Background Prognosis and treatment options differ for each molecular subtype of breast cancer, but risk of regional lymph node (LN) metastasis for each subtype has not been well-studied. Since LN status is the most important predictor for prognosis, the aim of this study is to investigate the propensity for LN metastasis in each of the five breast cancer molecular subtypes. Methods Under an IRB-approved protocol, we retrospectively reviewed the charts of all pathologically confirmed breast cancer cases from 1/2004 to 6/2012. Five subtypes were defined as luminal A (hormone receptor +, Ki67 low), luminal B (hormone receptor+, Ki67 high), luminal-human epidermal growth factor receptor 2 (HER-2), HER-2-enriched (hormone receptor negative), and triple negative (TN). Results A total of 375 patients with complete data were classified by subtype: 95 (25.3%) luminal A, 120 (32%) luminal B, 69 (18.4%) luminal-HER-2, 26 (6.9%) HER-2-enriched, and 65 (17.3%) TN. On univariate analysis, age (<50), higher tumor grade, HER-2 + status, tumor size, and molecular subtype were significant for LN positivity. Molecular subtype correlated strongly with tumors size (X2; p=0.0004); therefore, multivariable logistic regression did not identify molecular subtype as an independent variable to predict LN positivity. Conclusions Luminal A tumors have the lowest risk of LN metastasis, while luminal HER-2 subtype has the highest risk of LN metastasis. Immunohistochemical-based molecular classification can be readily performed and knowledge of the factors that affect LN status may help with treatment decisions.

The sternal origin of the pectoralis major was thin and highly variable, suggesting that its partial release for implant medialization during subpectoral augmentation is unsafe.

Background: Reduction mammaplasty is a highly effective procedure for treatment of symptomatic macromastia. Prediction of resection weight is important for the surgeon and the patient, but none of the current prediction models is widely accepted. Insurance carriers are arbitrarily using resection weight to determine medical necessity, despite published literature supporting that resection weight does not correlate with symptomatic relief. What is the most accurate method of predicting resection weight and what is its role in breast reduction surgery? Methods: The authors conducted a retrospective review of patients who underwent reduction mammaplasty at a single institution from 2012 to 2017. A senior biostatistician performed multiple regression analysis to identify predictors of resection weight, and linear regression models were created to compare each of the established prediction scales to actual resected weight. Patient outcomes were evaluated. Results: Three-hundred fourteen patients were included. A new prediction model was created. The Galveston scale performed the best (R 2 = 0.73; p < 0.001), whereas the Schnur scale performed the worst (R 2 = 0.43; p < 0.001). The Appel and Descamps scales had variable performance in different subcategories of body mass index and menopausal status (p < 0.01). Internal validation confirmed the Galveston scale’s best predictive value; 38.6 percent and 28.9 percent of actual breast resection weights were below Schnur prediction and 500-g minimum, respectively, yet 97 percent of patients reported symptomatic improvement or relief. Conclusions: The authors recommend a patient-specific and surgeon-specific approach for prediction of resection weight in breast reduction. The Galveston scale fits the best for older patients with higher body mass indices and breasts requiring large resections. Medical necessity decisions should be based on patient symptoms, physical examination, and the physician’s clinical judgment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.