Attualità in Senologia

Rassegna della letteratura: gennaio – marzo 2019
Chirurgia, chirurgia plastica e radioterapia 

Tejera Hernández AA, Vega Benítez VM, Rocca Cardenas JC et Al. – Inverse radiotherapy planning in reconstructive surgery for breast cancer. – Int J Surg. 2019 Jan 29. pii: S1743-9191(19)30024-X.

Background: Post-mastectomy radiotherapy reduces the risk of local-regional relapse and distant disease, and increases global survival in women with axillary involvement.With the new reconstruction techniques and increasing use of directed external radiotherapy, immediate reconstruction can be performed with good cosmetic results and low complication rates.

Methods: Observational study with consecutive sampling conducted in patients undergoing reconstructive surgery for breast cancer, between 2010 and 2016, with a 12-months minimum follow-up period. A group of patients radiated after receiving an expander (RT-Expander) were compared with a control group of non-radiated patients (Non-RT), who had been treated with the same surgicaltechnique.We compare general complications, reconstruction failure, aesthetic results and satisfaction degree with software IBM® SPSS® Statistics v. 21 and BREAST-Q scores.

Results: Reconstruction failure was observed in 15.6% of patients in a similar proportion in both groups. External radiotherapy was not an independent significant factor influencing the occurrence of general complications, capsular contracture grade > 3 or reconstruction failure. The Kaplan-Meyer curve showed no differences in reconstruction survival between groups. Aesthetic results were excellent-very good in 78.1% of patients.Absence of a contralateral procedure for symmetrization, occurrence of general complications, occurrence of capsular contracture grade > 3 and reconstruction failure were significantly associated to fair-poor cosmetic results. The satisfaction degree of operated patients was similar in both groups.

Conclusion: The evolution of external radiotherapy towards more directed techniques, which modulate the dose administered to the mammary tissue and adjacent structures, allowed us to make immediate reconstruction a reality for most patients, with complication rates, cosmetic results and satisfaction degrees similar to those of non-radiated patients.

Vane MLG, van Nijnatten TJA et Al. – Does the subtype of breast cancer affect the diagnostic performance of axillary ultrasound for nodal staging in breast cancer patients? – Eur J Surg Oncol. 2019 Jan 14. pii: S0748-7983(19)30035-6.

Background: Imaging findings can be affected by histopathological characteristics, such as breast cancer subtypes. The aim was to determine whether the diagnostic performance, in particular negative predictive value (NPV), of axillary US differs per subtype of breast cancer

Methods: All patients diagnosed between 2008 and 2016 in our hospital with primary invasive breast cancer and an axillary US prior to axillary surgery were included. Histopathology of axillary surgery specimens served as gold standard. The NPV, sensitivity, specificity, positive predictive value (PPV) and accuracy of the axillary US were determined for the overall population and for each subtype (ER+/PR+HER2-,HER2+, triple negative tumors). The Chi-square test was used to determine the difference in diagnostic performance parameters between the subtypes.

Results: A total of 1094 breast cancer patients were included. Of these, 35 were diagnosed with bilateral breast cancer, resulting in 1129 cancer cases. Most common subtype was ER+/PR+HER2- in 858 cases (76.0%), followed by 150 cases of HER2+ tumors (13.3%) and 121 cases of triple negative tumors (10.7%). Sensitivity, specificity and accuracy of axillary US did not significantly differ between the subtypes. There was a significant difference for NPV between triple negative tumors and HER2+ tumors (90.3% vs. 80.2%, p = 0.05) and between HER2+ and ER/PR+HER2- tumors (80.2% vs. 87.2%, p = 0.04).

Conclusion: There was no significant difference in the diagnostic performance of axillary US between the subtypes, except for NPV. This was highest in triple negative subtype and lowest in HER2+ tumors. This can be explained by the difference in prevalence of axillary lymph node metastases in our cohort.

Ojala K, Meretoja TJ, Mattson J, Leidenius MHK. – Surgical treatment and prognosis of breast cancer in elderly – A population-based study. – Eur J Surg Oncol. 2019 Jan 21. pii: S0748-7983(19)30042-3.

Background: The aim of this study was to investigate outcome of treatment in patients over 80 years of age with early breast cancer at the time of the diagnosis with special interest in surgical treatment

Methods: Breast cancer patients older than 80 years of age, treated at the Breast Surgery Unit of Helsinki University Hospital in 2005-2010 were identified from electronic patient records. Patients were followed-up until the end of 2014. Patient and tumour characteristics, recurrences, co-morbidities and reasons for omission of surgery were collected from electronic patient records. Survival data was obtained from Finnish Cancer Registry.

Results: 446 patients were eligible for the study: 401 (90%) received surgery. The median follow-up time was 52 months. In the entire study population, local and regional recurrences/disease progression were diagnosed in 16 (3.6%) and 6 (1.3%) patients, respectively. The five-year overall survival was 50.6% in the surgical treatment and only 15.2% in non-surgical treatment group, p < 0.001. Also, the five-year breast cancer specific survival was significantly better in the patients with surgery, 82.0%, but 56.0% in the patients without surgery, p < 0.001. There was no mortality related to the surgery, but 122 (30%) patients died within three years from surgery

Conclusion: Surgical treatment rate was high. OS and BCSS were better in surgically treated elderly patients. Local and regional disease control was excellent, probably due to high rate of surgical treatment. Surgical treatment also seemed safe in this elderly patient population. However, surgical overtreatment was obvious in some patients 

Taban F, Elia N, Rapiti E, Rageth C et AL – Impact of experience in breast cancer surgery on survival: the role of quality of care in a registry-based cohort. – Swiss Med Wkly. 2019 Jan 27;149:w14704. doi: smw.2019.14704. eCollection 2019 Jan 14.

Background: Previous studies have suggested that the surgeon’s experience in breast cancer surgery may affect patient survival. In this registry-based retrospective cohort study, we examined whether quality of care could partly explain this association.

Methods: All invasive breast cancers operated on in the private sector between 2000 and 2009 were identified in the Geneva Cancer Registry and followed up for 5 years. Surgeons were classified according to their experience into three categories: ≤5, 6–10, >10 breast cancer operations performed per year. We extracted patient and tumour characteristics. Quality of care was scored as the proportion of 11 quality indicators correctly fulfilled for each patient. Breast cancer-specific mortality was examined with a Cox model adjusted for variables known to affect survival, surgeon experience, and quality of care.

Results: A total of 1489 patients were operated on by 88 surgeons; 50 patients (3.4%) died from breast cancer during the 5 years of follow-up. Socioeconomic status and country of birth of the patients, as well as period of diagnosis, differed according to the surgeons’ experience. Quality of care provided improved with surgeon’s experience. Surgeons performing >10 operations/year more frequently assessed histology before surgery, excised sentinel lymph nodes, removed ≥10 lymph nodes, and prescribed adjuvant radiotherapy when indicated. Crude breast cancer-specific mortality was lower in patients treated by surgeons performing >10 compared with ≤5 operations/year (hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.17–0.67; p = 0.002). The strength of the association decreased after adjustment for patient and tumour characteristics (HR 0.45, 95% CI 0.21–0.94; p = 0.034) and decreased further after adjustment for quality of care (HR 0.51, 95% CI 0.24–1.08, p = 0.078).

Conclusion: The association between surgeon’s experience and 5-year breast cancer survival is at least partly explained by quality of care, patient and tumour characteristics. Further investigations on the impact of other quality indicators such as multidisciplinary networks are needed.

Ammitzbøll G, Kristina Kjær T et Al. – Effect of progressive resistance training on health-related quality of life in the first year after breast cancer surgery – results from a randomized controlled trial. – Acta Oncol. 2019 Jan 31:1-8. doi: 10.1080/0284186X.2018.1563718.

Background: To examine the effect of progressive resistance training (PRT) on health related quality of life and a predefined symptom cluster of pain-sleep-fatigue.

Methods: This study was a planned secondary analysis of a randomized controlled trial examining the effect of PRT on prevention of arm lymphedema in a population of women between 18 and 75 years undergoing breast cancer surgery with axillary lymph node dissection. Participants were allocated by computer randomization to usual care control or a PRT intervention in a 1:1 ratio. The intervention, initiated in the third post-operative week, consisted of three times PRT per week, supervised in groups in the first 20 weeks, and self-administered in the following 30 weeks. Questionnaire assessments were made at baseline, 20 weeks and 12 months, with the European Organization for Research and Treatment in Cancer Core questionnaire (EORTC QLQ C30) and the Functional Assessment of Chronic Illness Therapy-(FACIT) fatigue questionnaire. The symptom cluster of pain-sleep-fatigue was measured with a constructed score adding EORTC C30 subscales of insomnia, pain, and fatigue. Data were treated as repeated measurements and analyzed with mixed models.

Results: Among 158 recruited participants, we found a clinically relevant increased emotional functioning with nine points at both follow-ups (p = .02), and 16 and 11 points at 20 weeks and 12 months respectively (p = .04) in social functioning. Furthermore, in the subgroup of women with the symptom cluster pain-sleep-fatigue present at baseline, a significant effect was found for global health status (p = .01) and social functioning (p = .02).

Conclusion: To our knowledge, this is the first study to report clinically relevant effects of PRT on social and emotional functioning in the first postoperative year after breast cancer surgery. Furthermore, a subgroup of women with the pain-sleep-fatigue symptom cluster had particular benefit from PRT on global health status and social functioning.