Nashville Breast Center

Metropolitan Government of Nashville-Davidson (balance), TN, United States

Nashville Breast Center

Metropolitan Government of Nashville-Davidson (balance), TN, United States

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Vicini F.,William Beaumont Hospital | Beitsch P.,Dallas Breast Center | Quiet C.,Arizona Breast Cancer Specialists | Gittleman M.,Sacred Heart Hospital | And 6 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2011

Purpose: To present 5-year data on treatment efficacy, cosmetic results, and toxicities for patients enrolled on the American Society of Breast Surgeons MammoSite breast brachytherapy registry trial. Methods and Materials: A total of 1440 patients (1449 cases) with early-stage breast cancer receiving breast-conserving therapy were treated with the MammoSite device to deliver accelerated partial-breast irradiation (APBI) (34 Gy in 3.4-Gy fractions). Of 1449 cases, 1255 (87%) had invasive breast cancer (IBC) (median size, 10 mm) and 194 (13%) had ductal carcinoma in situ (DCIS) (median size, 8 mm). Median follow-up was 54 months. Results: Thirty-seven cases (2.6%) developed an ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial rate of 3.80% (3.86% for IBC and 3.39% for DCIS). Negative estrogen receptor status (p = 0.0011) was the only clinical, pathologic, or treatment-related variable associated with IBTR for patients with IBC and young age (<50 years; p = 0.0096) and positive margin status (p = 0.0126) in those with DCIS. The percentage of breasts with good/excellent cosmetic results at 60 months (n = 371) was 90.6%. Symptomatic breast seromas were reported in 13.0% of cases, and 2.3% developed fat necrosis. A subset analysis of the first 400 consecutive cases enrolled was performed (352 with IBC, 48 DCIS). With a median follow-up of 60.5 months, the 5-year actuarial rate of IBTR was 3.04%. Conclusion: Treatment efficacy, cosmesis, and toxicity 5 years after treatment with APBI using the MammoSite device are good and similar to those reported with other forms of APBI with similar follow-up. Copyright © 2011 Elsevier Inc.


Hunt K.K.,The Surgical Center | McCall L.M.,Duke Cancer Institute | Boughey J.C.,Mayo Medical School | Mittendorf E.A.,The Surgical Center | And 7 more authors.
Annals of Surgery | Year: 2012

Objective: To determine factors important in local-regional recurrence (LRR) in patients with negative sentinel lymph nodes (SLNs) by hematoxylin and eosin (H&E) staining. Background: Z0010 was a prospective multicenter trial initiated in 1999 by the American College of Surgeons Oncology Group to evaluate occult disease in SLNs and bone marrow of early-stage breast cancer patients. Participants included women with biopsy-proven T1-2 breast cancer with clinically negative nodes, planned for lumpectomy and whole breast irradiation. Methods: Women with clinical T1-2,N0,M0 disease underwent lumpectomy and SLN dissection. There was no axillary-specific treatment for H&E-negative SLNs, and clinicians were blinded to immunohistochemistry results. Systemic therapy was based on primary tumor factors. Univariable and multivariable analyses were performed to determine clinicopathologic factors associated with LRR. Results: Of 5119 patients, 3904 (76.3%) had H&E-negative SLNs. Median age was 57 years (range 23-95). At median follow-up of 8.4 years, there were 127 local, 20 regional, and 134 distant recurrences. Factors associated with local-regional recurrence were hormone receptor-negative disease (P = 0.0004) and younger age (P = 0.047). In competing risk-regression models, hormone receptor-positive disease and use of chemotherapy were associated with reduction in local-regional recurrence. When local recurrence was included in the model as a time-dependent variable, older age, T2 disease, high tumor grade, and local recurrence were associated with reduced overall survival. Conclusions: Local-regional recurrences are rare in early-stage breast cancer patients with H&E-negative SLNs. Younger age and hormone receptor-negative disease are associated with higher event rates, and local recurrence is associated with reduced overall survival. © 2012 Lippincott Williams & Wilkins.


Giuliano A.E.,The Surgical Center | Giuliano A.E.,Cedars Sinai Medical Center | Hawes D.,University of Southern California | Ballman K.V.,Mayo Medical School | And 9 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Immunochemical staining of sentinel lymph nodes (SLNs) and bone marrow identifies breast cancer metastases not seen with routine pathological or clinical examination. Objective: To determine the association between survival and metastases detected by immunochemical staining of SLNs and bone marrow specimens from patients with early-stage breast cancer. Design, Setting, and Patients: From May 1999 to May 2003, 126 sites in the American College of Surgeons Oncology Group Z0010 trial enrolled women with clinical T1 to T2N0M0 invasive breast carcinoma in a prospective observational study. Interventions: All 5210 patients underwent breast-conserving surgery and SLN dissection. Bone marrow aspiration at the time of operation was initially optional and subsequently mandatory (March 2001). Sentinel lymph node specimens (hematoxylineosin negative) and bone marrow specimens were sent to a central laboratory for immunochemical staining; treating clinicians were blinded to results. Main Outcome Measures: Overall survival (primary end point) and disease-free survival (a secondary end point). Results: Of 5119 SLN specimens (98.3%), 3904 (76.3%) were tumor-negative by hematoxylin-eosin staining. Of 3326 SLN specimens examined by immunohistochemistry, 349 (10.5%) were positive for tumor. Of 3413 bone marrow specimens examined by immunocytochemistry, 104 (3.0%) were positive for tumors. At a median follow-up of 6.3 years (through April 2010), 435 patients had died and 376 had disease recurrence. Immunohistochemical evidence of SLN metastases was not significantly associated with overall survival (5-year rates: 95.7%; 95% confidence interval [CI], 95.0%-96.5% for immunohistochemical negative and 95.1%; 95% CI, 92.7%-97.5% for immunohistochemical positive disease; P=.64; unadjusted hazard ratio [HR], 0.90; 95% CI, 0.59-1.39; P=.64). Bone marrow metastases were associated with decreased overall survival (unadjusted HR for mortality, 1.94; 95% CI, 1.02-3.67; P=.04), but neither immunohistochemical evidence of tumor in SLNs (adjusted HR, 0.88; 95% CI, 0.45-1.71; P=.70) nor immunocytochemical evidence of tumor in bone marrow (adjusted HR, 1.83; 95% CI, 0.79-4.26; P=.15) was statistically significant on multivariable analysis. Conclusion: Among women receiving breast-conserving therapy and SLN dissection, immunohistochemical evidence of SLN metastasis was not associated with overall survival over a median of 6.3 years, whereas occult bone marrow metastasis, although rare, was associated with decreased survival. Trial Registration: clinicaltrials.gov Identifier: NCT00003854. ©2011 American Medical Association. All rights reserved.


Vicini F.,Michigan HealthCare Professionals 21st Century Oncology | Vicini F.,Oakland University | Shah C.,Oakland University | Lyden M.,Biostat Inc. | Whitworth P.,Nashville Breast Center
Clinical Breast Cancer | Year: 2012

Background: Single-frequency bioelectrical impedance (BI) has been used to measure extracellular fluid in the upper limbs. The purpose of the study was to evaluate BI's ability to detect and monitor upper limb changes in based upon the extent of various treatments and to assess its practicality. Methods: Patients with newly diagnosed breast cancer were evaluated at baseline and after procedures that could potentially affect fluid accumulation in the arm and signal the possible development of early lymphedema. The magnitude of the change in lymphedema index ratios (LIR) from these procedures was evaluated to determine the sensitivity of BI. Results: A total of 64 patients were evaluated. Although no difference in LIRs was noted by the extent of surgical procedure (lumpectomy 2.1 vs. mastectomy 1.1; P = .49), a trend was noted for increased LIRs with more aggressive axillary staging when sentinel lymph node was compared with axillary lymph node dissection (1.3 vs. 3.4; P = .08). A trend for an increased LIR with more aggressive local therapy also was noted when using a cutoff of less than 4 lymph nodes sampled compared with 4 or more nodes sampled (1.2 vs. 2.6; P = .09). Conclusions: In this limited analysis, L-Dex readings paralleled the extent of surgical interventions and suggest that they can be used to monitor patients for the early onset of edema. Further studies are needed to help validate the extent, degree, and chronologic time frame of these changes to help define recommendations for closer monitoring of patients and possible early intervention. © 2012 Elsevier Inc. All rights reserved.


Beitsch P.D.,The Surgical Center | Whitworth P.W.,Nashville Breast Center
Annals of Surgical Oncology | Year: 2014

Results: By January 2, 2014, 907 responses (34.84 %) had arrived from breast surgeons nationwide working in academic settings (20 %), solo or small group private practice (39 %), large multispecialty groups (18 %), and other settings. More than half said they performed 3-generation pedigrees, ordered genetic testing, and provided pre- and posttest counseling. Most noted that they would welcome continuing educational support in genetics.Background: Whether breast cancer surgeons are adequately trained, skilled, and experienced to provide breast cancer genetic assessment, testing, and counseling came under debate in September 2013 when a major third-party payer excluded nongenetics specialists from ordering such testing. A literature search having failed to uncover any study on breast surgeons’ skill and practice in this area, the American Society of Breast Surgeons (ASBrS) surveyed its members on their experience with the recognized crucial components of such testing.Methods: In late 2013, ASBrS e-mailed a link to an online questionnaire to its U.S. members (n = 2,603) requesting a self-assessment of skills and experience in genetic assessment, testing, interpretation, and counseling. After approximately 6 weeks, the results were collated and evaluated.Conclusions: Currently the majority of breast surgeons provide genetic counseling and testing services to their patients. They report practices that meet or exceed recognized guidelines, including the necessary elements and processes for best practices in breast cancer genetics test counseling. Because breast cancer genetic testing is grossly underutilized relative to the size of the U.S. BRCA mutation carrier population, these appropriate services should not be restricted but rather supported and expanded. © 2014, Society of Surgical Oncology.


Giuliano A.E.,John Wayne Cancer Institute | Hunt K.K.,University of Texas M. D. Anderson Cancer Center | Ballman K.V.,Mayo Medical School | Beitsch P.D.,Dallas Surgical Group | And 6 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Sentinel lymph node dissection (SLND) accurately identifies nodal metastasis of early breast cancer, but it is not clear whether further nodal dissection affects survival. Objective: To determine the effects of complete axillary lymph node dissection (ALND) on survival of patients with sentinel lymph node (SLN) metastasis of breast cancer. Design, Setting, and Patients: The American College of Surgeons Oncology Group Z0011 trial, a phase 3 noninferiority trial conducted at 115 sites and enrolling patients from May 1999 to December 2004. Patients were women with clinical T1-T2 invasive breast cancer, no palpable adenopathy, and 1 to 2 SLNs containing metastases identified by frozen section, touch preparation, or hematoxylin-eosin staining on permanent section. Targeted enrollmentwas 1900 women with final analysis after 500 deaths, but the trial closed early because mortality rate was lower than expected. Interventions: All patients underwent lumpectomy and tangential whole-breast irradiation. Those with SLN metastases identified by SLND were randomized to undergo ALND or no further axillary treatment. Those randomized to ALND underwent dissection of 10 or more nodes. Systemic therapy was at the discretion of the treating physician. Main Outcome Measures: Overall survival was the primary end point, with a non-inferiority margin of a 1-sided hazard ratio of less than 1.3 indicating that SLND alone is noninferior to ALND. Disease-free survival was a secondary end point. Results: Clinical and tumor characteristics were similar between 445 patients randomized to ALND and 446 randomized to SLND alone. However, the median number of nodes removed was 17 with ALND and 2 with SLND alone. At a median follow-up of 6.3 years (last follow-up, March 4, 2010), 5-year overall survival was 91.8% (95% confidence interval [CI], 89.1%-94.5%)with ALND and 92.5% (95% CI, 90.0%-95.1%) with SLND alone; 5-year disease-free survival was 82.2% (95% CI, 78.3%-86.3%) with ALND and 83.9% (95% CI, 80.2%-87.9%) with SLND alone. The hazard ratio for treatment-related overall survival was 0.79 (90% CI, 0.56-1.11) without adjustment and 0.87 (90% CI, 0.62-1.23) after adjusting for age and adjuvant therapy. Conclusion: Among patients with limited SLN metastatic breast cancer treated with breast conservation and systemic therapy, the use of SLND alone compared with ALND did not result in inferior survival. Trial Registration clinicaltrials.gov Identifier: NCT00003855. ©2011 American Medical Association. All rights reserved.


Giuliano A.E.,John Wayne Cancer Institute | McCall L.,The American College | Beitsch P.,Dallas Surgical Group | Whitworth P.W.,Nashville Breast Center | And 6 more authors.
Annals of Surgery | Year: 2010

Background and Objective: Sentinel lymph node dissection (SLND) has eliminated the need for axillary dissection (ALND) in patients whose sentinel node (SN) is tumor-free. However, completion ALND for patients with tumor-involved SNs remains the standard to achieve locoregional control. Few studies have examined the outcome of patients who do not undergo ALND for positive SNs. We now report local and regional recurrence information from the American College of Surgeons Oncology Group Z0011 trial. Methods: American College of Surgeons Oncology Group Z0011 was a prospective trial examining survival of patients with SN metastases detected by standard H and E, who were randomized to undergo ALND after SLND versus SLND alone without specific axillary treatment. Locoregional recurrence was evaluated. Results: There were 446 patients randomized to SLND alone and 445 to SLND + ALND. Patients in the 2 groups were similar with respect to age, Bloom-Richardson score, estrogen receptor status, use of adjuvant systemic therapy, tumor type, T stage, and tumor size. Patients randomized to SLND + ALND had a median of 17 axillary nodes removed compared with a median of only 2 SN removed with SLND alone (P < 0.001). ALND also removed more positive lymph nodes (P < 0.001). At a median follow-up time of 6.3 years, there were no statistically significant differences in local recurrence (P = 0.11) or regional recurrence (P = 0.45) between the 2 groups. Conclusions: Despite the potential for residual axillary disease after SLND, SLND without ALND can offer excellent regional control and may be reasonable management for selected patients with early-stage breast cancer treated with breast-conserving therapy and adjuvant systemic therapy. © 2010 by Lippincott Williams & Wilkins.


Shah C.,University of Washington | Arthur D.,Virginia Commonwealth University | Riutta J.,Beaumont Health System | Whitworth P.,Nashville Breast Center | Vicini F.A.,Michigan HealthCare Professionals 21st Century Oncology
Breast Journal | Year: 2012

With improved outcomes following treatment of breast cancer, chronic toxicities including breast cancer related lymphedema (BCRL), gain increased significance with limited evidence-based guidelines present. This review attempts to summarize data addressing these concerns and provides recommendations based on currently published data. Substantial differences exist in rates of BCRL reported in the literature ranging from less than 5% to 65% based on locoregional therapy. Based on recent data, early diagnosis of BCRL appears critical and requires careful attention to patient risk factors and the use of newer diagnostic tools. Initial treatment with decongestive lymphatic therapy/compressive stockings can provide significant improvement in patient symptoms and volume reduction of edematous extremities. At this time, consensus recommendations for disease classification, diagnostic testing and treatment are still lacking. Awareness of the frequency of this toxicity is now important as more accurate clinical aids have become accessible to diagnose the condition at an earlier stage allowing timely intervention providing the opportunity for treatment strategies to be more effective. © 2012 Wiley Periodicals, Inc.


Whitworth P.W.,Nashville Breast Center | Whitworth P.W.,Vanderbilt University
Annals of Surgical Oncology | Year: 2011

Background: Open surgical excision (OSE) is generally recommended when image-guided core needle breast biopsy demonstrates a high-risk lesion (HRL). We evaluated intact percutaneous excision (IPEX) with standard radiologic and histologic criteria for definitive diagnosis of HRL, particularly atypical ductal hyperplasia (ADH).The primary goal was to confirm criteria associated with <2% risk for upgrade to carcinoma, equivalent to risk associated with BI-RADS 3 lesions, for which imaging surveillance is considered sufficient. Methods: In an institutional review board-approved prospective trial, 1,170 patients recommended for breast biopsy at 25 institutions received IPEX with a vacuum- and radiofrequency-assisted device. ADH patients in whom the imaged lesion had been removed and the lesion adequately centered for definitive characterization were designated as the potential surgical avoidance population (PSAP) before OSE. Subsequent OSE specimen pathology was compared with IPEX findings. Results: In 1,170 patients, 191 carcinomas and 83 (7%) HRL, including 32 ADH (3%), were diagnosed via IPEX. None of the 51 non-ADH HRL were upgraded to carcinoma on OSE (n = 24) or, if OSE was declined, on radiologic follow-up (n = 27). No ADH lesions meeting PSAP criteria (n = 10) were upgraded to carcinoma on OSE; 3 (14%) of 22 non-PSAP ADH lesions were upgraded to carcinoma on OSE. In summary, no upgrades to carcinoma were made in patients with non-ADH lesions who underwent IPEX or in ADH patients who had IPEX, met histologic and radiologic criteria, and underwent OSE. Conclusions: IPEX combined with straightforward histologic and radiologic criteria and imaging surveillance constitutes acceptable management of image-detected HRL, including ADH. © 2011 Society of Surgical Oncology.


Whitworth P.W.,Nashville Breast Center
Annals of surgical oncology | Year: 2011

Open surgical excision (OSE) is generally recommended when image-guided core needle breast biopsy demonstrates a high-risk lesion (HRL). We evaluated intact percutaneous excision (IPEX) with standard radiologic and histologic criteria for definitive diagnosis of HRL, particularly atypical ductal hyperplasia (ADH).The primary goal was to confirm criteria associated with <2% risk for upgrade to carcinoma, equivalent to risk associated with BI-RADS 3 lesions, for which imaging surveillance is considered sufficient. In an institutional review board-approved prospective trial, 1,170 patients recommended for breast biopsy at 25 institutions received IPEX with a vacuum- and radiofrequency-assisted device. ADH patients in whom the imaged lesion had been removed and the lesion adequately centered for definitive characterization were designated as the potential surgical avoidance population (PSAP) before OSE. Subsequent OSE specimen pathology was compared with IPEX findings. In 1,170 patients, 191 carcinomas and 83 (7%) HRL, including 32 ADH (3%), were diagnosed via IPEX. None of the 51 non-ADH HRL were upgraded to carcinoma on OSE (n = 24) or, if OSE was declined, on radiologic follow-up (n = 27). No ADH lesions meeting PSAP criteria (n = 10) were upgraded to carcinoma on OSE; 3 (14%) of 22 non-PSAP ADH lesions were upgraded to carcinoma on OSE. In summary, no upgrades to carcinoma were made in patients with non-ADH lesions who underwent IPEX or in ADH patients who had IPEX, met histologic and radiologic criteria, and underwent OSE. IPEX combined with straightforward histologic and radiologic criteria and imaging surveillance constitutes acceptable management of image-detected HRL, including ADH.

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