Publications by authors named "Melissa Anne Mallory"

12 Publications

  • Page 1 of 1

Bilateral mastectomy operations and the role for the cosurgeon technique: A Nationwide analysis of surgical practice patterns.

Breast J 2020 02 9;26(2):220-226. Epub 2019 Sep 9.

Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Traditionally, bilateral mastectomy (BM) operations are performed by a single surgeon but a two-attending co-surgeon technique (CST) has been described. A questionnaire was sent to members of the American Society of Breast Surgeons to assess national BM practices and analyze utilization and perceived benefits of the CST. Among surgeons responding, most continue to use the single-surgeon approach for BMs; however, 14.1% utilize the CST and up to 31% are interested in future CST use. Time savings, mentorship, cost savings, and opportunity to learn new techniques were identified as perceived CST advantages.
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http://dx.doi.org/10.1111/tbj.13522DOI Listing
February 2020

Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery.

Ann Surg Oncol 2018 Sep 21;25(9):2573-2578. Epub 2018 May 21.

Department of Surgery, Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, MA, USA.

Background: Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center.

Methods: Retrospective analyses of patients with clinical stage I-II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of 'no ink on tumor' margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation.

Results: Overall, 490 patients with stage I (n  = 408) and stage II (n  = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n  = 114) and varied among surgeons (range 15-40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n  = 7, 6%) and bilateral mastectomy (n  = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm (range 24.5-156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17-15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94-21.22; OR 3.41, 95% CI 1.07-10.85).

Conclusions: Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.
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http://dx.doi.org/10.1245/s10434-018-6526-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6264913PMC
September 2018

Bilateral mastectomies: can a co-surgeon technique offer improvements over the single-surgeon method?

Breast Cancer Res Treat 2018 Aug 23;170(3):641-646. Epub 2018 Apr 23.

Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.

Purpose: Bilateral mastectomy (BM) is traditionally performed using a single-surgeon (SS) technique (SST); a co-surgeon (CS) technique (CST), where each attending surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We sought to compare the CST and SST for BM with respect to operative times and complications.

Methods: Patients undergoing BM without reconstruction at our institution between 2005 and 2015 were identified using operative caselogs and stratified into CS- and SS-cohorts. Operative time (OT; incision to closure) was calculated. Patient age, cancer presence/stage, hormone receptor/BRCA status, breast weight, axillary procedure, and 30-day complications were extracted. Differences in OT, complications, and demographics between cohorts were assessed with t tests and Chi-square tests. A multivariate linear regression model was fit to identify factors independently associated with OT.

Results: Overall, 109 BM cases were identified (CS, n = 58 [53.2%]; SS, n = 51 [46.8%]). Average duration was significantly shorter for the CST by 33 min (21.6% reduction; CS: 120 min vs. SS: 153 min, p < 0.001), with no difference in complication rates (p = 0.65). Demographic characteristics did not differ between cohorts except for total breast weight (TBW) (CS: 1878 g vs. SS: 1452 g, p < 0.05). Adjusting for TBW, CST resulted in a 27.8% reduction in OT (44-min savings, p < 0.001) compared to SST.

Conclusions: The CST significantly reduces OT for BM procedures compared to the SST without increasing complication rates. While time-savings was < 50% and may not be ideal for every patient, the CST offers an alternative BM approach potentially best-suited for large TBW patients and those undergoing axillary procedures.
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http://dx.doi.org/10.1007/s10549-018-4794-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6026038PMC
August 2018

Reply to K. Lin et al.

J Clin Oncol 2016 10 25;34(28):3485-6. Epub 2016 Jul 25.

Brigham and Women's Hospital, Boston, MA

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http://dx.doi.org/10.1200/JCO.2016.68.7723DOI Listing
October 2016

Patient Prognostic Score and Associations With Survival Improvement Offered by Radiotherapy After Breast-Conserving Surgery for Ductal Carcinoma In Situ: A Population-Based Longitudinal Cohort Study.

J Clin Oncol 2016 Apr 1;34(11):1190-6. Epub 2016 Feb 1.

Yasuaki Sagara, Melissa Anne Mallory, Fatih Aydogan, and Mehra Golshan, Brigham and Women's Hospital; Yasuaki Sagara, Harvard T.H. Chan School of Public Health; Rachel A. Freedman, Ines Vaz-Luis, Stephen DeSantis, and William T. Barry, Dana-Farber Cancer Institute, Boston, MA; Stephanie M. Wong, McGill University Health Centre, Montreal, Quebec, Canada; and Fatih Aydogan, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey.

Purpose: Radiotherapy (RT) after breast-conserving surgery (BCS) is a standard treatment option for the management of ductal carcinoma in situ (DCIS). We sought to determine the survival benefit of RT after BCS on the basis of risk factors for local recurrence.

Patients And Methods: A retrospective longitudinal cohort study was performed to identify patients with DCIS diagnosed between 1988 and 2007 and treated with BCS by using SEER data. Patients were divided into the following two groups: BCS+RT (RT group) and BCS alone (non-RT group). We used a patient prognostic scoring model to stratify patients on the basis of risk of local recurrence. We performed a Cox proportional hazards model with propensity score weighting to evaluate breast cancer mortality between the two groups.

Results: We identified 32,144 eligible patients with DCIS, 20,329 (63%) in the RT group and 11,815 (37%) in the non-RT group. Overall, 304 breast cancer-specific deaths occurred over a median follow-up of 96 months, with a cumulative incidence of breast cancer mortality at 10 years in the weighted cohorts of 1.8% (RT group) and 2.1% (non-RT group; hazard ratio, 0.73; 95% CI, 0.62 to 0.88). Significant improvements in survival in the RT group compared with the non-RT group were only observed in patients with higher nuclear grade, younger age, and larger tumor size. The magnitude of the survival difference with RT was significantly correlated with prognostic score (P < .001).

Conclusion: In this population-based study, the patient prognostic score for DCIS is associated with the magnitude of improvement in survival offered by RT after BCS, suggesting that decisions for RT could be tailored on the basis of patient factors, tumor biology, and the prognostic score.
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http://dx.doi.org/10.1200/JCO.2015.65.1869DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4872326PMC
April 2016

Does "Two is Better Than One" Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies.

Ann Surg Oncol 2016 Apr 29;23(4):1111-6. Epub 2015 Oct 29.

Department of Surgery, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA.

Background: Bilateral mastectomies (BM) are traditionally performed by single surgeons (SS); a co-surgeon (CS) technique, where each surgeon concurrently performs a unilateral mastectomy, offers an alternative approach. We examined differences in general surgery time (GST), overall surgery time (OST), and patient complications for BM performed by CS and SS.

Methods: Patients undergoing BM with tissue expander reconstruction (BMTR) between January 2010 and May 2014 at our center were identified through operative case logs. GST (incision to end of BM procedure), reconstruction duration (RST) (plastic surgery start to end of reconstruction) and OST (OST = GST + RST) was calculated. Patient age, presence/stage of cancer, breast weight, axillary procedure performed, and 30-day postoperative complications were extracted from medical records. Differences in GST and OST between CS and SS cases were assessed with a t test. A multivariate linear regression was fit to identify factors associated with GST.

Results: A total of 116 BMTR cases were performed [CS, n = 67 (57.8 %); SS, n = 49 (42.2 %)]. Demographic characteristics did not differ between groups. GST and OST were significantly shorter for CS cases, 75.8 versus 116.8 min, p < .0001, and 255.2 versus 278.3 min, p = .005, respectively. Presence of a CS significantly reduces BMTR time (β = -38.82, p < .0001). Breast weight (β = 0.0093, p = .03) and axillary dissection (β = 28.69, p = .0003) also impacted GST.

Conclusions: The CS approach to BMTR reduced both GST and OST; however, the degree of time savings (35.1 and 8.3 %, respectively) was less than hypothesized. A larger study is warranted to better characterize time, cost, and outcomes of the CS-approach for BM.
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http://dx.doi.org/10.1245/s10434-015-4956-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775338PMC
April 2016

Computed Tomographic Imaging in the Diagnosis of Recurrent Ventral Hernia.

JAMA Surg 2016 Jan;151(1):13-4

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1001/jamasurg.2015.2587DOI Listing
January 2016

A low cost training phantom model for radio-guided localization techniques in occult breast lesions.

J Surg Oncol 2015 Sep 6;112(4):449-51. Epub 2015 Aug 6.

Women's Cancer Center, Dana-Farber/Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Radio-guided localization (RGL) for identifying occult breast lesions has been widely accepted as an alternative technique to other localization methods, including those using wire guidance. An appropriate phantom model would be an invaluable tool for practitioners interested in learning the technique of RGL prior to clinical application. The aim of this study was to devise an inexpensive and reproducible training phantom model for RGL. We developed a simple RGL phantom model imitating an occult breast lesion from inexpensive supplies including a pimento olive, a green pea and a turkey breast. The phantom was constructed for a total cost of less than $20 and prepared in approximately 10 min. After the first model's construction, we constructed approximately 25 additional models and demonstrated that the model design was easily reproducible. The RGL phantom is a time- and cost-effective model that accurately simulates the RGL technique for non-palpable breast lesions. Future studies are warranted to further validate this model as an effective teaching tool.
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http://dx.doi.org/10.1002/jso.23984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4583351PMC
September 2015

The Influence of Radiology Image Consultation in the Surgical Management of Breast Cancer Patients.

Ann Surg Oncol 2015 Oct 23;22(10):3383-8. Epub 2015 Jul 23.

Department of Surgery, Dana Farber/Brigham and Women's Cancer Center, Boston, MA, USA.

Background: Patients referred to comprehensive cancer centers arrive with clinical data requiring review. Radiology consultation for second opinions often generates additional imaging requests; however, the impact of this service on breast cancer management remains unclear. We sought to identify the incidence of additional imaging requests and the effect additional imaging has on patients' ultimate surgical management.

Methods: Between November 2013 and March 2014, 153 consecutive patients with breast cancer received second opinion imaging reviews and definitive surgery at our cancer center. We identified the number of additional imaging requests, the number of fulfilled requests, the modality of additional imaging completed, the number of biopsies performed, and the number of patients whose management was altered due to additional imaging results.

Results: Of 153 patients, the mean age was 55 years; 98.9% were female; 23.5% (36) had in situ carcinoma (35 DCIS/1 LCIS), and 76.5% (117) had invasive carcinoma. Additional imaging was suggested for 47.7% (73/153) of patients. After multidisciplinary consultation, 65.8% (48/73) of patients underwent additional imaging. Imaging review resulted in biopsy in 43.7% (21/48) of patients and ultimately altered preliminary treatment plans in 37.5% (18/48) of patients (Fig. 1). Changes in management included: conversion to mastectomy or breast conservation, neoadjuvant therapy, additional wire placement, and need for contralateral breast surgery. Fig. 1 Impact of second-opinion imaging reviews on the management of breast cancer patients

Conclusions: Our analysis of second opinion imaging consultation demonstrates the significant value that this service has on breast cancer management. Overall, 11.7% (18/153) of patients who underwent breast surgery had management changes as a consequence of radiologic imaging review.
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http://dx.doi.org/10.1245/s10434-015-4663-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4648348PMC
October 2015

Survival Benefit of Breast Surgery for Low-Grade Ductal Carcinoma In Situ: A Population-Based Cohort Study.

JAMA Surg 2015 Aug;150(8):739-45

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

Importance: While the prevalence of ductal carcinoma in situ (DCIS) of the breast has increased substantially following the introduction of breast-screening methods, the clinical significance of early detection and treatment for DCIS remains unclear.

Objective: To investigate the survival benefit of breast surgery for low-grade DCIS.

Design, Setting, And Participants: A retrospective longitudinal cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from October 9, 2014, to January 15, 2015, at the Dana-Farber/Brigham Women's Cancer Center. Between 1988 and 2011, 57,222 eligible cases of DCIS with known nuclear grade and surgery status were identified.

Exposures: Patients were divided into surgery and nonsurgery groups.

Main Outcomes And Measures: Propensity score weighting was used to balance patient backgrounds between groups. A log-rank test and multivariable Cox proportional hazards model was used to assess factors related to overall and breast cancer-specific survival.

Results: Of 57,222 cases of DCIS identified in this study, 1169 cases (2.0%) were managed without surgery and 56,053 cases (98.0%) were managed with surgery. With a median follow-up of 72 months from diagnosis, there were 576 breast cancer-specific deaths (1.0%). The weighted 10-year breast cancer-specific survival was 93.4% for the nonsurgery group and 98.5% for the surgery group (log-rank test, P < .001). The degree of survival benefit among those managed surgically differed according to nuclear grade (P = .003). For low-grade DCIS, the weighted 10-year breast cancer-specific survival of the nonsurgery group was 98.8% and that of the surgery group was 98.6% (P = .95). Multivariable analysis showed there was no significant difference in the weighted hazard ratios of breast cancer-specific survival between the surgery and nonsurgery groups for low-grade DCIS. The weighted hazard ratios of intermediate- and high-grade DCIS were significantly different (low grade: hazard ratio, 0.85; 95% CI, 0.21-3.52; intermediate grade: hazard ratio, 0.23; 95% CI, 0.14-0.42; and high grade: hazard ratio, 0.15; 95% CI, 0.11-0.23) and similar results were seen for overall survival.

Conclusions And Relevance: The survival benefit of performing breast surgery for low-grade DCIS was lower than that for intermediate- or high-grade DCIS. A prospective clinical trial is warranted to investigate the feasibility of active surveillance for the management of low-grade DCIS.
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http://dx.doi.org/10.1001/jamasurg.2015.0876DOI Listing
August 2015

Bilateral synchronous benign phyllodes tumors.

Am Surg 2015 May;81(5):E192-4

Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.

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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4477195PMC
May 2015

Surgical Options and Locoregional Recurrence in Patients Diagnosed with Invasive Lobular Carcinoma of the Breast.

Ann Surg Oncol 2015 Dec 18;22(13):4280-6. Epub 2015 Apr 18.

Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.

Purpose: Recent consensus guidelines on margins for breast-conserving surgery (BCS) recommend the use of "no ink on tumor" as the standard for an adequate margin. The recommendations extend to invasive lobular carcinoma (ILC), but the data on this subset are limited. We reviewed our modern dataset on margin status with outcomes of ILC.

Methods: We performed a retrospective cohort study on 736 patients with a diagnosis of stage I-III ILC treated at our cancer center between May 1997 and December 2007. Clinicopathologic data were extracted from the Clinical Research Information Systems Database. Margin status was defined using the latest ASCO/ASTRO/SSO consensus guideline criteria.

Results: The initial surgery performed was mastectomy in 352 patients (48 %) and BCS in 384 patients (52 %). In multivariate analysis, tumor size and multifocality were significantly associated with high rates of mastectomy and positive surgical margins at initial BCS. After initial BCS, additional surgery was performed in 92 patients (24 %). During a 72-month median follow-up period, 12 (3.1 %) ipsilateral breast tumor recurrences (IBTR) and 5 (1.3 %) other locoregional recurrences (LRR) were observed. Patients with margins with ink on tumor who did not receive further surgery were found to have significantly increased LRR [odds ratio (OR) 5.5; p = 0.02] and IBTR (OR 8.5; p = 0.006), whereas patients with close margins (1-3 mm) and margins within 1 mm were not.

Conclusions: Our study supports the validity of using "no ink on tumor" as the standard for a negative margin for pure and mixed ILC treated with multimodality therapy.
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http://dx.doi.org/10.1245/s10434-015-4570-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4801503PMC
December 2015