Comparison of excised breast volume, re-excision rate and margin positivity in breast-conserving surgery in breast cancer patients using and not using neoadjuvant chemotherapy

Emine Yıldırım; Eren Ozan Yıldız; İklil Eryılmaz; Muzaffer Er; Sibel Bektaş

doi:10.28982/josam.1049330

Authors

Emine Yıldırım https://orcid.org/0000-0003-2733-402X
Eren Ozan Yıldız Gaziosmanpaşa Eğitim ve Araştırma Hastanesi https://orcid.org/0000-0001-6432-3587
İklil Eryılmaz Gaziosmanpaşa Eğitim ve Araştırma Hastanesi https://orcid.org/0000-0002-8580-6542
Muzaffer Er Gaziosmanpasa Training and Research Hospital https://orcid.org/0000-0001-8578-1229
Sibel Bektaş Gaziosmanpasa Training and Research Hospital https://orcid.org/0000-0003-0248-9869

DOI:

https://doi.org/10.28982/josam.1049330

Keywords:

Breast cancer, Breast-conserving surgery, Resection volume, Re-excision rate

Abstract

Background/Aim: One of the purposes of using neoadjuvant chemotherapy (NAC) is to evaluate the patients according to tumor-to-gland ratio, save them from mastectomy by reducing tumor dimension, and get more beautiful results cosmetically with less volume excision during breast-conserving surgery (BCS). Is it possible to achieve the goal of less volume excision after NAC? We aimed to compare the excised volume with BCS, margin positiveness and re-excision rates between the patients who received NAC and the ones who didn’t receive NAC in patients with breast cancer and to calculate the increase in BCS performability with NAC. Methods: Among 306 patients diagnosed with breast cancer between 2013 and 2021 at Gaziosmanpasa Training and Research Hospital, 105 patients who underwent BCS were included in this retrospective cohort study. Excised breast volume, surgical margin positiveness, re-excision and mastectomy rates were retrospectively compared in breast cancer patients underwent BCS with and without NAC. The patients who received BCS following NAC were named the primary chemotherapy (PC), and the patients whose treatment was initiated with BCS were named the primary surgery (PS) groups. Results: BCS was performed to 105 breast cancer patients, of which 28 (26.7%) received NAC, and 77(73.7%) started the treatment with surgery. There were no significant differences between the PC and PS groups with respect to excision volume (755.86 (725.69) and 709 (637.36), P=0.822). Re-excision was more common in PS than in the PC group (39.0% vs 10.7%, P=0.008). Fourteen patients who were candidates for mastectomy at the beginning, became eligible for BCS by receiving NAC, which caused a 15.38% increase in BCS applicability. Surgical margin positivity was seen in only 3 patients, which is why a statistical comparison wasn’t made. Conclusions: Although the tumor size was higher in the PC group, the excised breast volume did not show a significant difference between the two groups. PC decreased the re-excision rates in the chemotherapy candidate group. This data shows that patients who are candidates for adjuvant chemotherapy might be considered for PC to increase BCS success with lower re-excision rates and equivalent excised breast volume.

Downloads

Download data is not yet available.

References

Halsted W. The results of radical operation for the cure of carcinoma of the breast. Ann Surg. 1907 Jul;46(1):1-19. doi: 10.1097/00000658-190707000-00001.

Robinson GN, Van Heerden JA, Payne WS, Taylor WF, Gaffey TA. The primary surgical treatment of carcinoma of the breast: a changing trend toward modified radical mastectomy. Mayo Clinic Proceedings. 1976 Jul;51(7):433–42. PMID: 933559

Keynes G. The Radium treatment of primary carcinoma of the breast. Can Med Assoc J. 1934 Jan;30(1):24-30. PMID: 20319353; PMCID: PMC403171.

Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018 Jan;19(1):27-39. doi: 10.1016/S1470-2045(17)30777-5.

Mittendorf EA, Buchholz TA, Tucker SL, Meric-Bernstam F, Kuerer HM, Gonzalez-Angulo AM, et al. Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy. Ann Surg. 2013 Feb;257(2):173-9. doi: 10.1097/SLA.0b013e3182805c4a

Delpech Y, Coutant C, Hsu L, Barranger E, Iwamoto T, Barcenas CH, et al. Clinical benefit from neoadjuvant chemotherapy in oestrogen receptor-positive invasive ductal and lobular carcinomas. Br J Cancer. 2013 Feb 5;108(2):285-91. doi: 10.1038/bjc.2012.557. Epub 2013 Jan 8

Clement Z, McLeay W, Hoffmann C, Shin P, Chowdhry M, Eaton M. Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study. Breast Dis. 2019;38(1):7-13. doi: 10.3233/BD-180339.

Hortobagyi G, Connolly JL, D’Orsi CJ, Edge SB, Mittendorf EA, Rugo HS, et al. Breast. In: AJCC cancer staging manual, 8th edn Amin MB, Edge SB, Greene FL (eds.). New York, Springer, pp 587-628, 2017

Fitzgibbons P, Connolly J, Bose S, Chen Y, Baca M, Ergerton M. CAP protocol for the examination of specimens from patients with ınvasive carcinoma of the breast. Available at: https://documents.cap.org/protocols/cp-breast-invasive-18protocol-4100.pdf [Last accessed on April 3, 2021]

Goldhirsch A, Winer EP, Coates AS, Gelber RD, Piccart-Gebhart M, Thurlimann B, et al. Personalizing the treatment of women with early breast cancer: Highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013. Ann Oncol. 2013 Sep;24(9):2206-23. doi: 10.1093/annonc/mdt303

Ogston KN, Miller ID, Payne S, Hutcheon AW, Sarkar TK, Smith I, et al. A new histological grading system to assess response of breast cancers to primary chemotherapy: prognostic significance and survival. Breast. 2003 Oct;12(5):320–7. doi: 10.1016/s0960-9776(03)00106-1.

Schulman AM, Mirrielees JA, Leverson G, Landercasper J, Greenberg C, Wilke LG. Reexcision Surgery for Breast Cancer: An Analysis of the American Society of Breast Surgeons (ASBrS) MasterySM Database Following the SSO-ASTRO “No Ink on Tumor” Guidelines. Annals of Surgical Oncology. 2016;24(1):52–8. doi: 10.1245/s10434-016-5516-5.

Krekel NMA, Zonderhuis BM, Muller S, Brill H, van Slooten HJ, de Lange de Klerk E, et al. Excessive resections in breast conserving surgery: A retrospective multicentre study. Breast J. 2011;17(6):602-9. doi: 10.1111/j.1524-4741.2011.01198.x

Fisher B, Brown A, Mamounas E, E,Wieand S, Robidoux A, Margolese RG, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997 Jul;15(7):2483–93. doi: 10.1200/JCO.1997.15.7.2483

Takada M, Toi M. Neoadjuvant treatment for Her2-positive breast cancer. Chin Clin Oncol. 2020 Jun;9(3):32. doi: 10.21037/cco-20-123

Bergin ART, Loi S. Triple-negative breast cancer: recent treatment advances. F1000Res. 2019 Aug 2;8:F1000 Faculty Rev-1342. doi: 10.12688/f1000research.18888.1.

Golshan M, Cirrincione CT, Sikov WM, Berry DA, Jasinski S, Weisberg TF, et al. Impact of neoadjuvant chemotherapy in stage II-III triple negative breast cancer on eligibility for breast-conserving surgery and breast conservation rates: surgical results from CALGB 40603 (Alliance). Ann Surg. 2015 Sep;262(3):434-9. doi: 10.1097/SLA.0000000000001417.

Golshan M, Cirrincione CT, Sikov WM, Carey LA, Berry DA, Overmoyer B, et al. Impact of neoadjuvant therapy on eligibility for and frequency of breast conservation in stage II-III HER2-positive breast cancer: surgical results of CALGB 40601 (Alliance).Alliance for Clinical Trials in Oncology. Breast Cancer Res Treat. 2016 Nov;160(2):297-304. doi: 10.1007/s10549-016-4006-6.

Hennigs A, Hartmann B, Rauch G, Golatta M, Tabatabai P, Domschke C, et al. Long-term objective esthetic outcome after breast-conserving therapy. Breast Cancer Res. Treat. 2015 Sep;153(2):345–51. doi: 10.1007/s10549-015-3540-y

Hashem T, Morsi A, Farahat A, Zaghloul T, Hamed A. Correlation of Specimen/Breast Volume Ratio to Cosmetic Outcome After Breast Conserving Surgery Indian J Surg Oncol 2019 Dec;10(4):668-72. doi: 10.1007/s13193-019-00973-y.

Valejo FAM, Tiezzi DG, Mandarano LRM, de Sousa CB, de Andrade JM. Volume of breast tissue excised during breast-conserving surgery in patients undergoing preoperative systemic therapy. Rev Bras Ginecol Obstet. 2013 May;35(5):221-5. doi: 10.1590/s0100-72032013000500006.

Komenaka IK, Hibbard ML, Hsu CH, Low BG, Salganick JA, Bouton ME, Jha C. Preoperative chemotherapy for operable breast cancer improves surgical outcomes in the community hospital setting. Oncologist. 2011;16(6):752-9. doi: 10.1634/theoncologist.2010-0268

Karanlik H, Ozgur I, Cabioglu N, Sen F, Erturk K, Kilic B, et al. Preoperative chemotherapy for T2 breast cancer isassociated with improved surgical outcome. Eur J Surg Oncol. 2015 Sep;41(9):1226-33. doi: 10.1016/j.ejso.2015.06.003

Volders JH, Negenborn VL, Spronk PE, Krekel NMA, Schoonmade LJ, Meijer S, et al. Breastconserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes. Breast Cancer Res Treat. 2018 Feb;168(1):1–12 doi: 10.1007/s10549-017-4598-5

Volders JH, Haloua MH, Krekel NMA, Negenborn VL, Barbé E, Sietses C, et al. “the nationwide network and registry of histo- and cytopathology in the Netherlands (PALGA)”. Neoadjuvant chemotherapy in breast-conserving surgery - Consequences on margin status and excision volumes: A nationwide pathology study. Eur J Surg Oncol. 2016 Jul;42(7):986-93. doi: 10.1016/j.ejso.2016.02.252

Devane LA, Baban CK, O'Doherty A, Quinn C, McDermott EW, Prichard RS. The Impact of Neoadjuvant Chemotherapy on Margin Re-excision in Breast-Conserving Surgery. World J Surg. 2020 May;44(5):1547-1551. doi: 10.1007/s00268-020-05383-8.

Spronk PER, Volders JH, van den Tol P, Smorenburg CH, Vrancken Peeters MTFD. Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit. Eur J Surg Oncol. 2019 Feb;45(2):110-117. doi: 10.1016/j.ejso.2018.09.027.

Woeste MR, Bhutiani N, Donaldson M, McMasters KM, Ajkay N. Evaluating the effect of neoadjuvant chemotherapy on surgical outcomes after breast conserving surgery. J Surg Oncol. 2021 Feb;123(2):439-445. doi: 10.1002/jso.26301.

Christy CJ, Thorsteinsson D, Grube BJ, Abu-Khalaf M, Chung GG, DiGiovanna MP, et al. Preoperative chemotherapy decreases the need for re-excision of breast cancers between 2 and 4 cm diameter. Ann Surg Oncol. 2009 Mar;16(3):697–702. doi: 10.1245/s10434-008-0268-5.