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Additional Notable Research and Presented at the 15th Annual Meeting of the
American Society of Breast Surgeons
The following newsworthy abstracts presented at the 15th Annual Meeting of the American
Society of Breast Surgeons (ASBrS) may be of particular interest to press, in addition to
presentations during the Media Press Briefing. Researchers are available for telephone
interviews. Onsite media is invited to attend all scientific sessions.
Abstracts
Contralateral Prophylactic Mastectomy Provides No Survival Benefit In Young
Women With Estrogen Receptor Negative Breast Cancer
Lead Author: Dr. Catherine Pesce
NorthShore University HealthSystem
Evanston, IL
Total Skin-Sparing Mastectomy and Immediate Breast Reconstruction: An
Evolution of Technique over 986 Cases.
Lead Author: Dr. Frederick Wang
University of California, San Francisco
San Francisco, CA
Reasons for Re-excision After Lumpectomy for Breast Cancer can be Identified in
the American Society of Breast Surgeons (ASBrS) MasterySM Program
Lead Author: Jeffrey Landercasper
Gundersen Health System
La Crosse, WI
Page 1 of 8
Breast Imaging Second Opinions at a Tertiary Care Center: Impact on Clinical and
Surgical Management
Lead Author: Kjirsten Carlson
Rush University Medical Center
Chicago, IL
Prospective Randomized Trial of Drain Antisepsis to Reduce Bacterial
Colonization of Surgical Drains After Mastectomy with Immediate
Expander/Implant Reconstruction
Lead Author: Amy Degnim
Mayo Clinic
Rochester, MN
ATTRIBUTION TO THE 15th ANNUAL MEETING OF THE AMERICAN SOCIETY OF BREAST
SURGEONS IS REQUESTED IN ALL COVERAGE.
Page 2 of 8
Presenter: Catherine Pesce
Institution: NorthShore University HealthSystem, Evanston, IL
Title: Contralateral Prophylactic Mastectomy Provides No Survival Benefit In Young Women
With Estrogen Receptor Negative Breast Cancer
Objective: Several studies have shown that contralateral prophylactic mastectomy (CPM)
provides a disease free and overall survival benefit in young women with unilateral breast
cancer that is estrogen receptor (ER) negative. We utilized the National Cancer Data Base to
evaluate CPM’s survival benefit for young women with early stage breast cancer in the years
that ER status was available.
Method: We selected women <45 years old with AJCC Stage I-II breast cancer who underwent
unilateral mastectomy or CPM from 2004-2006. Five-year overall survival (OS) was compared
between those who had unilateral mastectomy and CPM using the Kaplan-Meier method and
Cox regression analysis. Median follow up was 5.9 years.
Results: A total of a 393,582 women fulfilled eligibility criteria. 84.3% of women underwent
unilateral mastectomy and 15.7% of women underwent CPM. 58.2% of women had Stage 1
disease vs 41.8% with Stage 2 disease. 79.7% were ER positive and 20.3% ER negative. Of all
women <45 years old who underwent CPM, there was no improvement in OS compared with
women who underwent unilateral mastectomy (HR=1.183, 95% CI 0.985-1.422) after adjusting
for patient age, race, insurance status, year of diagnosis, ER status, tumor size, nodal status,
grade, histology, facility type, facility location, co-morbidities, use of adjuvant radiation and
chemohormonal therapy. When women <45 years old with T1N0 tumors were examined, there
was also no improvement in OS compared with women who underwent unilateral mastectomy
(HR=1.317, p=0.2071) after adjusting for the aforementioned factors. Among women <45 years
old with ER negative tumors who underwent CPM, there was no improvement in OS compared
with women who underwent unilateral mastectomy (HR=0.947, p=0.6922) adjusting for the
same aforementioned factors for both Stage I and II disease.
Conclusion: CPM provides no survival benefit to young patients with early stage breast cancer
and no benefit to ER negative patients. Future studies with longer follow up are required to
determine if CPM will provide a survival benefit in this cohort of patients.
Page 3 of 8
Presenter: Frederick Wang
Institution: University of California, San Francisco, San Francisco, CA
Title: Total Skin-Sparing Mastectomy and Immediate Breast Reconstruction: An Evolution of
Technique over 986 Cases.
Objective: Total skin-sparing mastectomy (TSSM) with complete preservation of the breast and
nipple-areolar complex (NAC) skin and excision of nipple tissue was developed to improve
aesthetic outcomes for treatment of early stage breast cancer or for prophylactic indications.
Over the past 12 years, TSSM has been offered for a wider range of indications as NAC
preservation rates improved and as locoregional recurrence rates were shown to be similar to
other mastectomy techniques. We aim to demonstrate that the technique of TSSM has
developed into a feasible standard for mastectomy.
Methods: We reviewed our experience of TSSM and immediate breast reconstruction from
October 2001 to December 2012. Cases were divided into several learning cohorts defined by
intentional changes in technique and management, which led to serial improvements in
outcomes. The initial cohort focused on defining the appropriate placement of incisions for
TSSM to maximize NAC survival. Subsequent improvements included increasing the minimum
time from completion of radiation therapy to expander-implant exchange from 3 months to 6
months, switching from cephalosporins to trimethoprim-sulfamethoxazole for standard
postoperative antibiotic prophylaxis unless contraindicated, and examining the utility of acellular
dermal matrix in tissue expander/implant reconstruction. Postoperative complications and
outcomes were obtained via retrospective chart review from 2001-2005 and gathered
prospectively from 2005-2012.
Results: A total of 640 patients underwent 986 cases of TSSM with mean follow-up time of
25±20 months. The mean age at mastectomy was 47±10 years. 32.5% of patients underwent
neoadjuvant chemotherapy and 16.4% underwent adjuvant chemotherapy for breast cancer
treatment. Comorbidities among patients included diabetes (1.6%), current or prior smoking
(16.6%), and prior radiation history (7.7%). Of all TSSM cases, 35.0% were performed for
prophylactic indications while therapeutic cases included stage 0 (35.9%), stage 1 (28.9%),
stage 2 (23.4%), stage 3 (10.9%), and stage 4 (0.9%) disease. Post-mastectomy radiation
therapy was performed in 18.9% of the therapeutic cases. Immediate breast reconstruction was
performed in all cases with either tissue expander placement (85.1%), pedicle TRAM (6.3%),
free TRAM (4.8%), permanent implant (3.0%), or latissimus flap (0.4%). Postoperative
complications included the development of serious infection requiring IV antibiotics or operative
intervention (9.8%), partial nipple necrosis (0.6%), complete nipple necrosis (1.0%), skin flap
necrosis (8.4%), and expander/implant loss (8.4%). Radiation therapy was shown to increase
the risk for developing serious infections (RR 2.7, p<0.05), major skin flap necrosis (RR 2.1,
p<0.05), and expander/implant loss (RR 3.6, p<0.05) but had no significant effect on partial or
complete NAC necrosis. Smoking history was shown to increase the risk of serious infection
(RR 1.9, p<0.05), skin necrosis (RR 1.6, p<0.05), and expander/implant loss (RR 1.8, p<0.05).
The 5-year cumulative incidence of locoregional recurrence was 3.0%, and the 5-year diseasefree survival was 92.2%.
Conclusion: Our technique of TSSM and immediate breast reconstruction has undergone
substantial development since 2001. We have improved outcomes and decreased
postoperative complications through a systematic series of learning cohorts. Serial
improvements in technique and emerging data on longer-term oncologic safety make this
surgical approach feasible as a standard for mastectomy.
Page 4 of 8
Presenter: Jeffrey Landercasper
Institution: Gundersen Health System, La Crosse, WI
Title: Reasons for re-excision after lumpectomy for breast cancer can be identified in the
American Society of Breast Surgeons (ASBrS) MasterySM Program
Objective: There is strong evidence of marked variability of re-excision rates after initial
lumpectomy for breast cancer. Reasons for re-excision have not been well documented. Recent
research suggests some re-excisions are performed unnecessarily due to differences in
surgeon opinion regarding adequacy of margin width. We hypothesized the ASBrS MasterySM
Program can identify variation in re-excision rates and reasons for re-excision to aid the
development of performance improvement strategies to reduce secondary breast operations.
Methods: In the ASBrS MasterySM Program, surgeons can enter information on patient
demographics, surgical procedures and quality measures with immediate peer performance
comparison as a method of performance assessment and improvement. Data from January 1 –
November 5, 2013 were evaluated to determine re- excision lumpectomy rate (RELR). On June
1, 2013, a dropdown menu was added to the MasterySM data collection tool to track reasons for
re-excision. RELR was defined as the number of patients undergoing re-excision after
lumpectomy divided by the number of patients having initial lumpectomy for cancer. Variation in
re-excision rates by surgeon and patient characteristics was performed by chi square for
univariate analysis.
Results: Three hundred twenty six surgeons reported on 6523 unique patients who had
undergone initial lumpectomy for cancer, with 1458 (22.4%) undergoing one or more reexcisions. Two hundred thirteen surgeons reported at least 10 lumpectomies (range 10-163)
during the queried period. For patients having re-excision by these surgeons, the number of reexcisions ranged from 1- 4 (mean 1.1). Re-excision rates were higher in non-Caucasian
(p=0.006) and Hispanic (p=0.008) patients, were lower in surgeons who had been in practice
longer (p< 0.001), and were no different according to primary insurance type (p=0.15). Reasons
for re-excision were documented in 1575 re-excision procedures and are detailed in the table
below. The most common reasons were an ink positive margin (49.7%) or a margin < 1 mm
(34.3%).
Conclusion: The ASBrS MasterySM Program provides a rapid, contemporary, and valuable
source of data on specific reasons for re-excision lumpectomy. Variability of re-excision by
surgeon and patient characteristics was identified. Most re-excisions are performed for margins
that are positive or < 1 mm. This information corroborates surgeon survey data regarding
reasons for re-excision and provides proof of concept the MasterySM Program can measure reexcisions in real time, providing a method for monitoring during future performance initiatives.
Reasons for Re-excision Lumpectomy Procedures
Reason
N
Percent
Ink positive margin
Margin < 1 mm
Margin 1-2 mm
Post lumpectomy imaging demonstrated evidence of residual
disease
Prior surgery elsewhere, margin status uncertain
Margin >2 mm but desire wider margins
783
540
114
38
49.7%
34.3%
7.2%
2.4%
25
16
1.6%
1.0%
Page 5 of 8
Tumor board recommended wider margins
Fragmented specimen, margin status uncertain
Radiation oncologist recommended wider margins
Other
Total procedures
Page 6 of 8
6
3
2
48
1575
0.4%
0.2%
0.1%
3.1%
100%
Presenter: Kjirsten Carlson
Institution: Rush University Medical Center, Chicago, IL
Title: Breast Imaging Second Opinions at a Tertiary Care Center: Impact on Clinical and
Surgical Management
Objective: Breast surgeons often see women for second opinions for abnormalities found on
breast imaging. For second opinions, these images are submitted for review and interpretation
by dedicated breast imagers. This study aims to evaluate the conformity of results among
interpretation of imaging submitted from outside hospitals both from tertiary care centers as well
as community programs, in an attempt to evaluate the utility of this practice for the sake of
clinical management and resource utilization.
Methods: A retrospective chart review was conducted on all breast patients that submitted
outside imaging films for the years 2011 to 2013 at our University Medical Center (UMC). The
radiologic diagnosis and each patient’s proposed management plan was collected and
evaluated for concordance between the outside institutions and UMC.
Results: A total of 380 patients who presented for second opinions with an interpretation of
outside exams were evaluated. In 47.4% (95% confidence interval [CI] 42.4 – 52.4%) of cases
there was distinct variance in radiologic impression. For 53.5% (95% CI 48.4 – 58.5%) of
patients there was a change in recommended management plan which included
recommendations for either additional imaging or need for additional biopsy. In total, this
changed the overall surgical management in 27.1% (95% CI 22.8 – 31.9%) of cases. In five
patients the re-interpretation of outside imaging detected new malignancies not previously
identified. Overall, 83.7% (95% CI 79.7 – 87.1%) of patients who submitted imaging from
outside institutions chose to complete the remainder of their treatment at UMC.
Conclusion: The practice of submission of outside imaging to a dedicated breast imager is a
common practice and the impact was evaluated in terms of radiologic concordance among
institutions, differences in recommended workup, and how the second opinion ultimately
affected definitive management. Review by a dedicated breast imager at our specialized center
(UMC) resulted in an increased number of breast abnormalities detected. Second opinion
review also resulted in a spectrum of additional workup including further mammographic views,
different imaging modalities (ultrasound and/or MRI), and in some cases, additional biopsies. In
rare cases the re-interpretation of imaging reported benign findings when additional workup was
recommended by the outside institution. Overall definitive management was changed based on
the second opinions at our specialty center in more than one in four cases. Most importantly, the
review identified five previously unrecognized malignancies. For every 100 images submitted for
review 1.3 new malignancies were identified. Given this data, the practice of second opinions
and interpretation of outside exams should continue despite the additional resources required.
Page 7 of 8
Presenter: Amy Degnim
Institution: Mayo Clinic, Rochester, MN
Title: Prospective Randomized Trial of Drain Antisepsis to Reduce Bacterial Colonization of
Surgical Drains After Mastectomy with Immediate Expander/Implant Reconstruction
Objective: Bacterial colonization of surgical drains after breast and axillary surgery may
contribute to surgical site infection (SSI). In the setting of implant-based immediate breast
reconstruction, SSI can result in reconstruction failure. We designed a randomized trial to
investigate the efficacy of antiseptic drain care in reducing bacterial colonization of surgical
drains placed at mastectomy with immediate expander/implant reconstruction.
Methods: With IRB approval, patients undergoing bilateral mastectomy and immediate tissue
expander or implant-based breast reconstruction were randomly assigned to standard drain
care (control) for one side, and drain antisepsis (treatment) for the other side. Thus, the design
was a paired, within-patient comparison of the treated and control sides. For standard drain care
(control), the exit site was cleaned twice daily with alcohol and covered with sterile gauze.
Antisepsis drain care (treatment) included: 1) a chlorhexidine disc and occlusive dressing at the
drain exit site, and 2) irrigation of the drain bulb twice daily with dilute sodium hypochlorite
solution. Drain bulb fluid was collected at one week for bacterial culture (primary endpoint). At
drain removal, both subcutaneous drain tubing and drain bulb fluid were also cultured. Primary
analysis was modified intent-to-treat. A side was classified as positive for colonization if any of
the drains on that side demonstrated positive cultures (1+ or greater growth in drain fluid; >50
CFU for drain tubing). Colonization and SSI outcomes were compared between sides within
patients using the exact sign test for paired proportions.
Results: Overall, 104 patients across two institutions were included and 101 (97%) had results
for the primary endpoint. Cultures of drain bulb fluid at one week were positive in 20.8%
(21/101) of control sides compared to 9.9% of treatment sides (10/101), (p=0.03). Among 45
patients whose drains were removed after the 1 week visit, positive cultures of drain bulb fluid at
removal were also more frequent among control sides as compared to treatment sides, 47%
(21/45) vs 27% (12/45), p=0.02. Drain tubing cultures demonstrated >50 CFU in 5.9% (6/101) of
control drains versus 0% of treated drains (p=0.03). SSI was diagnosed within 30 days for 3
sides in 3 patients; these infections all occurred on the control side, for a frequency of 2.9%
(3/104) of control sides versus 0% of antisepsis sides (p = 0.25). Including all infections within 1
year, infections occurred in 5/104 (4.8%) of control sides as compared to 3/104 (2.9%) of
antisepsis sides (p = 0.69). The sides with colonization of either tubing or bulb fluid at any time
point showed a subsequent infection rate of 8.1% as compared to 1.4% infection rate on sides
without colonization of bulb fluid or tubing (p = 0.04).
Conclusion: Simple and inexpensive local antiseptic interventions with a chlorhexidine disc and
hypochlorite solution reduce bacterial colonization of drains, and reduced colonization is
associated with fewer SSIs. Drain antisepsis techniques warrant further study toward reducing
SSI in immediate tissue expander/implant breast reconstruction.
Page 8 of 8