Purpose The increased breast cancer risk conferred by a diagnosis of lobular carcinoma in situ (LCIS) is poorly understood. Here we review our 29-year longitudinal experience with LCIS to evaluate factors associated with breast cancer risk. Methods Patients participating in surveillance following an LCIS diagnosis are followed in a prospectively maintained database. Comparisons were made among women choosing surveillance, with or without chemoprevention, and those undergoing bilateral prophylactic mastectomies between 1980 and 2009. Results 1060 patients with LCIS without concurrent breast cancer were identified. Median age at LCIS diagnosis was 50 years (range, 27–83). 56 (5%) underwent bilateral prophylactic mastectomy; 1004 chose surveillance with (n=173) or without (n=831) chemoprevention. At a median follow-up of 81 months (6–368 months), 150 patients developed 168 breast cancers (63% ipsilateral, 25% contralateral, 12% bilateral), with no dominant histology (ductal carcinoma in situ 35%, infiltrating ductal carcinoma 29%, infiltrating lobular carcinoma 27%, other 9%). Breast cancer incidence was significantly reduced in women taking chemoprevention (10-year cumulative risk: 7% chemoprevention; 21% no chemoprevention, p<.0001). In multivariate analysis, chemoprevention was the only clinical factor associated with breast cancer risk (hazard ratio 0.27, 95% confidence interval 0.15–0.50). In a subgroup nested case-control analysis, volume of disease defined as the ratio of slides with LCIS to total number of slides reviewed was also associated with breast cancer development (p=0.008). Conclusion We observed a 2% annual incidence of breast cancer among women with LCIS. Common clinical factors used for risk prediction including age and family history were not associated with breast cancer risk. The lower breast cancer incidence in women opting for chemoprevention highlights the potential for risk reduction in this population.

IMPORTANCE To our knowledge, there has been little research conducted on the attitudes of residents toward their pregnant peers and parental leave. OBJECTIVE To examine the perceptions of current surgery residents regarding parental leave. DESIGN, SETTING, AND PARTICIPANTS A 36-item survey was distributed to current US general surgery residents and residents in surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. Questions were associated with general information/demographics, parental leave, having children, and respondents' knowledge regarding the current parental leave policy as set by the American Board of Surgery. The study was conducted from August to September 2018 and the data were analyzed in October 2018. MAIN OUTCOMES AND MEASURES Main outcomes included the attitudes of residents toward pregnancy and parental leave, parental leave policy, and the association of parental leave with residency programs. RESULTS A total of 2188 completed responses were obtained; of these, 1049 (50.2%) were women, 1572 (75.8%) were white, 164 (7.9%) were Hispanic/Latinx, 75 (3.6%) were African American, 2 (0.1%) were American Indian or Alaskan Native, 263 (12.7%) were Asian, and 5 (0.2%) were Native Hawaiian or Pacific Islander. From the number of residents who had/were expecting children (581 [28.6%]), 474 (81.6%) had or were going to have a child during the clinical years of residency. Many residents (247 [42.5%]) took fewer than 2 weeks of parental leave. Many residents did not feel supported in taking parental leave (177 [30.4%] did not feel supported by other residents and 190 [32.71%] did not feel supported by the faculty). Only 83 respondents (3.8%%) correctly identified the current American Board of Surgery parental leave policy. Residents who took parental leave identified a lack of a universal leave policy, strain on the residency program, a loss of education/training time, a lack of flexibility of programs, and a perceived or actual lack of support from faculty/peers as the top 5 biggest obstacles to taking leave during the clinical years of residency. CONCLUSIONS AND RELEVANCE Most of the modifiable factors that inhibit residents from having children during residency are associated with policies (eg, a lack of universal leave policy and lack of flexibility) and personnel (eg, a strain on the residency program and lack of support from peers/faculty). These data suggest that policies at the level of the Accreditation Council for Graduate Medical Education or Resident Review Committee (RRC), as well as education and the normalization of pregnancy during training, may be effective interventions.

Background Whether extracapsular extension of tumor (ECE) in the sentinel lymph node (SLN) is an indication for axillary dissection (ALND) in patients managed by ACOSOG Z0011 criteria is controversial. Here we examine the correlation between ECE in the SLN and disease burden in the axilla. Methods Patients meeting Z0011 clinicopathologic criteria (pT1-T2,cN0 with <3 positive SLNs) were selected from a prospectively maintained database (2006-2013). Chart review documented presence/extent of ECE. Neoadjuvant chemotherapy patients were excluded. Comparisons were made by presence/extent (≤2mm vs.>2mm) of ECE. Results Of 11,730 patients, 778 were pT1-T2, cN0 with <3 positive SLNs without ECE and 331 (2.8%) had ECE. Of these, 180 had ≤2mm, and 151 had >2mm ECE. Patients with ECE were older (57 vs54 yrs;p=0.001) and had larger (2.0cm vs 1.7cm,p<0.0001), multifocal (p=0.006), HR-positive tumors (p=0.0164), with LVI (p<0.0001). Presence and extent of ECE was associated with greater axillary disease burden; 20% and 3% of patients with and without ECE, respectively, had ≥4 additional positive nodes at cALND (p<0.0001) and 33% of patients with >2mm ECE had ≥4 additional positive nodes at cALND compared to 9% in the <2mm group(p<0.0001). On multivariate analysis,>2mm ECE was the strongest predictor of ≥4 positive nodes at cALND (OR 14.2). Conclusions Presence and extent of ECE were significantly correlated with nodal tumor burden at cALND, suggesting that >2mm of ECE may be an indication for ALND or RT when applying Z0011 criteria to patients with metastases in <3 SLNs. ECE reporting should be standardized to facilitate future studies.

Background ACOSOG Z0011 results support the omission of axillary lymph node dissection (ALND) in women with <3 positive sentinel lymph nodes (SLNs) undergoing breast-conserving surgery (BCS) and radiation therapy. We sought to determine if abnormal axillary imaging is predictive of the need for ALND in this population. Study Design Patients with cT1-2N0 breast cancer by physical examination undergoing BCS were managed according to Z0011 criteria independent of axillary imaging. Patient characteristics and rates of ALND were compared among those with and without abnormal LNs detected by mammogram, ultrasound (US), or MRI. All available axillary imaging was reviewed by one breast radiologist. Results Between 8/2010–12/2013, 3253 breast cancer patients were treated with BCS and SLN biopsy; 425 patients met Z0011 criteria (cT1-2N0) and had nodal metastasis on SLN biopsy. Clinicopathologic features were: median patient age 58 years; median tumor size 1.8cm; 85% ductal histology; 89% estrogen receptor positive. All women had a mammogram, 242 had axillary US, 172 had MRI. Abnormal LNs were seen on 7%, 25%, and 30% of mammograms, US, and MRIs, respectively. While abnormal LNs on mammogram or US were associated with a significant increase in ALND and a non-significant trend was seen with MRI, 68–73% of women with abnormal axillary imaging did not require ALND. Conclusions Among clinically node negative patients with abnormal axillary imaging, 71% did not meet criteria for ALND and were spared further surgical morbidity. Abnormal nodes on US, MRI, or mammogram in clinically node-negative patients are not reliable indicators of the need for ALND.

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