 664 patients were enrolled in the trial. 450 patients had preoperative breast density information available, and formed the basis for this analysis. As expected, higher BD was associated with younger age, lower BMI and smaller breast and specimen volume. Increased BD was also associated with increased use of preoperative MRI imaging (odds ratio 2.2, p<0.0001). Higher BD was also associated with a significant increase in main lumpectomy specimen positive margin rate (Table). The odds ratio was 1.46 per change in density category (p=0.011). BD remained significantly associated with positive margins after controlling for age, BMI and breast volume. Conclusions: Higher BD is an independent risk factor for positive margins in main lumpectomy specimens, suggesting that adjunctive methods for intraoperative margin assessment may be particularly helpful in these patients. (table present)

PURPOSE: To evaluate the relationship between mammographic breast density (MBD), background parenchymal enhancement (BPE), and fibroglandular tissue (FGT) in women with breast cancer (BC) and at high risk for developing BC. METHODS: Our institutional database was queried for patients who underwent mammography and MRI. RESULTS: Four hundred three (85%) had BC and 72 (15%) were at high risk. MBD (P=.0005), BPE (P<.0001), and FGT (P=.02) were all higher in high-risk women compared to the BC group. CONCLUSIONS: Higher levels of MBD, BPE and FGT are seen in women at higher risk for developing BC when compared to women with BC.