Annual Report 2019
Department of Breast Surgery
Akihiko Suto, Shin Takayama, Kenjiro Jimbo, Sho Shiino, Takeshi Murata, Chikashi Watase
Introduction
The Department of Breast Surgery deals with treatment of breast disease through surgeries, as well as diagnosis of breast diseases and assessment of lymph nodes in the axillary and clavicular regions which are suspected of harboring metastases. In fiscal 2019, we performed a total of 721 operations on breast diseases (667 were primary breast cancer or breast sarcoma) (Table 1, Table 2). As the "Table" shows, the figure for 2018 was the highest ever, but in 2019, the number was slightly down. Surgical procedure trends have also been changing in recent years. Although breast partial resection (Bp) accounted for 37% of the total surgeries in our department in 2019, the Bp rate has been constant. On the other hand, immediate reconstruction surgeries have rapidly increased in recent years. One of the reasons is the increasing needs of patients for immediate reconstruction surgeries. In our hospital, since 2010, immediate breast reconstruction became one of the choices for patients for whom breast preservation was cosmetically difficult, and a total of 104 immediate breast reconstructions were performed in fiscal 2019 comprising 26% of all cases. Fifteen of 104 were tissue expander (TE) operations and eight direct implant (DIM), and 81 autologous reconstruction (69 DIEP: deep inferior epigastric perforator flap; 23 LD: latissimus dorsi muscle flap) (Table 3) were performed. Implant reconstruction significantly decreased and the rate of autologous tissue reconstruction increased during the year as implant bags were reported to be associated with occurrence of malignant lymphoma (Breast Implant-Associated Anaplastic Large Cell Lymphoma: BIA-ALCL). We perform these reconstruction surgeries in cooperation with plastic surgeons depending on patients’ needs. And the new less-invasive technique, radiofrequency abrasion (RFA), is another topic of our surgeries. RFA is a new treatment which boils tumors using electro-radio waves; in addition, it reduces the physical burden on patients and breast deformation after surgery. So as to make RFA one of the standard treatments in breast cancer in the near future, we are currently researching the efficacy and safety of RFA (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 2019, 28 RFAs were performed. In the future, we think that the number of RFAs is expected to increase with the registration of this new study. When focusing on axillary staging management, sentinel lymph node (SLN) biopsies (SLNBs) were performed in 85% of cases. Following SLNB, the axillary lymph node dissection (ALND) could be avoided when the SLNB was negative. Another new challenge we are engaging in concerns OSNA (One-step nucleic acid amplification). OSNA quantitatively measures CK19 mRNA from sentinel lymph node metastases even at molecular levels. And in conjunction with this assay and conventional microscopic method, we began to be able to evaluate the SLNs more precisely. Further, by comparing the OSNA results with those of conventional histological diagnosis, we try to realize the possibility of omitting axillary lymph node dissection by using two methods. As a result, we established a model for intraoperatively predicting axillary lymph node metastasis based on the combined use of OSNA and histological examination (NCS score), and these results were published in the European Journal of Surgical Oncology (Nov 2019). We believed that axillary dissection can be omitted for clinical node negative patients by using this prediction model, and we thought that the use of this model will facilitate the selection of optimal adjuvant therapies without requiring unnecessary axillary lymph node dissection. Thus, we are striving continuously to meet the diverse needs of breast cancer patients.
Table 2. Type of procedure (breast surgery)
The Team and What We Do
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. Nakadaira), and two or three rotating residents. From 7:30 every morning, all the staff and residents perform in-patient rounds together. Weekly conferences are held on Monday from 17:00 to 18:00, and on every Friday from 7:45 to 8:15. On Friday, we hold a journal club and share the most up-to-date knowledge on breast oncology. On Monday, we share discussions with surgeons, and the diagnostic images are reviewed for every pre-operative patient. 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.
Surgery
We perform surgeries from Monday to Friday; there are usually 12 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. The rate of mastectomy was 391 cases (57%), including 104 cases of immediate reconstruction. SLNB was performed on 529 (85%) patients, and many patients were spared from ALND in 2019.
Research activities and Clinical trials
1. Radiofrequency ablation therapy for early breast cancer as local therapy (RAFAELO study)
2. Patients offered Radio Radiofrequency ablation therapy for early breast cancer as local therapy (PO-RAFAELO study)
3. Intensive versus standard post-operative surveillance in high risk breast cancer patients (JCOG1204, INSPIRE Trial)
4. 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)
5. Postoperative Therapy with Endocrine and TS-1 (POTENT study)
6. Registration Data-base System of breast cancer patients who received lymph node metastasis diagnosis by the OSNA method (LynoLog Data-base)
7. Olaparib as Adjuvant Treatment in Patients With Germline BRCA Mutated High Risk HER2 Negative Primary Breast Cancer (OlympiA)
8. Hair Loss Prevention System with chemotherapy-induced alopecia in breast cancer patients in Japan (HOPE)
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 the future of cancer fields.
List of papers published in 2019
Journal
1. Jimbo K, Kinoshita T, Ogura T, Watase C, Murata T, Shiino S, Takayama S, Yoshida M. Prediction score model for non-sentinel and four or more nodal metastases using a combined method of one-step nucleic acid amplification and histology in sentinel node-positive breast cancer patients. Eur J Surg Oncol, 46:516-521, 2020
2. Shiino S, Yoshida M, Tokura M, Watase C, Murata T, Jimbo K, Takayama S, Suto A, Satomi K, Miyagi Maeshima A, Kikuchi M, Uchiyama N, Kinoshita T. Locally advanced triple negative breast cancer arising from fibroadenoma with complete response to neoadjuvant chemotherapy: A case report. Int J Surg Case Rep, 68:234-238, 2020
3. Ohno S, Mukai H, Narui K, Hozumi Y, Miyoshi Y, Yoshino H, Doihara H, Suto A, Tamura M, Morimoto T, Zaha H, Chishima T, Nishimura R, Ishikawa T, Uemura Y, Ohashi Y. Participants in a randomized controlled trial had longer overall survival than non-participants: a prospective cohort study. Breast Cancer Res Treat, 176:631-635, 2019
4. Murata T, Yanagisawa T, Kurihara T, Kaneko M, Ota S, Enomoto A, Tomita M, Sugimoto M, Sunamura M, Hayashida T, Kitagawa Y, Jinno H. Salivary metabolomics with alternative decision tree-based machine learning methods for breast cancer discrimination. Breast Cancer Res Treat, 177:591-601, 2019
5. Takayama S, Satomi K, Yoshida M, Watase C, Murata T, Shiino S, Jimbo K, Suto A. Spontaneous regression of occult breast cancer with axillary lymph node metastasis: A case report. Int J Surg Case Rep, 63:75-79, 2019
6. Hironaka-Mitsuhashi A, Sanchez Calle A, Ochiya T, Takayama S, Suto A. Towards Circulating-Tumor DNA-Based Precision Medicine. J Clin Med, 8:1365, 2019
7. Narui K, Ishikawa T, Shimizu D, Yamada A, Tanabe M, Sasaki T, Oba MS, Morita S, Nawata S, Kida K, Mogaki M, Doi T, Tsugawa K, Ogata H, Ota T, Kosaka Y, Sengoku N, Kuranami M, Niikura N, Saito Y, Suzuki Y, Suto A, Arioka H, Chishima T, Ichikawa Y, Endo I, Tokuda Y. Anthracycline could be essential for triple-negative breast cancer: A randomised phase II study by the Kanagawa Breast Oncology Group (KBOG) 1101. Breast, 47:1-9, 2019