Faculty Bibliography

Current guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS). We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. Patients were divided according to final pathology (DCIS or invasive cancer). Clinico-pathologic variables were analyzed using Pearson's chi-squared, Wilcoxon Rank-Sum and logistic regression. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P = .0289), palpability (P < .0001), extent of disease on imaging (P = .0121), mass on preoperative imaging (P = .0003), multifocality (P = .0231) and multicentricity (P = .0395). In multivariate analysis, palpability (P = .0080), extent of disease on imaging (P = .0074) and mass on preoperative imaging (P = .0245) remained significant (Table 2). In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.

Pregnancy-associated breast cancer (PABC) refers to breast cancer (BC) diagnosed during pregnancy, lactation, or in the postpartum period. There is evidence that PABC is associated with a poorer prognosis, and that the development of the disease is influenced by the unique hormonal milieu of pregnancy. The purpose of this study was to investigate the clinicopathologic characteristics associated with PABC in a contemporary cohort of women with newly diagnosed BC. Our institutional Breast Cancer Database was queried for women diagnosed with BC between 2009-2018 who had at least one full-term pregnancy (FTP). Variables of interest included patient demographics and clinical and tumor characteristics. PABC was defined as breast cancer diagnosed within 24 months of delivery. Statistical analyses included Pearson's chi-square and logistic regression. Out of a total of 2202 women, 46 (2.1%) had PABC. Median follow-up in the total cohort was 5.5 years. After adjusting for age at first FTP, PABC was associated with younger age at diagnosis, older age at first FTP, non-Caucasian race, BRCA positivity, presentation with a palpable mass, higher pathologic stage, higher histologic grade, and ER-negative and triple-negative receptor status. The association of PABC with non-Caucasian race may be reflected in the increased proportion of triple-negative breast cancers in the PABC group. PABC was also associated with older age at first FTP. As more women delay childbearing, risk for PABC may increase. Our findings suggest that women who become pregnant at older ages should be followed carefully during pregnancy and the postpartum period, especially if they are BRCA mutation carriers. The optimal approach for monitoring older women during pregnancy and the postpartum period is unclear.

This pilot, double-blind, randomized, placebo-controlled study is aimed at evaluating the effectiveness of low-level laser therapy (LLLT) as a complementary treatment to complete decongestive therapy (CDT) treating lymphedema among breast cancer patients for 12 months post-intervention. Study population was breast cancer patients who were diagnosed and referred to lymphedema clinic for CDT. Participants (n = 22) were randomized and assigned into either an active laser intervention group or an inactive laser placebo-control group. Active LLLT was administered to participants twice a week at the beginning of each CDT session. Outcome measures included lymphedema symptoms, symptom distress, and limb volume by an infrared perometer. Participants in the active and placebo laser groups were comparable in demographic and clinical predictors of lymphedema. In comparison with the placebo group (83.3%), significantly fewer participants in the active laser group (55.6%) reported more than one lymphedema symptom (p = 0.012) at 12 months post-intervention. Significantly, more patients in the active laser group (44.4%) reported less than two impaired limb mobility symptoms in comparison with the placebo group (33.3%) at 12 months post-intervention (p = 0.017). The active laser group had statistically significant improvements in symptom distress of sadness (p = 0.005) from 73 to 11% and self-perception (p = 0.030) from 36 to 0% over time from baseline to 12-months post-intervention. There was no significant reduction in limb volume. Findings of the trial demonstrated significant benefits of complementary LLLT for relieving symptoms and improvement of emotional distress in breast cancer patients with lymphedema.

Introduction The use of neoadjuvant chemotherapy (NAC) has enabled more patients to be eligible for breast-conservation surgery (BCS). Achieving negative lumpectomy margins, however, may be challenging after NAC due to changes in tissue density and the potential for residual carcinoma to be scattered in the tumor bed. Data regarding patients undergoing BCS after NAC has shown variable re-excision rates. MarginProbe (Dune Medical Devices Ltd, Israel) has been shown to identify positive resection margins intraoperatively and reduce the number of re-excisions in primary BCS, but has not been previously studied in NAC+BCS cases. The purpose of our study was to investigate the clinicopathologic characteristics, including margin status, and re-excision rates in patients who had NAC+BCS with and without the use of MarginProbe at our institution. Methods The Institutional Breast Cancer Database was queried for all patients who received NAC and had subsequent BCS from 2010-2019. Variables of interest included demographics, tumor characteristics, pathologic complete response (pCR), MarginProbe use, treatment and outcomes. Statistical methods included Chi-Square and Fisher's Exact tests. Results A total of 214 patients had NAC in our study population, and 61 (28.5%) of those patients had NAC+BCS. The median age was 53.5 years. A total of 19 (31.1%) patients had pCR. Of the remaining 42 patients, 9 (21%) had close or positive margins that required re-excision. Re-excision was associated with a larger residual tumor size (p=0.025), and ER-positive disease before NAC (p=0.041). Breast density and the presence of palpable disease did not differ between the groups. MarginProbe use was associated with a lower re-excision rate in patients with NAC+BCS (6% vs. 31%, respectively). Conclusion The use of NAC may enable more patients to undergo BCS. Patients with larger residual tumor burden and ER-positive disease were at an increased risk for inadequate margins at the time of surgery. The use of Margin-Probe was associated with a lower re-excision rate. Techniques to reduce the need for re-excision will support the use of BCS after NAC

Background/Objective: According to the US Census data, adoptees account for 2.5% of the US population (7.8 million). However, the number of adoptees diagnosed with breast cancer is unknown. Many adoptees face the unique challenge of lacking access to their family health history and limited access to screening and risk-reducing interventions. This important health disparity among adoptees has raised awareness in the importance genetic testing (GT), although it does not completely fill the disparity gap of lacking family history. The National Society of Genetic Counselors (NSGC) released an updated position statement in 2018 that supported the use of genetic testing, including genome-wide testing, for adopted adults. The purpose of our study was to investigate the adoptees in a cohort of newly diagnosed breast cancers and to look at the clinicopathologic characteristics, including the uptake of genetic testing, and to see if there were any differences compared to the non-adopted breast cancer patients.
Method(s): The Institutional Breast Cancer Database was queried for all patients diagnosed with breast cancer between 2010-2018. Variables of interest included adoption status and other clinical and tumor characteristics. Statistical analyses included descriptive and Pearson's Chi Square tests.
Result(s): Out of 3,507 patients newly diagnosed with breast cancer, 34 (1%) were adopted. The median age at diagnosis for the total population was 60 years (range 23-96 years). When we compared the adopted and non-adopted groups, age was not statistically different (p=0.817); race was not statistically different (p=0.077), although there was a slightly higher proportion of Hispanics in the adopted vs. non-adopted cohorts (15% vs. 6%). When we looked at genetic testing, 56% of the adoptees were tested compared to 45% of non-adopted patients, but this was not significant (p=0.229). All adopted patients were negative for BRCA1/2 and other mutations. Interestingly, 29% of the adopted patients had a first-degree relative with breast cancer compared to 31% of non-adopted patients. The tumor characteristics between the adopted and non-adopted cohorts were not statistically different. The majority had early stage (Stage 0, I, II) disease (93%), invasive ductal and lobular carcinoma (73%), and ER/PR-positive and HER2-negative cancers (71%).
Conclusion(s): In a contemporary cohort of newly diagnosed breast cancer patients, we found no difference between the adopted and non-adopted patients based on age, race, education, and tumor characteristics. However, there was a higher proportion of adopted patients who got genetic testing compared to the non-adopted cohort. Both groups also reported a similar proportion of having a first-degree relative with breast cancer, which indicates the increased communication between the adoptees and their biological parents

INTRODUCTION/BACKGROUND:Ductal carcinoma in situ (DCIS) with foci of invasion measuring ≤ 1 mm (DCISM), represents < 1% of all invasive breast cancers. Sentinel lymph node biopsy (SLNB) has been a standard component of surgery for patients with invasive carcinoma or extensive DCIS. We hypothesize that selective performance of SLNB may be appropriate given the low incidence of sentinel node (SN) metastasis for DCISM. We investigated the clinicopathologic predictors for SN positivity in DCISM, to identify which patients might benefit from SLNB. METHODS:A retrospective review of the National Cancer Database was performed for cases from 2012 to 2015. Clinical and tumor characteristics, including SN results, were evaluated, and Pearson's Chi square tests and logistic regression were performed. RESULTS:Of 7803 patients with DCISM, 306 (4%) had at least one positive SN. Patients with positive SNs were younger, more often of Black race, had higher-grade histology and larger tumor size, and were more likely to have lymphovascular invasion (LVI; all p < 0.001). In an adjusted model, the presence of LVI was associated with the highest odds ratio (OR) for node positivity (OR 8.80, 95% confidence interval 4.56-16.96). CONCLUSIONS:Among women with DCISM, only 4% had a positive SN. Node positivity was associated with more extensive and higher-grade DCIS, and the presence of LVI was strongly correlated with node positivity. Our data suggest that LVI is the most important factor in determining which patients with DCISM will benefit from SN biopsy.

BACKGROUND:Growing evidence suggests that the tumor immune microenvironment influences breast cancer development and prognosis. Density of tumor-infiltrating lymphocytes (TILs) within invasive breast cancer is correlated with response to therapy, especially in triple-negative disease. The clinical relevance and outcomes of TILs within ductal carcinoma in situ (DCIS) are less understood. METHODS:Our institutional database of 668 patients with pure DCIS from 2010 to 2018 was queried. TILs were evaluated by International TILs Working Group guidelines. Percentage of TILs was assessed from the densest focus (hotspot) in one high-power field of stroma touching the basement membrane. Statistical methods included cluster analyses (to define sparse versus dense TILs), logistic, and Cox regression models. RESULTS:Sixty-nine patients with DCIS and TILs were evaluated, of whom 54 (78%) were treated by breast-conserving surgery. Thirteen (19%) patients had ipsilateral recurrence. Each recurrence (n = 13) was matched to four controls (n = 56) based on date of surgery. Median follow-up was 6.7 years. TILs were defined as sparse (< 45%) or dense (≥ 45%). Dense TILs were associated with younger age (p = 0.045), larger tumor size (p < 0.001), high nuclear grade (p = 0.010), comedo histology (p = 0.033), necrosis (p = 0.027), estrogen receptor (ER) negativity (p = 0.037), and ipsilateral recurrence (p = 0.001). Nine patients with dense TILs had mean time to recurrence of 73.5 months compared with four patients with sparse TILs with mean time to recurrence of 97.9 months (p = 0.003). CONCLUSIONS:Dense TILs were significantly associated with age, tumor size, nuclear grade, comedo histology, necrosis, and ER status and was a significant predictor of recurrence in patients with pure DCIS.

BACKGROUND:Mammographic breast density (MBD) is an independent risk factor for breast cancer. Information regarding the relationship of MBD and breast cancer biology in women with ductal carcinoma in situ (DCIS) is currently lacking. This study aimed to examine the clinicopathologic characteristics of DCIS in women stratified by MBD. METHODS:A retrospective review was performed to identify women with pure DCIS who underwent preoperative mammography between 2010 and 2018. Clinicopathologic and demographic data were collected. For the purpose of analysis, MBD was categorized as "non-dense" (Breast Imaging-Reporting and Data System [BI-RADS] density categories A and B) or "dense" (BI-RADS C and D) according to its identification in radiology reports. RESULTS:Of 3227 patients with a breast cancer diagnosis enrolled in the institutional Breast Cancer Database during the study period, 658 (20%) had pure DCIS. Of these 658 patients, 42% had non-dense breasts, and 58% had dense breasts. Most lesions were non-palpable (92%) and detected by mammography (84%). Patients with dense breasts were more likely to be younger at the time of diagnosis (p < 0.001), premenopausal (p < 0.001), and Asian (p = 0.018), and to have higher-grade disease (p = 0.006; Table 2). Family history, BRCA status, parity, mammogram frequency, palpability, method of presentation, lesion size, hormone receptor status, comedo histology, and recurrence did not differ significantly between the two groups (Table 1). The median follow-up period was 7.1 years. CONCLUSION/CONCLUSIONS:Women with pure DCIS and higher MBD are more likely to be younger at the time of diagnosis, premenopausal, and Asian, and to present with higher-grade disease. Further research on the relationship of age, MBD, and tumor biology in DCIS is warranted.

BACKGROUND:Postmastectomy reconstruction remains underused. In 2011, new legislation in New York State mandated discussion of reconstructive options before mastectomy. This study assesses the impact of this policy on immediate breast reconstruction rates. METHODS:The Statewide Planning and Research Cooperative System database was queried to identify women undergoing mastectomy from January of 2005 to October of 2015 and follow them for at least 1 year postoperatively to determine the incidence and timing of reconstruction. Demographic and socioeconomic characteristics were collected. Chi-square test and multivariable logistic regression were used to compare periods before (2005 to 2010) and after (2011 to 2015) the legislative change. RESULTS:Of 52,837 records, there were 24,340 patients (46 percent) who underwent immediate breast reconstruction. The incidence of immediate breast reconstruction increased over the study period, most significantly in 2008 to 2009. Rates of immediate breast reconstruction continued to increase, although at a slower rate, after 2011 compared with before 2011 across all subgroups. Both implant and autologous reconstructive techniques increased over time. Implant-based reconstruction increased steadily, whereas autologous reconstruction increased most significantly between 2008 and 2009. CONCLUSIONS:Despite an overall increase in immediate breast reconstruction, there was an overall lack of effect on post-2011 reconstructive rates attributable to the legislative changes. Reconstructive rates have increased significantly in New York State over the past decade, and these changes appear to be largely independent of the 2011 New York State Breast Reconstruction Act. There are likely nonlegislative drivers of breast reconstruction use.

BACKGROUND:A positive lumpectomy margin after breast-conserving surgery (BCS) is a significant predictor for ipsilateral cancer recurrence. The MarginProbe, a Food and Drug Administration (FDA)-approved device for intraoperative assessment of lumpectomy margins, is associated with a reduction in re-excision surgery. This study aimed to evaluate the relationship of mammographic breast density (MBD) and clinicopathologic characteristics with margin status in women undergoing BCS with the MarginProbe. METHODS:The institutional database was queried for patients with breast cancer who had BCS with the MarginProbe from 2013 to 2017. Clinicopathologic characteristics were collected. The study defined MBD as less dense (Breast Imaging Reporting and Data System [BI-RADS] A and B) and more dense (BI-RADS C and D). A positive margin was defined as smaller than 1 mm. Pearson Chi square and uni- and multivariate logistic regression were performed. RESULTS:Of 1734 patients, 341 met the study criteria. The median patient age was 63 years. The patients with higher mammographic density were younger (p < 0.0001) and had a lower body mass index (BMI) (p < 0.0001). The patients with higher MBD were more likely to present with a palpable mass (p = 0.0360). Of the 341 patients, 135 (39.6%) had one or more positive margins on the main specimen, and 101 (74.8%) were converted to final negative margins after the MarginProbe directed re-excisions. Positive final margins were associated with larger tumor size (p = 0.0242) and more advanced stage of disease at diagnosis (p = 0.0255). CONCLUSIONS:In this study of patients undergoing BCS, breast density was not correlated with the likelihood of a positive margin. The presence of positive final lumpectomy margins was associated with older age and more extensive disease.