These data suggest that increasing use of CPM is not associated with increased recognition of patients at high risk for CBC. Treatment factors, such as immediate reconstruction, preoperative MRI, and unsuccessful attempts at breast conservation, are associated with increased rates of CPM. Efforts to optimize breast conservation, minimize unnecessary tests, and improve patient education about the low risk of CBC may help to curb this trend.

Tumor presentation varies among molecular subtypes; this information may be useful in selecting local therapy. Neoadjuvant therapy and lymph nodes evaluation before surgery or neoadjuvant therapy are likely to be beneficial in HER-2-overexpressing tumors.

Background Rates of mastectomy with immediate reconstruction are rising. Skin flap necrosis after this procedure is a recognized complication that can impact cosmetic outcomes and patient satisfaction, and, in worst cases, potentially delay adjuvant therapies. Many retrospective studies of this complication have identified variable event rates and inconsistent associated factors. Methods We designed a prospective study to capture the rate of skin flap necrosis and pre-, intra-, and post-operative variables with follow-up to 8 weeks post-operatively. Univariate and multivariate analyses were performed for factors associated with skin flap necrosis. Results Out of 606 consecutive procedures, 85 (14%) had some level of skin flap necrosis: 46 (8%) mild, 6 (1%) moderate, 31 (5%) severe, and 2 (0.3%) uncategorized. On univariate analysis for any necrosis, smoking, history of breast augmentation, nipple-sparing mastectomy, and time from incision to specimen removal were significant. In multivariate models, nipple-sparing, time from incision to specimen removal, sharp dissection, and previous breast reduction were significant for any necrosis. When looking only at moderate or severe necrosis, BMI, diabetes, nipple-sparing mastectomy, specimen size, and expander size were significant on univariate analysis. Nipple-sparing mastectomy and specimen size were significant on multivariate analysis. Nipple-sparing mastectomy was associated with higher rates of necrosis at every level of severity. Conclusions Rates of skin flap necrosis are likely higher than reported in retrospective series. Modifiable technical variables have limited impact on rates of necrosis. Patients with multiple risk factors should be counseled about the risks, especially if they are contemplating nipple-sparing mastectomy.

Background or Purpose The extent to which ACOSOG Z0011 findings are applicable to patients undergoing breast-conserving therapy (BCT) is uncertain. We prospectively assessed how often axillary dissection (ALND) was avoided in an unselected, consecutive patient cohort meeting Z0011 eligibility criteria and whether subgroups requiring ALND could be identified preoperatively. Methods Patients with cT1,2cN0 breast cancer undergoing BCT were managed without ALND for metastases in <3 sentinel nodes (SNs) and no gross extracapsular extension (ECE). Patients with and without indications for ALND were compared using Fisher's exact and Wilcoxon rank sum tests. Results From 8/2010-11/2012, 2157 invasive cancer patients had BCT. 380 had histologic nodal metastasis; 93 did not meet Z0011 criteria. Of 287 with ≥1 H&E-positive SN (209 macrometastases), 242(84%) had indications for SN only. ALND was indicated in 45 for ≥3 positive SNs (n=29) or ECE (n=16). The median number of SNs removed in the SN group was 3 versus 5 in the ALND group (p<.0001). Age, hormone receptor and HER2 status, and grade did not differ between groups; tumors were larger in the ALND group (p<0.0001). 72% of ALND patients had additional positive nodes (median=1;1-19). No axillary recurrences have occurred (median follow-up, 13 months). Conclusions ALND was avoided in 84% of a consecutive series of patients having BCT, suggesting that most patients meeting ACOSOG Z0011 eligibility have a low axillary tumor burden. Age, ER, and HER2 status were not predictive of ALND, and the criteria used for ALND (≥3SNs, ECE) reliably identified patients at high risk for residual axillary disease.

Low-volume SLN disease after NAC is not an indicator of a low risk of additional positive axillary nodes and remains an indication for ALND, even when not detected on intraoperative FS.