Bernd Gerber

The aim of the study was to investigate the accuracy of ultrasound-derived estimated fetal weight (EFW) and to determine its impact on management and outcome of delivery. In this single-center cohort analysis, women with a singleton term pregnancy in the beginning stages of labor were included. Women with immediately antepartum EFW (N = 492) were compared to women without ultrasound (N = 515). EFW was correct (deviation from birth weight ≤ 10%) in 72.2% (355/492) of patients with fetal biometry; 19.7% (97/492) were underestimated, and 8.1% (40/492) were overestimated. Newborns with a lower birth weight were more frequently overestimated, and newborns with higher birth weight were more frequently underestimated. The mean difference between EFW and real birth weight was − 114.5 g (standard deviation ±313 g, 95% confidence interval 87.1–142.0). The rate of non-reassuring fetal heart tracing (9.8% vs. 1.9%, P < 0.001) and of caesarean delivery (9.1% vs. 5.0%, P = 0.013) was higher in women with EFW. Overestimation was associated with an increased risk for delivery by caesarean section (odds ratio 2.80; 95% confidence interval 1.2–6.5, P = 0.017). After adjustment, EFW remained associated with increased non-reassuring fetal heart tracing (odds ratio 4.73; 95% confidence interval 2.3–9.6) and caesarean delivery (odds ratio 1.86; 95% confidence interval 1.1–3.1). The incidence of perineal tears of grade 3/4, shoulder dystocia, postnatal depression and neonatal acidosis did not differ between groups. Antepartum ultrasound-derived EFW does not improve maternal and fetal outcome and is therefore not recommended.

As a result of mammography screening and neoadjuvant systemic treatment (NAST), more than 75% of all breast cancer cases in Germany are treated with breast-conserving surgery (BCS). Although contraindications for BCS like multifocality/multicentricity have been softened, mastectomy is still indicated in many patients. Mastectomy is not always performed as a simple mastectomy with axillary lymph node dissection. Today, nipple-/skin-sparing mastectomies (NSM, SSM) with autologous or heterologous reconstruction are used more frequently [1].

Seit über 30 Jahren findet regelmäßig (in den letzten 6 Jahren alle 2 Jahre) die internationale St. Gallen-Konsensuskonferenz zur Behandlung von Patientinnen mit primärem Mammakarzinom statt. Die Ergebnisse des internationalen St. Gallen-Konsensus-Panels wurden auch dieses Jahr wieder von einer deutschen Arbeitsgruppe führender Brustkrebsexperten für den Klinikalltag in Deutschland diskutiert. Fünf der Brustkrebsexperten aus Deutschland sind zugleich Mitglieder des diesjährigen St. Gallen-Panels. Der Vergleich der St. Gallen-Empfehlungen mit den jährlich aktualisierten Therapieempfehlungen der Arbeitsgemeinschaft Gynäkologische Onkologie (AGO-Mamma 2017) und der aktuell im Jahre 2017 abgestimmten S3-Leitlinie ist sinnvoll. Die Empfehlungen des St. Gallen-Panels stellen ein Meinungsbild von Experten unterschiedlicher Länder und Fachdisziplinen dar, wohingegen S3-Leitlinie und AGO-Empfehlungen evidenzbasiert sind. Die diesjährige 15. St. Gallen-Konsensuskonferenz stand unter dem Motto „Escalating and De-Escalating“, das sich durch alle Therapiebereiche zog, die zur Abstimmung standen. Ziel war es, Patientinnen individuellere Therapieoptionen anzubieten und das Risiko einer Über- bzw. Untertherapie zu vermeiden. The St. Gallen International Consensus Conference on the treatment of patients with primary breast cancer has been held regularly (every second year in the last six years) for more than 30 years. This year, the findings of the International St. Gallen Consensus Panel and their implications for clinical practice were again discussed by a German working group of leading breast cancer specialists. Five of the breast cancer specialists from Germany were also members of this year’s St. Gallen panel. A comparison between the St. Gallen recommendations and the annually updated treatment guidelines of the Gynecologic Oncology Group (AGO 2017) and the S3-guideline agreed upon in 2017 is useful. The recommendations of the St. Gallen panel represent an international crosssection of opinions of experts from different countries and different disciplines, while the S3-guideline and AGO guidelines are evidence-based. The motto of this year’s 15th St. Gallen Conference was “Escalating and De-Escalating“. The rationale behind this concept was to promote more individualized treatment and thereby reduce overtreatment as well as undertreatment. ^* St. Gallen Panel Expert

555 Background: It is not clear whether SLNB performed with LSG is necessary to reliably detect sentinel lymph nodes (SLN) in breast cancer. The omission of LSG might offer an accelerated preoperative workflow, cost reduction, and the opportunity for developing innovative, safe detection strategies. Methods: Patients with cN0 early breast cancer or extensive/high grade DCIS received standard radiolabeled colloid LSG and SLNB. Patients were randomized 1:1 to either conducting SLNB with the performing surgeon knowing the preoperative LSG pictures and results or without knowledge of the LSG results. Since the false negative rate (FNR) of SLNB correlates with the number of harvested SLN, our primary endpoint was the average number of histologically detected SLN per patient in both treatment arms in a non-inferiority design. An average number of 2.7 SLN with a standard deviation of 1.8 was assumed. LSG of all patients were collected postoperatively for central review. Results: Between May 2014 and October 2015 n = 1198 patients were randomized in 23 participating breast centers. Baseline characteristics were well-balanced between the treatment arms. Modified intention-to-treat analysis (n = 1163) confirmed the omission of LSG. The average number of histologically detected SLN was 2.207 with LSG and 2.258 without. The range for the one-sided 95% CI for the difference between the arms was (-0.18, +infinity), i.e. above the pre-specified non-inferiority margin of -0.27. Secondary endpoints were analyzed to rule out differences in reliable detection of nodal metastases. Rates of nodal positive disease as identified by SLNB (Odds ratio (OR) 1.005, 95%CI (0.759, 1.33), p = 0.972) and rates of completion axillary dissection (OR 0.984, 95% CI (0.567, 1.71), p = 0.954) in the two treatment arms and in specific subgroups showed no statistically significant differences. Conclusions: Our results support the hypothesis that SLNB is equally effective irrespective of the knowledge of preoperative LSG results. We therefore suggest performing SLNB without LSG to accelerate the preoperative workflow, reduce costs, and improve the comfort for the patients. Clinical trial information: NCT02481128.

We did not address the issue of lymphedema as this problem is significantly in decline today and typically develops with some delay. The downward trend started with the introduction of less radical axillary surgery

Every year in Germany, mastectomy is required for 27% of the 75 000 women newly diagnosed with breast cancer. Approximately one-third of women choose ipsilateral breast reconstruction, and a further 1000 prophylactic mastectomy with reconstruction (n...

Breast cancer is the most frequent cancer in women in Western countries and despite the availability of modern treatment options it is the most frequent cancer-related cause of death in women. According to the Robert Koch Institute, every year approximately 75,000 women are diagnosed with breast cancer in Germany alone. Diagnostic procedures and treatment of breast cancer are cost intensive and burden the national health insurance. Therefore, strategies to prevent breast cancer are of great socioeconomic interest. The articles in this issue of BREAST CARE deal primarily with the prevention of breast cancer in healthy women and in those with an increased risk.

Evaluation of axillary lymph node status by sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection (ALND) are an inherent part of breast cancer treatment. Increased understanding of tumor biology has changed the prognostic and therapeutic impact of lymph node status. Non-invasive imaging techniques like axillary ultrasound, FDG-PET, or MRI revealed moderate sensitivity and high specificity in evaluation of lymph node status. Therefore, they are not sufficient for lymph node staging. Otherwise, the impact of remaining micrometastases and even macrometastases for prognosis and treatment decisions is overestimated. Considering tumor biology, the distinction of axillary metastases in isolated tumor cells (ITC, pN0(i+)); micrometastases (pN1mi), and macrometastases (pN1a) is not comprehensible. Increasing data support the thesis that remaining axillary metastases neither increase the axillary recurrence rate nor decrease overall survival. It is doubtful that axillary tumor cells are capable to complete the complex multistep metastatic process. If applied, axillary metastases are sensitive to systemic treatment and are targeted by postoperative tangential breast irradiation. Therefore, the controversy about the clinical relevance of tumor cell clusters or micrometastases in SLN is a sophisticated but not contemporary discussion. Currently, there is no indication for axillary surgery in elderly patients with favorable tumors and clinically tumor-free lymph nodes. Nonetheless, a rational and evidence-based approach to the management of clinically and sonographically N0 patients with planned breast-conserving surgery and limited tumor size is needed now.