Department of Breast Surgery

Akihiko Suto, Shin Takayama, Kenjiro Jimbo, Sho Shiino, Takeshi Murata, Chikashi Watase

Introduction

The Department of Breast Surgery mainly deals with surgical treatment of breast cancer, as well as diagnosis of breast diseases, postoperative adjuvant endocrine therapy and surveillance after surgery. In fiscal 2021, we performed a total of 719 operations on breast diseases (686 were primary breast cancer or breast sarcoma) (Table 1, Table 2). Although the number of surgeries increased year by year until 2018, for the next two years, the number decreased slightly, reflecting the decrease in breast cancer screening because of the turmoil of COVID-19. In 2021, the number of surgeries has gradually increased again.

Breast conserving surgery such as breast partial resection (Bp) or Radiofrequency Ablation (RFA) accounted for 41% (287 of 695) of the total breast surgeries in our department in 2021, and the breast conserving rate has been constant in recent years. On the other hand, the rate of immediate reconstruction surgeries has gradually increased. One of the reasons is the increasing need of patients for immediate reconstruction surgeries. In our hospital, since 2010, immediate breast reconstruction has become one of the choices for patients for whom breast preservation is cosmetically difficult, and a total of 126 immediate breast reconstructions were performed in fiscal 2021 comprising 31% of all mastectomies. Twenty-two of 126 were tissue expander (TE) insertions, and 105 autologous reconstructions (83 DIEP: deep inferior epigastric perforator flap; 22 LD: latissimus dorsi muscle flap) were performed (Table 3). In 2018, since Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) was reported overseas, implant reconstruction significantly decreased and the rate of autologous tissue reconstruction increased. We perform these reconstruction surgeries in cooperation with plastic surgeons depending on patients’ needs.

Table 1. Number of patients


Table 2. Type of procedure (breast surgery)

The new less invasive technique, RFA, is one the topics of our surgeries. RFA is a new treatment which ablates tumors using electro-radio waves. The merits of RFA are reduced physical burden on the patient, lower morbidity, lower operating time and avoiding breast deformation after surgery. So as to make RFA one of the standard treatments in breast cancer in the future, we are currently researching its efficacy and safety (RAFAELO and PO-RAFAELO study). Although RAFAELO study recruitment ended in 2017, new recruitment for the PO-RAFAELO study started at the end of fiscal 2018. And in fiscal 2021, 23 RFAs were performed in our hospital. In the near future, we aim for this technique to become one of the choices of standard treatments for early stage breast cancer.

On the other hand, we are also focusing on extended surgery. For example, for ulcerating breast cancer with distant metastasis and bulky breast cancer judged to be unresectable at another hospital, we perform palliative breast resection with or without reconstruction as much as possible for the purpose of local control. We performed one palliative and 12 salvage surgeries (cT4) in fiscal 2020. We are actively working to improve not only the patient's survival but also QOL.

Table 3. Type of procedure (reconstruction surgery)


Furthermore, we also started working on management of hereditary breast cancer and ovarian cancer syndrome (HBOC) in 2020. Many patients had prior genetic counseling and then took the genetic testing. Some of them underwent the contra-lateral risk reduction mastectomy (CRRM). In 2021, a total of 16 cases had CRRM. We manage HBOC patients with genetic specialists and gynecologists to match their needs. As mentioned above, we engage in various activities to meet the diverse needs of breast cancer patients.

Our Team and Daily Activities

Our department is comprised of six staff surgeons specialized in breast cancer (Dr. Suto, Dr. Takayama, Dr. Jimbo, Dr. Shiino, Dr. Murata, and Dr. Watase), one chief resident (Dr. Ogawa), and two or three rotating residents. From 7:30 every morning, all the staff and residents perform in-patient rounds together. Weekly pre-operative and neo-adjuvant conferences are held on Monday from 17:00 to 18:30. At the conferences, we share discussions with surgeons, and the diagnostic images are reviewed for every pre-operative patient. On every Friday from 7:45 to 8:15, we hold a journal club and share the most up-to-date knowledge on breast oncology. A breast pathology/imaging conference is held on the second Wednesday every two months from 18:00 to 19:00 to discuss problems with diagnostic imaging, and with pathologically interesting cases. A conference about studies, institutional treatment guidelines, and recent topics regarding breast cancer is also held irregularly by a multidisciplinary team. Treatment guidelines for primary and metastatic breast cancer have been updated regularly through this multidisciplinary discussion since 2003.

We perform surgeries from Monday to Friday; there are usually 14 to 16 cases of breast cancer in a week. Table 1 shows the total number of patients with primary breast cancer (including breast primary sarcoma) and other breast diseases. The types and number of operative procedures are shown in Table 2. SLNB was performed on 488 (80% of) patients, and many patients were spared from ALND in 2021.

Research activities and Clinical trials

1. Patients offered Radio Radiofrequency ablation therapy for early breast cancer as local therapy (PO-RAFAELO study)

2. Intensive versus standard post-operative surveillance in high risk breast cancer patients (JCOG1204, INSPIRE Trial)

3. Single-arm confirmatory trial of endocrine therapy alone for estrogen positive, low-risk ductal carcinoma in situ of the breast (Low-risk DCIS with endocrine therapy alone-TAM) (JCOG1505, LORETTA Trial)

    

4. Avoid Mastectomy Using Trastuzumab, Pertuzumab and Radiation Study for Breast Cancer (JCOG1806, AMATERAS-BC)

    

5. A multicenter, randomized, open-label phase III study comparing T-DXd and T-DM1 in high-risk HER2-positive breast cancer patients with residual invasive lesions in the breast or axillary lymph nodes after postoperative therapy (DESTINY-Breast05)

Future prospects

The aims of our activities are as follows:

1. Clinical activities
    To provide the very best breast surgical treatment

2.  Research activities
    To develop less invasive breast surgical procedures

3. Educational activities
    To train specialists in breast cancer who will lead cancer fields in the future.

List of papers published

Journal

1. Shiino S, Ball G, Syed BM, Kurozumi S, Green AR, Tsuda H, Takayama S, Suto A, Rakha EA. Prognostic significance of receptor expression discordance between primary and recurrent breast cancers: a meta-analysis. Breast Cancer Res Treat. 2022 191:1-14.

2. Watase C, Shiino S, Shimoi T, Noguchi E, Kaneda T, Yamamoto Y, Yonemori K, Takayama S, Suto A. Breast Cancer Brain Metastasis-Overview of Disease State, Treatment Options and Future Perspectives. Cancers (Basel). 2021 13:1078.

3. Ochi E, Tsuji K, Narisawa T, Shimizu Y, Kuchiba A, Suto A, Jimbo K, Takayama S, Ueno T, Sakurai N, Matsuoka Y. Cardiorespiratory fitness in breast cancer survivors: a randomised controlled trial of home-based smartphone supported high intensity interval training. BMJ Support Palliat Care. 2022 12:33-37.

4. Tokura M, Nakayama J, Prieto-Vila M, Shiino S, Yoshida M, Yamamoto T, Watanabe N, Takayama S, Suzuki Y, Okamoto K, Ochiya T, Kohno T, Yatabe Y, Suto A, Yamamoto Y. Single-Cell Transcriptome Profiling Reveals Intratumoral Heterogeneity and Molecular Features of Ductal Carcinoma In Situ. Cancer Res. 2022 82:3236-3248.

5. Kurita A, Yoshida M, Murata T, Yoshida A, Uchiyama N, Takayama S. A case of ALK-positive histiocytosis with multiple lesions in the unilateral breast: A case report. Int J Surg Case Rep. 2022 21;97:

6. Yazaki S, Salgado R, Shimoi T, Yoshida M, Shiino S, Kaneda T, Kojima Y, Sumiyoshi-Okuma H, Nishikawa T, Sudo K, Noguchi E, Murata T, Takayama S, Suto A, Ohe Y, Yonemori K. Impact of adjuvant chemotherapy and radiotherapy on tumour-infiltrating lymphocytes and PD-L1 expression in metastatic breast cancer. Br J Cancer. 2022

7. Sekine C, Uchiyama N, Watase C, Murata T, Shiino S, Jimbo K, Iwamoto E, Takayama S, Kurihara H, Satomi K, Yoshida M, Kinoshita T, Suto A. Preliminary experiences of PET/MRI in predicting complete response in patients with breast cancer treated with neoadjuvant chemotherapy. Mol Clin Oncol. 2022 16:50.

8. Osako T, Matsuura M, Yotsumoto D, Takayama S, Kaneko K, Takahashi M, Shimazu K, Yoshidome K, Kuraoka K, Itakura M, Tani M, Ishikawa T, Ohi Y, Kinoshita T, Sato N, Tsujimoto M, Nakamura S, Tsuda H, Noguchi S, Akiyama F. A prediction model for early systemic recurrence in breast cancer using a molecular diagnostic analysis of sentinel lymph nodes: A large-scale, multicenter cohort study. Cancer. 2022. 128:1913-1920.

9. Jimbo K, Nakadaira U, Watase C, Murata T, Shiino S, Takayama S, Suto A. Clinical significance of discordances in sentinel lymph node reactivity between radioisotope and indocyanine green fluorescence in patients with cN0 breast cancer. Asian J Surg. 2023 Jan;46(1):277-282. doi: 10.1016/j.asjsur.2022.03.075.Epub 2022.

10. Murata T, Watase C, Shiino S, Kurita A, Ogawa A, Jimbo K, Iwamoto E, Yoshida M, Takayama S, Suto A. Development and validation of a pre- and intra-operative scoring system that distinguishes between non-advanced and advanced axillary lymph node metastasis in breast cancer with positive sentinel lymph nodes: a retrospective study. World J Surg Oncol. 2022.

11. Yazaki S, Shimoi T, Yoshida M, Sumiyoshi-Okuma H, Arakaki M, Saito A, Kita S, Yamamoto K, Kojima Y, Nishikawa T, Tanioka M, Sudo K, Noguchi E, Murata T, Shiino S, Takayama S, Suto A, Ohe Y, Fujiwara Y, Yonemori K. Integrative prognostic analysis of tumor-infiltrating lymphocytes, CD8, CD20, programmed cell death-ligand 1, and tertiary lymphoid structures in patients with early-stage triple-negative breast cancer who did not receive adjuvant chemotherapy.Breast Cancer Res Treat. 2022.

12.  Maseki H, Takayama S, Yoshida M, Nakadaira U, Watase C, Shiino S, Murata T, Jimbo K, Suto A. A case of lymph node dissection for contralateral axillary lymph node metastasis of ipsilateral breast tumor recurrence after identifying the primary lymphatic drainage by lymphoscintigraphy. Int Cancer Conf J. 2021. 10:154-158.

13. Tsuji K, Matsuoka YJ, Kuchiba A, Suto A, Ochi E. Accuracy of exercise-based tests for estimating cardiorespiratory fitness and muscle strength in early-stage breast cancer survivors in Japan. Support Care Cancer. 2022;30:3857-3863.

14. Teng X, Hayashida T, Murata T, Nagayama A, Seki T, Takahashi M, Kitagawa Y. A transposon screen identifies enhancement of NF-κB pathway as a mechanism of resistance to eribulin. Breast Cancer. 2021;28:884-895.

15. Hayashida T, Odani E, Kikuchi M, Nagayama A, Seki T, Takahashi M, Futatsugi N, Matsumoto A, Murata T, Watanuki R, Yokoe T, Nakashoji A, Maeda H, Onishi T, Asaga S, Hojo T, Jinno H, Sotome K, Matsui A, Suto A, Imoto S, Kitagawa Y. Establishment of a deep-learning system to diagnose BI-RADS4a or higher using breast ultrasound for clinical application. Cancer Sci. 2022;113:3528-3534.