Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy

Breast Care ◽  
2021 ◽  
pp. 1-7
Author(s):  
Tal Hadar ◽  
Michael Koretz ◽  
Mahmood Nawass ◽  
Tanir M. Allweis
Keyword(s):  
Systemic Therapy ◽  
Percutaneous Biopsy ◽  
Complete Response ◽  
Breast Conserving Surgery ◽  
Response To Therapy ◽  
Neoadjuvant Endocrine Therapy ◽  
Oncoplastic Breast Surgery ◽  
Tumor Bed ◽  
Treatment Indications ◽  
Neoadjuvant Systemic Therapy

<b><i>Background:</i></b> The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST. <b><i>Summary:</i></b> In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST – both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar – “no tumor on ink” for invasive cancer. Oncoplastic breast surgery after NST is feasible – both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach. <b><i>Key Messages:</i></b> Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.

scholarly journals Minimally Invasive Complete Response Assessment of the Breast After Neoadjuvant Systemic Therapy for Early Breast Cancer (MICRA trial): Interim Analysis of a Multicenter Observational Cohort Study

2020 ◽  
Author(s):  
Ariane A. van Loevezijn ◽  
Marieke E.M. van der Noordaa ◽  
Erik D. van Werkhoven ◽  
Claudette E. Loo ◽  
Gonneke A. O. Winter-Warnars ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Systemic Therapy ◽  
Triple Negative ◽  
False Negative ◽  
False Negative Rate ◽  
Complete Response ◽  
Ultrasound Guided ◽  
Her2 Positive ◽  
Surgical Specimen ◽  
Neoadjuvant Systemic Therapy

Abstract Background The added value of surgery in breast cancer patients with pathological complete response (pCR) after neoadjuvant systemic therapy (NST) is uncertain. The accuracy of imaging identifying pCR for omission of surgery, however, is insufficient. We investigated the accuracy of ultrasound-guided biopsies identifying breast pCR (ypT0) after NST in patients with radiological partial (rPR) or complete response (rCR) on MRI. Methods We performed a multicenter, prospective single-arm study in three Dutch hospitals. Patients with T1–4(N0 or N +) breast cancer with MRI rPR and enhancement ≤ 2.0 cm or MRI rCR after NST were enrolled. Eight ultrasound-guided 14-G core biopsies were obtained in the operating room before surgery close to the marker placed centrally in the tumor area at diagnosis (no attempt was made to remove the marker), and compared with the surgical specimen of the breast. Primary outcome was the false-negative rate (FNR). Results Between April 2016 and June 2019, 202 patients fulfilled eligibility criteria. Pre-surgical biopsies were obtained in 167 patients, of whom 136 had rCR and 31 had rPR on MRI. Forty-three (26%) tumors were hormone receptor (HR)-positive/HER2-negative, 64 (38%) were HER2-positive, and 60 (36%) were triple-negative. Eighty-nine patients had pCR (53%; 95% CI 45–61) and 78 had residual disease. Biopsies were false-negative in 29 (37%; 95% CI 27–49) of 78 patients. The multivariable associated with false-negative biopsies was rCR (FNR 47%; OR 9.81, 95% CI 1.72–55.89; p = 0.01); a trend was observed for HR-negative tumors (FNR 71% in HER2-positive and 55% in triple-negative tumors; OR 4.55, 95% CI 0.95–21.73; p = 0.058) and smaller pathological lesions (6 mm vs 15 mm; OR 0.93, 95% CI 0.87–1.00; p = 0.051). Conclusion The MICRA trial showed that ultrasound-guided core biopsies are not accurate enough to identify breast pCR in patients with good response on MRI after NST. Therefore, breast surgery cannot safely be omitted relying on the results of core biopsies in these patients.

Towards omitting breast cancer surgery in select patient groups: Assessment of pathologic complete response after neoadjuvant systemic therapy using biopsies—The MICRA trial.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. TPS593-TPS593 ◽  
Author(s):  
Marieke Van Der Noordaa ◽  
Frederieke van Duijnhoven ◽  
Claudette Loo ◽  
Koen van der Vijver ◽  
Gabe S. Sonke ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Cancer Patients ◽  
Systemic Therapy ◽  
Breast Surgery ◽  
Pathologic Complete Response ◽  
Complete Response ◽  
Breast Cancer Patients ◽  
Systemic Treatments ◽  
Neoadjuvant Systemic Therapy ◽  
Tumor Area

TPS593 Background: Improvements in systemic treatments for breast cancer patients has led to increasing rates of pathologic complete response (pCR). In addition, the identification of a pCR has been greatly improved with magnetic resonance imaging (MRI). In patients with a pCR, surgical resection of (part of) the original tumor area is performed to confirm the absence or presence of pCR and is not likely to contribute to locoregional control. With the MICRA trial (Minimally Invasive Complete Response Assessment) we aim to omit breast surgery in breast cancer patients achieving pathologic complete response (pCR) after neoadjuvant systemic therapy (NST) using biopsies, thus preventing overtreatment and improving quality of life. Methods: The MICRA trial is a multi-center observational prospective cohort study. In all breast cancer patients receiving NST, a marker is placed in the center of the tumor area before NST. 440 patients with radiologic complete response or partial response (0.1-2.0 cm residual contrast enhancement, ≥30% decrease in tumor size according to RECIST criteria) on contrast enhanced MRI will be included in the MICRA trial. Patients with hormone receptor positive, triple negative and Human Epidermal growth factor Receptor 2 tumors are eligible. After NST, 8 ultrasound-guided biopsies are obtained in the region surrounding the marker, while the patient is under general anesthesia. Immediately hereafter, breast surgery is performed and pathology results of the biopsies and resected specimens are compared. The primary endpoint is specificity of post-NST biopsies. In addition, sensitivity and positive and negative predictive value will be calculated. We will perform a multivariable analysis using data on MRI and ultrasound findings, pre-NST pathology parameters and post-NST biopsy results to determine what the most reliable method is to assess pCR and how many biopsies are needed for this purpose. Conclusion: With the MICRA-trial we aim to select a group of breast cancer patients in whom surgery of the breast after NST can be omitted, by predicting the presence of a pCR on biopsies. Clinical trial information: NTR6120.

Sign in / Sign up

Export Citation Format

Share Document