UNASSIGNED: Breast angiosarcoma is a rare, aggressive tumour affecting adult women. It can occur in two forms, primary form and secondary forms or radiation-induced breast angiosarcoma affecting patients with history of breast or chest radiotherapy.
UNASSIGNED: The authors report a new case of breast angiosarcoma in 52-year-old women, with history of invasive ductal carcinoma, and reporting a discoloration of her breast skin. The patient did undergo a mastectomy of right breast and adjuvant chemotherapy.
UNASSIGNED: Surgery with total excision associated or not to adjuvant chemotherapy remains the treatment of choice in breast angiosarcoma.

Five-fraction adjuvant whole breast radiation has been shown to be a safe and effective alternative to longer fractionation regimens. Given the lack of international consensus on patient selection for the protocol, we developed a consensus protocol to guide patient selection and facilitate safe and efficient five-fraction radiation in our radiation medicine department. In developing the directive, we surveyed departmental physicians about their choice of adjuvant breast regimen for various clinical scenarios. Patient travel burden was the factor most strongly impacting radiation oncologists’ decision-making when considering prescribing a five-fraction course of adjuvant breast radiation; the length of clinical trial follow-up data and acute and late normal tissue effects also impacted it, along with personal clinical experience and experience of dosimetry and physics personnel. Relative value unit (RVU) reimbursement and financial toxicity to the patient were reported to be less important in decision-making. Physicians were most comfortable using five-fraction radiation in women >50 years of age with low-risk cancer and for patients unable to attend for longer treatment courses. Eight months after implementation, the protocol accounts for 4.7% of breast irradiation delivered in our department.

OBJECTIVE: Radiation to breast, chest wall, and/or regional nodes is an integral component of breast cancer management in many situations. Irradiating left-sided breast and/or regional nodes may be technically challenging because of cardiac tolerance and subsequent risk of long-term cardiac complications. Deep inspiratory breath-hold (DIBH) technique physically separates cardiac structures away from radiation target volume, thus reducing cardiac dose with either photon (Ph) or proton beam therapy (PBT). The utility of combining PBT with DIBH is less well understood.
METHODS: We compared photon-DIBH (Ph-DIBH) versus proton DIBH (Pr-DIBH) for different planning parameters, including target coverage and organ at risk (OAR) sparing. Necessary ethical permission was obtained from the institutional review board. Ten previous patients with irradiated, intact, left-sided breast and Ph-DIBH were replanned with PBT for dosimetric comparison. Clinically relevant normal OARs were contoured, and Ph plans were generated with parallel, opposed tangent beams and direct fields for supraclavicular and/or axillae whenever required. For proton planning, all targets were delineated individually and best possible coverage of planning target volume was achieved. Dose-volume histogram was analyzed to determine the difference in doses received by different OARs. Minimum and maximum dose (Dmin and Dmax ) as well as dose received by a specific volume of OAR were compared. Each patient\'s initial plan (Ph-DIBH) was used as a control for comparing newly devised PBT plan (Pr-DIBH). Matched, paired t tests were applied to determine any significant differences between the 2 plans.
RESULTS: Both the plans were adequate in target coverage. Dose to cardiac structure subunits and ipsilateral lung were significantly reduced with the proton breath-hold technique. Significant dose reduction with Pr-DIBH was observed in comparison to Ph-DIBH for mean dose (D mean) to the heart (0.23 Gy versus 1.19 Gy; P < .001); D mean to the left ventricle (0.25 Gy versus 1.7 Gy; P < .001); D mean, D max, and the half-maximal dose to the left anterior descending artery (1.15 Gy versus 5.54 Gy; P < .003; 7.7 Gy versus 22.15 Gy; P < .007; 1.61 Gy versus 4.42 Gy, P < .049); D max of the left circumflex coronary artery (0.13 Gy versus 1.35 Gy; P < .001) and D mean, the volume to the ipsilateral lung receiving 20 Gy and 5 Gy (2.28 Gy versus 8.04 Gy; P < .001; 2.36 Gy versus 15.54 Gy, P < .001; 13.9 Gy versus 30.28 Gy; P = .002). However, skin dose and contralateral breast dose were not significantly improved with proton.
CONCLUSIONS: This comparative dosimetric study showed significant benefit of Pr-DIBH technique compared with Ph-DIBH in terms of cardiopulmonary sparing and may be the area of future clinical research.

BACKGROUND: The internal mammary artery (IMA) has supplanted the thoracodorsal artery as the primary recipient vessel in autologous breast reconstruction. Additionally, the IMA continues to be the preferred bypass graft choice in patients undergoing coronary artery bypass grafting (CABG). However, practice patterns in breast reconstruction have evolved considerably since the adoption of the IMA for this application. The authors sought to evaluate the safety of IMA harvest for breast reconstruction in our current practice, given the possibility that patients may require CABG in the future.
METHODS: The authors reviewed the prospective database of free flaps for breast reconstruction performed at their center from 2009 to 2017. Patients were divided into three groups (2009-2011, 2011-2013, 2014-2017) and compared on the basis of demographics, medical comorbidities, and laterality of reconstruction. Patients were further risk stratified for 10-year risk of cardiovascular events using the American College of Cardiology\'s atheroscletoric and cardiovascular disease (ASCVD) risk calculator.
RESULTS: There was a marked increase in the number of patients who underwent microsurgical breast reconstruction at our institution over the past three years (2009-2011, n = 55; 2012-2014, n = 50; 2015-2017, n = 145). The distribution of unilateral versus bilateral flaps changed meaningfully; however, they did not change statistically significantly over the study period (2009-2011 = 32.7%, 2012-2014 = 28.0%, 2015-2017 = 49.0%, p = 0.12). The rise in bilateral reconstructions over the study period is commensurate with the observed significant rise in contralateral prophylactic mastectomies (2009-2011 = 25.5%, 2012-2014 = 20.0%, 2015-2017 = 42.1%, p = 0.022). The mean 10-year risk of major cardiovascular events in the entire sample was 6.3 ± 7.1% (median 4.0%). The maximum individual risk score exceeded 25% in all three groups.
CONCLUSIONS: Given overall trends in breast reconstruction and the sometimes-elevated cardiac risk profiles of our patients, the authors recommend risk stratification of all patients using the proposed Breast Reconstruction Internal Mammary Assessment (BRIMA) scoring system and consideration of left internal mammary artery preservation in select cases.

BACKGROUND: Men represent a small proportion of breast cancer diagnoses, and they are often excluded from clinical trials. Current treatments are largely extrapolated from evidence in women. We compare practice patterns between men and women with breast cancer following the publication of several landmark clinical trials in surgery.
METHODS: Patients with invasive breast cancer (2004-2015) from the National Cancer Data Base were identified; subcohorts were created based on eligibility for NSABP-B06, CALGB 9343, and ACOSOG Z0011. Practice patterns were stratified by gender and compared. Cox proportional hazards regression analyses were utilized to estimate the association between OS and gender.
RESULTS: Of the 1,664,746 patients identified, 99% were women and 1% were men. Among NSABP-B06 eligible men, mastectomy rates did not change (consistently ~ 80%), and their adjusted OS was minimally worse compared with women (HR 1.19, 95% CI 1.11-1.28). Following publication of CALGB 9343, omission of radiation after lumpectomy was less likely in men and lagged behind that of women, despite similar OS (male HR 0.92, 95% CI 0.59-1.44). Application of ACOSOG Z0011 findings resulted in deescalation of axillary surgery for men and women with comparable OS (male HR 0.69, 95% CI 0.33-1.45).
CONCLUSIONS: Uptake of clinical trial results for men with breast cancer often mirrors that for women, despite exclusion from these studies. Furthermore, when study findings were applied to eligible patients, men and women demonstrated similar survival. Observational studies can help inform the potential application of study findings to this unique population and improve patient enrollment in clinical trials.

To investigate adverse events (AEs, CTCAE v4.0) and clinical outcomes for proton beam therapy (PBT) reirradiation (reRT) for breast cancer. From 2011 to 2016, 50 patients received PBT reRT for breast cancer in the prospective Proton Collaborative Group (PCG) registry. Acute AEs occurred within 180 days from start of reRT. Late AEs began or persisted beyond 180 days. Fisher\'s exact and Mann-Whitney rank-sum tests were utilized. Kaplan-Meier methods were used to estimate overall survival (OS) and local recurrence-free survival (LFRS). Median follow-up was 12.7 months (0-41.8). Median prior RT dose was 60 Gy (10-96.7). Median reRT dose was 55.1 Gy (45.1-76.3). Median cumulative dose was 110.6 Gy (70.6-156.8). Median interval between RT courses was 103.8 months (5.5-430.8). ReRT included regional nodes in 84% (66% internal mammary node [IMN]). Surgery included the following: 44% mastectomy, 22% wide local excision, 6% lumpectomy, 2% reduction mammoplasty, and 26% no surgery. Grade 3 AEs were experienced by 16% of patients (10% acute, 8% late) and were associated with body mass index (BMI) > 30 kg/m2 (P = 0.04), bilateral recurrence (P = 0.02), and bilateral reRT (P = 0.004). All grade 3 AEs occurred in patients receiving IMN reRT (P = 0.08). At 1 year, LRFS was 93%, and OS was 97%. Patients with gross disease at time of PBT trended toward worse 1-year LRFS (100% without vs. 84% with, P = 0.06). PBT reRT is well tolerated with favorable local control. BMI > 30, bilateral disease, and IMN reRT were associated with grade 3 AEs. Toxicity was acceptable despite median cumulative dose > 110 Gy.

Radiotherapy (RT) for breast cancer improves survival, but poses risk to the heart, resulting from a linear relationship between RT dose and heart disease. This review presents studies worldwide reporting heart doses from whole breast RT after 2014 to update a previous systematic review (Taylor et al, Int J Radiat Oncol Biol Phys, 2015) in order to determine patterns of current heart dosimetry among varying RT regimens. Studies published between January 2014 and September 2017 were included if they reported whole heart dose based on whole breast RT technique or treatment position and had a sample size of ≥ 20 patients. Studies reporting brachytherapy, proton RT only, or boost to tumor bed were excluded. Among 99 studies, whole heart dose was reported by 231 regimens. The mean heart dose for left-sided breast cancer, reported by 84 studies (196 regimens), was 3.6 Gy, compared with a review of those previously reported (5.4 Gy). Regimens employing breathing control in any position had a significantly lower mean heart dose (1.7 Gy) compared with regimens without breathing control (4.5 Gy) (P < .0001). The mean heart dose varied significantly between continents (P < .0001), with heterogeneity reported among countries within Europe (P = .04) although not within other continents. On average, the mean heart dose steadily decreased between 2014 (4.6 Gy) and 2017 (2.6 Gy) (P = .003). Other heart dose parameters including the mean dose to the left anterior descending artery were reported by 80 left-sided regimens, and the mean left anterior descending artery dose was 12.4 Gy.

Nipple-areola reconstruction represents the completion of the breast restorative process and is associated with significant positive psychological implications. While factors such as medical comorbidities, smoking status, and radiation therapy have been shown to be associated with an increase in complications following breast reconstruction, their impact on nipple reconstruction remains largely unaddressed in the literature. An IRB-approved, retrospective review of 472 patients who underwent nipple reconstruction at Wake Forest University over a 15-year period was completed. Demographic and surgical characteristics were assessed including age, body mass index, medical comorbidities, smoking status, need for radiation, breast reconstruction type, and nipple flap used. Four hundred and seventy-two patients with 641 nipple reconstructions were included with an average follow-up of 56.5 months. Radiation prior to nipple reconstruction was required in 146 breasts (22.8%). Overall, postoperative nipple projection problems occurred in 7.6% of reconstructions with a 4.1% rate of other complications, including nipple necrosis, tip loss, wound infection and wound breakdown. Implant-based reconstruction and radiation were associated with significantly more nipple projection problems (p = 0.009 and 0.05, respectively). Higher rates of complications and nipple projection problems were seen with skate flap reconstruction compared to a star flap (p = 0.046 and 0.001, respectively). Implant-based breast reconstruction and radiotherapy are associated with higher rates of nipple reconstruction problems. Identification of patient and surgical variables associated with increased risk of poor outcomes preoperatively could help in patient counseling and selection of the most appropriate method of breast and nipple reconstruction.

Ductal carcinoma in situ (DCIS) traditionally has been managed through various combinations of surgery, radiation, and endocrine therapy. However, concern for under- or over-treatment of DCIS has led many surgeons to question historically standardized approaches and instead begin to tailor treatment based on individual prognostic indicators. Recent and ongoing clinical trials have investigated the potential for active surveillance in DCIS, the possibility of eliminating radiation therapy (RT), and ways in which adjuvant systemic therapy may be refined. This review will summarize the current trends in the treatment of DCIS, as well as highlight the most pertinent clinical trials that are shaping management today.

Ductal carcinoma-in situ (DCIS) is a non-obligate precursor for invasive breast cancer and concern exists regarding the potential for overdiagnosis and overtreatment as the natural history of DCIS progression to invasive breast cancer may never occur or take decades in some cases. Preoperative systemic therapy window studies may provide powerful clues to best uncover which particular DCIS lesions respond to systemic therapies and allow for future selective personalized management recommendations. One of the main challenges for instituting active surveillance for DCIS with vacuum-assisted core needle biopsy alone and no surgery is concern for leaving untreated occult invasive carcinoma. Breast MRI lacks sufficient diagnostic ability to differentiate pure DCIS from invasive cancer with DCIS. Current novel randomized trials investigating active surveillance versus active management are described. Multigene expression assays may someday prove useful in stratifying patients at increased risk for progression to invasive breast cancer in the absence of surgery.