Is Nodal Clipping Beneficial for Node-Positive Breast Cancer Patients Receiving Neoadjuvant Chemotherapy?

BACKGROUND

In cN1 patients rendered cN0 with neoadjuvant chemotherapy, the false-negative rate of sentinel lymph node biopsy (SLNB) is < 10% when ≥ 3 sentinel lymph nodes (SLNs) are removed. The added value of nodal clipping in this scenario is unknown. Here we determine how often the clipped node is a sentinel node when ≥ 3 SLNs are retrieved.

METHODS

We identified cT1-3N1 patients treated between 02/2018 and 10/2021 with a clipped lymph node at presentation. SLNB was performed with a standardized approach of dual-tracer mapping and retrieval of ≥ 3 SLNs. Clipped nodes were not localized; SLNs were X-rayed intraoperatively to determine clip location. Axillary lymph node dissection (ALND) was performed for any residual disease or retrieval of < 3 SLNs.

RESULTS

Of 269 patients, 251 (93%) had ≥ 3 SLNs. Median age was 51 years; the majority (92%) had ductal histology; 46% were HR+/HER2-. The median number of SLNs removed was 4 (IQR 3,5). The clipped node was an SLN in 88% (220/251) of cases. Of the 31 where the clipped node was not, 13 had a positive SLN mandating ALND, and the clip was identified in the ALND specimen. In the remaining 18, where ≥ 3 negative SLNs were retrieved and an ALND was not performed, the clip was not retrieved, with no axillary failures in this group (median follow-up: 55 months).

CONCLUSION

When the SLNB procedure is optimized with dual tracer and retrieval of ≥ 3 SLNs, the clipped node is an SLN in the majority of cases, suggesting that failure to retrieve the clipped node should not be an indication for ALND.

Lobular Carcinoma of the Breast Metastatic to the Ovary: A Clinicopathologic Study of 38 Cases

We evaluated the clinicopathologic features of 38 cases of metastatic lobular (n=33) or predominantly lobular (n=5) carcinoma involving the ovary. The patients were from 39 to 91 years of age (mean: 53 y). In 2 cases, the breast primary and ovarian metastasis were diagnosed synchronously, and in 5, the breast primary was only discovered after the metastatic carcinoma in the ovary was found. In the majority of cases (79%), both ovaries were involved; the mean ovarian tumor size was 5.9 cm. The ovarian tumors demonstrated a range of architectural patterns including macronodular (71%), diffuse/solid growth (87%), single-cell infiltration (87%), cords (74%), and small nests/clusters (50%). Nine cases demonstrated focal signet ring cell morphology. The associated stromal reaction ranged from none to marked, with almost half of cases demonstrating a marked stromal response, largely prominent sclerosis. A variety of neoplasms, most typically sex cord-stromal tumors, lymphoma/leukemia, and desmoplastic small round cell tumor, may enter the differential. In addition to the obvious help afforded in most cases by the clinical history, a combination of judicious sampling, particularly to unearth the delicate cords or single-cell growth of lobular carcinoma, appropriate consideration of the cytologic features of the neoplastic cells, and immunohistochemistry can resolve the diverse issues in differential diagnosis that may arise.

Impact of Preoperative Magnetic Resonance Imaging on Surgical Outcomes in Women with Invasive Breast Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Currently, whether magnetic resonance imaging (MRI) should be routinely applied to patients with breast cancer before surgery remains controversial. A pooled analysis of the association between preoperative MRI and surgical outcomes in female patients with newly diagnosed invasive breast cancer was conducted to provide evidence-based medicine for clinical practice.

METHODS

Three independent researchers searched the following databases: PubMed, Medline, Embase, Ovid, Cochrane Library, and Web of Science from inception to April 2022. Literature was included and excluded according to Cochrane's principles. The basic information from eligible documents was extracted. Systematic evaluation and meta-analysis were performed, and the odds ratio (OR) was analyzed by the random-effect model. The quality of the literature was assessed using the modified Jadad scale and the Newcastle-Ottawa (NOS) mean scale.

RESULTS

A total of 19 studies were included, including 4 randomized controlled trials and 15 observational comparative studies. Among them, most studies were not limited to a specific pathological type, with the exception of 3 that were limited to invasive lobular carcinoma. The results showed that preoperative MRI examination would significantly reduce the reoperation rate (OR = 0.77, P=0.02) and increase the mastectomy rate (OR = 1.36, P=0.001). In comparison, preoperative MRI did not significantly affect the rate of secondary mastectomy (OR = 0.77, P=0.02), the rate of positive margin (OR = 1.08, P=0.66), the rate of mastectomy (OR = 1.00, P < 0.05), and reoperations (OR = 0.65, P=0.19) in the subgroup analysis of patients with invasive lobular carcinoma.

CONCLUSION

Available evidence suggests that preoperative MRI examination increases the rate of mastectomy and reduces the rate of reoperations. The results indicate that preoperative MRI examination has the potential to benefit patients with breast cancer, but more high-quality studies are needed for confirmation.

Characteristics of clinically node negative breast cancer patients needing preoperative MRI

BACKGROUND

International guidelines do not recommend magnetic resonance imaging (MRI) for all breast cancer patients at primary diagnostics. This study aimed to understand which patient or tumor characteristics are associated with the use of MRI. The role of MRI among other preoperative imaging methods in clinically node negative breast cancer was studied.

MATERIAL AND METHODS

Patient and tumor characteristics were analyzed in association with the use of MRI by multivariable logistic regression analysis in 461 patients. Primary tumor size was compared between MRI, mammography (MGR), ultrasound (US) and histopathology by Spearman correlation. The delays in surgery and diagnosis were analyzed among patients with or without MRI, and axillary reoperations were evaluated.

RESULTS

Age (p < 0.0001), primary operation method (p < 0.0001), tumor histology (p < 0.0001) and HER2 status (p = 0.0064) were associated with the use of MRI. Spearman correlations between tumor size in histopathology and the difference in tumor size between histopathology and imaging methods were 0.52 in MGR, 0.66 in US and 0.36 in MRI (p < 0.0001 for all). A seven-day delay in surgical treatment was observed among patients with MRI compared to patients without MRI (p < 0.0001). Axillary reoperation rates were similar in patients with or without MRI (p = 0.57).

CONCLUSION

Patient selection through prearranged characterization is important in deciding on optimal candidates for preoperative MRI among breast cancer patients. MRI causes moderate delays in primary breast cancer surgery. Preoperative MRI is useful in the evaluation of tumor size but might be insufficient in detecting lymph node metastases.

The lobular neoplasia enigma: management and prognosis in a long follow-up case series

BACKGROUND

Many oncologists debate if lobular neoplasia (LN) is a risk factor or an obligatory precursor of more aggressive disease. This study has three aims: (i) describe the different treatment options (surgical resection vs observation), (ii) investigate the upgrade rate in surgically treated patients, and (iii) evaluate the long-term occurrences of aggressive disease in both operated and unoperated patients.

METHODS

A series of 122 patients with LN bioptic diagnosis and follow-up information were selected. Clinical, radiological, and pathological data were collected from medical charts. At definitive histology, either invasive or ductal carcinoma in situ was considered upgraded lesions.

RESULTS

Atypical lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS), and high-grade LN (HG-LN) were diagnosed in 44, 63, and 15 patients, respectively. The median follow-up was 9.5 years. Ninety-nine patients were surgically treated, while 23 underwent clinical-radiological follow-up. An upgrade was observed in 28/99 (28.3%). Age ≥ 54 years (OR 4.01, CI 1.42-11.29, p = 0.009), Breast Imaging-Reporting and Data System (BI-RADS) categories 4-5 (OR 3.76, CI 1.37-10.1, p = 0.010), and preoperatory HG-LN diagnosis (OR 8.76, 1.82-42.27, p = 0.007) were related to upgraded/aggressive disease. During follow-up, 8 patients developed an ipsilateral malignant lesion, four of whom were not initially operated (4/23, 17%).

CONCLUSIONS

BI-RADS categories 4-5, HG-LN diagnosis, and age ≥ 54 years were features associated with an upgrade at definitive surgery. Moreover, 17% of unoperated cases developed an aggressive disease, emphasizing that LN patients need close surveillance due to the long-term risk of breast cancer.

Long-Term Outcomes of Once-Daily Accelerated Partial-Breast Irradiation With Tomotherapy: Results of a Phase 2 Trial

PURPOSE

We report long-term outcomes of phase 2 trial on patients with invasive breast cancer treated with accelerated partial-breast irradiation (APBI) using tomotherapy after breast conservative surgery.

METHODS AND MATERIALS

From December 2010 to December 2018, we treated 338 women with APBI-tomotherapy: 38.5 Gy in 10 once-daily fractions. Patients selected were age ≥50 years old, with ≤3 cm in size unifocal tumor and at least 2 mm of clear margins. Disease outcomes were analyzed by clinicopathologic characteristics, molecular phenotypes, and American Society for Radiation Oncology (ASTRO) 2017 updated consensus groupings.

RESULTS

The median age was 65 years (range, 50-86). The invasive ductal (87.5%) and the luminal A-like molecular phenotype (70%) were the most common tumors. Overall 242 patients (71.6%) were considered "suitable" for enrollment in APBI according to the eligibility criteria of the ASTRO-2017 consensus statement. With a median follow-up of 76 months (range, 17-113), 2 patients (0.6%) had an invasive ipsilateral breast tumor recurrence (IBTR), and 2 patients (0.6%) had an axillary ipsilateral failure. The rate of local control in terms of free of IBTR was 99.4% and locoregional control (no recurrence in ipsilateral breast as well as in regional nodes) was 98.8%. Progression-free survival was 98.4% and 92% at 5 and 10 years, respectively. Acute and late skin toxicity, graded according to the Common Terminology Criteria for Adverse Events, were 7.7% (G1) and 0.6% (G2) and 4.4% (G1) and 1.1% (G2), respectively. There were no grade 3/4 toxicities, however. Very few patients (2%) or physicians (2%) assessed cosmetic outcome as fair or poor at the 2-year follow-up.

CONCLUSIONS

This phase 2 trial on APBI-tomotherapy shows excellent long-term results. Once-daily fractionation schedule was well tolerated with a low rate of adverse events and worse cosmetic outcome. In this series, even among those deemed cautionary or unsuitable for APBI by ASTRO criteria, we demonstrated a low rate of IBTR.

A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland

INTRODUCTION

In order to minimise the risk of breast cancer patients for COVID-19 infection related morbidity and mortality prioritisation of care has utmost importance since the onset of the pandemic. However, COVID-19 related risk in patients undergoing breast cancer surgery has not been studied yet. We evaluated the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland region.

METHODS

A prospective cohort study of patients having breast cancer surgery was carried out in a geographical region during the first eight weeks of the hospital lockdown and outcomes were compared to the regional cancer registry data of pre-COVID-19 patients of the same units (n = 1415).

RESULTS

188 operations were carried out in 179 patients. Tumour size was significantly larger in patients undergoing surgery during hospital lockdown than before (cT3-4: 16.8% vs. 7.4%; p < 0.001; pT2 - pT4: 45.5% vs. 35.6%; p = 0.002). ER negative and HER-2 positive rate was significantly higher during lockdown (ER negative: 41.3% vs. 17%, p < 0.001; HER-2 positive: 23.4% vs. 14.8%; p = 0.004). While breast conservation rate was lower during lockdown (58.6% vs. 65%; p < 0.001), level II oncoplastic conservation was significantly higher in order to reduce mastectomy rate (22.8% vs. 5.6%; p < 0.001). No immediate reconstruction was offered during lockdown. 51.2% had co-morbidity, and 7.8% developed postoperative complications in lockdown. There was no peri-operative COVID-19 infection related morbidity or mortality.

CONCLUSION

breast cancer can be safely provided during COVID-19 pandemic in selected patients.

Invasive lobular carcinoma of the breast: clinicopathological features and patient outcomes

AIM

The incidence of invasive lobular carcinoma (ILC), a breast cancer type comprising several variants with distinct morphological and molecular features and clinical behaviors, has been increasing in recent years. Unlike the well-defined classical lobular carcinoma, the most common ILC variant, some uncertainties remain regarding the features of other ILC variants. Therefore, we investigated the clinicopathological features and survival outcomes of specific ILC variants.

MATERIAL AND METHODS

This retrospective study compared the tumor and patient characteristics and outcomes according to specific ILC variants in 77 patients who underwent surgery for ILC between January 2010 and December 2016 at a single center in Turkey.

RESULTS

The mean patient age was 54.58 ± 11.7 years. The ILC variants were classical, pleomorphic, tubulolobular, solid, and signet ring cell in 49(63.6%), 14(18.2%), 10(12.8%), 2(2.7%), and 2(2.7%) patients, respectively. The mean tumor diameter, histological grade, Ki-67 proliferation index, nodal metastasis, E-cadherin expression, lymphovascular invasion, and type of surgery were significantly different among the variants. However, there were no significant differences in the rates of local recurrence, distant metastasis, and overall survival among the variants.

CONCLUSIONS

Despite the good prognostic characteristics and good response to treatment, several studies have reported that ILC is associated with poor long-term outcomes. Therefore, significant challenges remain in the management of ILC. Although it is believed to be a specific histological type, ILC is clinically and pathologically heterogenous. Therefore, the identification of patients with poor prognostic variants should aid in the implementation of efficient and personalized treatment options.

KEY WORDS

Breast cancer, Invasive cancer, Invasive lobuler carcinoma, Prognosis, Variants of lobuler carcinoma.

[A Case of Invasive Lobular Carcinoma of Accessory Mammary Gland That Was Difficult for Evaluate for Lesion Spread]

A 48-year-old female discovered a mass in her left axilla. A thorough examination resulted in a diagnosis of left invasive lobular carcinoma(ILC)of the accessory mammary gland with wide ductal spread. Considering the wide ductal spread, massive resection of the left axilla mass, left lymph node dissection, and a latissimus dorsi musculocutaneous flap procedure were performed. However, histological analysis revealed ILC measuring 80×50 mm with lymph node metastases(5/23)and extensive cancer spread, resulting in a positive surgical margin. It is important to recognize the characteristics of ILC, axillary accessory breast cancer, and the axilla in a treatment strategy.

The Effects of Low HER2/neu Expression on the Clinicopathological Characteristics of Triple-Negative Breast Cancer Patients

BACKGROUND

Triple-negative breast cancer (TNBC) is an aggressive type of breast cancer (BC), and its diagnosis is associated with negative expression of hormone receptors and HER2/neu. It consists of 10-20% of all BCs diagnosed.

METHODS AND MATERIALS

This study focuses on three groups with different pathology: group one showed complete triple-negative HER2 expression with IHC of BC; groups two and three included patients with ER-, PR-, and HER21+, and ER-, PR-, and HER22+ with a negative FISH test. These three groups were compared from the point of prognosis, which consisted of tumor size, patients' age, lymphatic, vascular and perineural invasion, organ metastasis, number of lymph nodes involvement, and the survival rate.

RESULTS

A total of 459 TNBC patients were enrolled, of which 268 were placed in the HER20 group, 146 in the HER21+ group, and 45 in the HER22+ group. Distant metastasis and recurrence rate were more common in HER20 patients, but bone metastasis was more common in patients with low HER2 expression. All patients with HER20 had a smaller tumor size at the time of BC diagnosis in comparison to patients in the low HER2 expression group. Patients with HER22+ had less lymphatic and vascular invasion as well as axillary lymph nodes involvement, but larger tumor size at presentation, resulting in a lower rate of recurrence and higher overall survival.

CONCLUSION

The findings revealed that patients with HER22+ had better outcome in comparison to the patients with HER20 and HER21+. Furthermore, the results showed that many patients with HER22+ expression were not basal-like and had good prognosis amongst TNBC patients.

A randomized study comparing different doses of superparamagnetic iron oxide tracer for sentinel lymph node biopsy in breast cancer: The SUNRISE study

INTRODUCTION

The non-radioactive method that uses the magnetic tracer (SPIO/Sienna) has shown to be a feasible technique for the SLN detection in breast cancer patients. The aim of this study is to assess the efficacy of different doses of a new magnetic tracer Sienna XP (Magtrace) compared to Tc-99 m and to evaluate its non-inferiority.

METHODS

Patients diagnosed with early-stage breast cancer cT1-3 N0, from October 2016 to August 2018 were eligible and consecutively randomized to three different doses of new SPIO used: group 1 (1 mL), group 2 (1.5 mL) and group 3 (2 mL).

RESULTS

A total of 135 patients were included in the study, 45 in each group. Detection of SLNs with the three doses of Sienna XP (1 mL, 1.5 mL and 2 mL) showed non-inferior rates compared to the conventional technique with radiotracer (p = 0.654). Concordance by patients with SLN positive was 100% for all groups. 83 (70.3%) patients reported skin staining at one month postoperatively, significantly lower in group 1 (p = 0.042). At 6 months follow up, group 1 remains with significantly lower skin discoloration (p = 0,01). In multivariate analysis, dose of 2 mL showed statistically significant for the skin staining. The majority of patients (70%) felt that skin discoloration does not represent a problem.

CONCLUSION

The use of the Sienna XP magnetic tracer at 1 mL is not inferior to higher doses of magnetic tracer neither is inferior to radiotracer. 1 mL of magnetic tracer resulted in significantly less skin discoloration compared to higher doses.

PD-L1 diagnostics in the neoadjuvant setting: implications of intratumoral heterogeneity of PD-L1 expression in triple negative breast cancer for assessment in small biopsies

PURPOSE

PD-L1 expression is a predictive biomarker for anti-PD-L1 immunotherapy in triple negative breast cancer (TNBC). In the neoadjuvant setting, immunohistochemical (IHC) evaluation of PD-L1 expression can only be performed on small tissue biopsies. In our study we investigated heterogeneity of PD-L1 expression in TNBC, and how reliably PD-L1 expression in small tissue samples reflects PD-L1 expression in larger tumor sections in TNBC.

METHODS

Tissue microarrays (TMAs) were constructed from surgical specimens of 110 patients with TNBC. TMAs contained 4 cores (1 mm in diameter) per patient. To evaluate PD-L1 expression, TMAs were stained with PD-L1 IHC 22C3 PharmDx. Single-core PD-L1 expression was compared to overall PD-L1 expression of each patient's tumor, to ascertain how often small samples of tumor tissue show the same PD-L1 expression as larger tumor samples.

RESULTS

Our study found substantial heterogeneity of PD-L1 expression between different TMA cores from the same patient. Heterogeneity was greater in immune cells (ICs) than in tumor cells, in large part due to the uneven distribution of ICs in the tumor. For IC PD-L1 expression, we found that sensitivity can be as low as 0.81 for detecting PD-L1 expression at the 1% threshold most commonly used in breast cancer. Negative predictive value for ICs was 0.7.

CONCLUSIONS

There is substantial heterogeneity of PD-L1 expression between small tissue samples from the same TNBC tumor, especially for IC expression. This poses challenges for evaluation of PD-L1 expression in the neoadjuvant setting. Negative biopsies should prompt further investigation, and multiple biopsies might be necessary.

Axillary lymph node dissection is not obligatory in breast cancer patients with biopsy-proven axillary lymph node metastasis

PURPOSE

The ACOSOG Z0011 trial demonstrated that axillary lymph node dissection (ALND) is unnecessary in select patients with cT1-2N0 tumors undergoing breast-conserving therapy with 1-2 positive sentinel lymph nodes (SLNs). However, patients with preoperatively confirmed ALN metastasis were not included and may be subjected to unnecessary ALND. The aim of this study is to identify patients who can be considered for ALND omission when the preoperative ALN biopsy results are positive.

METHODS

Breast cancer patients who underwent preoperative ALN biopsy and primary surgery were retrospectively reviewed. Among patients with positive ALN biopsy results, clinicopathological and imaging characteristics were compared according to LN disease burden (1-2 positive LNs vs. ≥ 3 positive LNs).

RESULTS

A total of 542 patients were included in the analysis. Among them, 225 (41.5%) patients had a preoperative positive ALN biopsy. More than 40% of the patients (n = 99, 44.0%) with a positive biopsy had only 1-2 positive ALNs. The association between nodal burden and imaging factors was strongest when ≥ 2 suspicious LNs were identified on PET/CT images (HR 8.795, 95% CI 4.756 to 13.262). More than one imaging modality showing ≥ 2 suspicious LNs was also strongly correlated with ≥ 3 positive ALNs (HR 5.148, 95% CI 2.881 to 9.200).

CONCLUSIONS

Nearly half of patients with a preoperative biopsy-proven ALN metastasis had only 1-2 positive LNs on ALND. Patients meeting ACOSOG Z0011 criteria with only one suspicious LN on PET/CT or those presenting with few abnormal ALNs on only one imaging modality appear appropriate for SLNB and consideration of ALND omission.

Hepatic resection for breast cancer liver metastases: Impact of intrinsic subtypes

INTRODUCTION

The role of surgery for breast cancer liver metastases (BCLM) remains controversial. This study aimed to analyze survival in patients treated with hepatectomy plus systemic therapy or systemic therapy alone for BCLM and to determine selection factors to guide surgical therapy.

MATERIALS AND METHODS

Patients who underwent hepatectomy plus systemic therapy (n = 136) and systemic therapy alone for isolated BCLM (n = 763) were compared. Overall survival (OS) was analyzed after propensity score matching. Intrinsic subtypes were defined as: luminal A (estrogen receptor [ER]+ and/or progesterone receptor positive [PR]+, human epidermal growth factor receptor 2 [HER2]-), luminal B (ER and/or PR+, HER2+), HER2-enriched (ER and PR-, HER2+), and basal-like (ER, PR, HER2-).

RESULTS

After hepatectomy, independent predictors of poor OS were number and size of liver metastases, and intrinsic subtype (hazard ratios, 1.11, 1.16, and 4.28, respectively). Median OS was 75 and 81 months among patients with luminal B and HER2-enriched subtypes, compared with 17 and 53 months among patients with basal-like and luminal A subtypes (P < .001). Median progression-free survival (PFS) was 60 months with the HER2-enriched subtype, compared with 17, 16, and 5 months with luminal A, luminal B, and basal-like subtypes, respectively (P < .001). After propensity score matching, 5-year OS rates were 56% vs. 40% in the surgery vs. systemic therapy alone groups (P = .018).

CONCLUSION

Surgical resection of BCLM yielded higher OS compared with systemic therapy alone and prolonged PFS among patients with the HER2-enriched subtype. These findings support the use of surgical therapy in appropriately selected patients, based on intrinsic subtypes.

Management of the axilla in breast cancer: outcome analysis in a series of ductal versus lobular invasive cancers

INTRODUCTION

Axillary lymph node dissection (ALND) has been considered essential for the staging of breast cancer (BC). As the impact of tumor biology on clinical outcomes is recognized, a surgical de-escalation approach is being implemented. We performed a retrospective study focused on surgical management of the axilla in invasive lobular carcinoma (ILC) versus invasive ductal carcinoma (IDC).

MATERIALS AND METHODS

1151 newly diagnosed BCs, IDCs (79.6%) or ILCs (20.4%), were selected among patients treated at our Breast Cancer Unit from 2012 to 2018. Tumor characteristics and clinical information were collected and predictors of further metastasis after positive sentinel lymph node biopsy (SLNB) analyzed in relation to disease-free survival (DFS) and overall survival (OS).

RESULTS

27.5% of patients with ILC had ≥ 3 metastatic lymph nodes at ALND after positive SLNB versus 11.48% of IDCs (p = 0.04). Risk predictors of further metastasis at ALND were the presence of > 2 positive lymph nodes at SLNB (OR = 4.72, 95% CI 1.15-19.5 p = 0.03), T3-T4 tumors (OR = 4.93, 95% CI 1.10-22.2, p = 0.03) and Non-Luminal BC (OR = 2.74, 95% CI 1.16-6.50, p = 0.02). The lobular histotype was not associated with the risk of further metastasis at ALND (OR = 1.62, 95% CI 0.77-3.41, p = 0.20).

CONCLUSIONS

ILC histology is not associated with higher risk of further metastasis at ALND in our analysis. However, surgical management decisions should be taken considering tumor histotype, biology and expected sensitivity to adjuvant therapies.

Clinicopathological and immunohistochemical characteristics of breast cancer patients from Northeast India with special reference to triple negative breast cancer: A prospective study

BACKGROUND

Molecular pathogenesis of Triple-negative breast cancer (TNBC) is inconclusively documented from resource limited countries and hence there is a lack of available targeted therapy for clinical interventions. Compared to other breast cancer subtypes, TNBC is more aggressive, higher recurrence rate, and higher prevalence in younger premenopausal women. Sporadic literature indicates predominance of TNBC in all reported breast cancer cases from Northeast India.

AIM

This study was conducted to evaluate the candidature of panel of key molecular markers involved in the development and progression of TNBC for prognosis and futuristic tailored targeted therapy.

MATERIALS AND METHODS

We analyzed the clinicopathological characterized and immunohistochemically screened the differential expression of key molecular markers involved in the development and progression of in TNBC cases vis-a-vis non-TNBC and autopsy-based control samples.

RESULTS

TNBC tends to display at an early reproductive age and is more aggressive in nature. Further, the differential expression of 2 specific markers viz., epidermal growth factor receptor (EGFR) and FolR1 was higher in TNBC cases compared to controls and non-TNBC (both in terms of susceptibility and specificity), clinical staging in TNBC cases (severity) and mortality (outcome). Although Ki67 and vascular endothelial growth factor expression also correlated with severity and outcome of the disease but their differences in non-TNBC cases were not significantly differentiable compared to TNBC.

CONCLUSIONS

The study indicates that EGFR and FolR1 could serve as useful biomarkers to determine TNBC prognosis. Further studies will be needed to evaluate EGFR and Folate pathways in order to screen out the molecular targets which may be meaningfully used for clinical stratification, intervention, and treatment.

Internal Mammary Sentinel Lymph Node Biopsy in Clinically Axillary Lymph Node-Positive Breast Cancer: Diagnosis and Implications for Patient Management

BACKGROUND

Routine performance of internal mammary sentinel lymph node biopsy (IM-SLNB) remains a subject of debate due to no clinical relevance in breast cancer, because it was performed only in clinically axillary lymph node (ALN)-negative patients. In this study, IM-SLNB was performed in clinically ALN-positive patients, and its impact on nodal staging and therapeutic strategy were subsequently analyzed.

METHODS

Clinically ALN-positive patients who underwent IM-SLNB were enrolled in this prospective study. Statistical analysis was performed using Chi square test, Mann-Whitney U and logistic regression models with a significance level of 0.05.

RESULTS

Among the 352 recruited patients, the internal mammary sentinel lymph node (IMSLN) visualization rate of patients who received initial surgery and neoadjuvant systemic therapy (NST) was 71.9% (123/171) and 33.1% (60/181), respectively. The 183 patients who underwent IM-SLNB successfully had the average time duration of 7 min and the median IMSLN number of 2. There were 87 positive IMSLNs in all the 347 removed IMSLNs, which were mainly concentrated in the second (50.6%) and third (34.5%) intercostal space. The IMSLN metastasis rate was 39.8% (initial surgery) and 13.3% (NST), respectively. All of the 183 IM-SLNB patients received more accurate nodal staging, 57 of whom had stage elevated, which might have prompted modifications to the therapeutic strategy.

CONCLUSIONS

IM-SLNB should be routinely performed in clinically ALN-positive patients, and thus more accurate nodal staging and perfect pathologic complete response definition could be put forward. The identification of IMLN metastases by IM-SLNB might potentially influence therapeutic strategies.

The Role of Sentinel Lymph Node Biopsy in Patients With B5c Breast Cancer Diagnosis

BACKGROUND/AIM

The histopathological assessment of the B5c category may sometimes be hampered by simple artifacts that may lead to over- or underestimation of that particular breast cancer so that its management is still controversial, especially with regard to the decision to proceed immediately to sentinel lymph node (SLN) biopsy. Hence, a retrospective study was performed in 174 patients undergoing breast-conserving surgery with a preoperative diagnosis of B5c in order to assess the usefulness of axillary node staging by means of SLN biopsy.

PATIENTS AND METHODS

Pre- and post-operative parameters including imaging data, histology of the primary tumor and SLN biopsy, biological prognostic factors, type of operation, and adjuvant regimens were computed.

RESULTS

Invasive carcinoma and carcinoma in situ were diagnosed in 46 (26.5%) and 128 patients (73.5%), respectively. Preoperative tumor size was significantly related to post-operative diagnosis of invasive carcinoma (p=0.020), retaining its predictive value at logistic regression analysis (p=0.046). Post-operative predictive factors of invasion were represented by tumor stage (p=0.008) and grading (p=0.008).

CONCLUSION

B5c preoperative diagnosis in patients undergoing breast conservative surgery would suggest an immediate wide local excision avoiding any further preoperative histologic assessment. Conversely, one-stage SLN biopsy might be suggested for patients eligible to mastectomy, similar to patients with carcinoma in situ, although its impact on the therapeutic and prognostic assessment seems negligible.

Association of LncRNA-GACAT3 with MRI features of breast cancer and its molecular mechanism

PURPOSE

This study was designed to investigate the relationship between the abnormal expression of LncRNA GACAT3 and the prognosis of breast cancer patients, preoperative magnetic resonance imaging (MRI) parameters and the molecular downstream mechanism.

METHODS

Quantitative fluorescence PCR was used to detect the expression of LCCRNA GACAT3 in 20 breast cancer tissues and adjacent tissues. Patients were divided into low expression group and high expression group according to the level of expression, and the differences and overall survival of MRI diffusion-weighted imaging parameters were analyzed. The expression of LCCRNA GACAT3 was interfered by MCV-7 cells transfected by recombinant adenovirus, and the proliferation and apoptosis of MCF-7 were detected by BrdU method and TUNEL method, respectively.

RESULTS

The expression of LncRNA GACAT3 was increased in breast cancer tissues and cell lines compared to paracancer tissues and normal cells. Compared with the low expression group, patients with high expression had poorer MRI diffusionweighted imaging and lower overall survival. Down-regulation of LncRNA GACAT3 increased the expression of miR-497, and miR-497 mimics reduced the luciferase of LncRNA GACAT3. Increased LrcRNA GACAT3 in breast cancer cells could downregulate the expression of miR-497, down-regulate Capsase 9 and up-regulate Bcl-2 to promote proliferation and anti-apoptosis of breast cancer cells.

CONCLUSION

LncRNA GAC AT3 is associated with poor prognosis of breast cancer, preoperative MRI perfusion-related diffusion (D) reduction, and elevated perfusion fraction (f). After targeting CIR-497, LncRNA GACAT3 promotes the progression of breast cancer by down- regulating Caspase 9 and up-regulating Bcl-2.

Comparisons of p53, KI67 and BRCA1 expressions in patients with different molecular subtypes of breast cancer and their relationships with pathology and prognosis

PURPOSE

To compare the expressions of p53, a tumor suppressor gene, KI67, a proliferating cell nuclear antigen, and breast cancer 1 (BRCA1), a breast cancer susceptibility gene, in patients with different molecular subtypes of breast cancer (BC) and investigate their relationships with pathology and prognosis.

METHODS

A total of 134 BC postoperative tissue specimens preserved from January 2012 to August 2013 were selected. The expressions of p53, KI67, and BRCA1 in different molecular subtypes of BC were compared, their relationships with pathological features were explored, and the expression correlations among p53, KI67, and BRCA1 were analyzed at the same time.

RESULTS

P53 expression was the lowest in Luminal A subtype and similar in human epidermal growth factor receptor 2 (HER-2)-overexpression subtype and triple-negative subtype, with higher expression rates than those in other molecular subtypes. The expression of KI67 was the lowest in Luminal A subtype, showing a significant difference (p<0.05) from that in other molecular subtypes and it was the highest in Luminal B subtype (p<0.05). BRCA1 exhibited the lowest expression in Luminal B-like subtype but the highest expression in Luminal A subtype. The protein expressions of p53 and KI67 were not related to age but correlated with tumor size, histological grade, lymph node metastasis, estrogen receptor (ER)/progesterone receptor (PR) status, and HER-2 status. The expression of p53 was increased with larger tumor size, higher histological grade, presence of lymph node metastasis (n), lower expression of ER/PR, and higher expression of HER-2. BRCA1 expression had no relation with age, tumor size, histological grade, lymph node metastasis (n), ER/PR status, and HER-2 status. A positive correlation was found between p53 and KI67 (r=0.893, p=0.021). There were negative correlations between p53 and BRCA1 (r=-0.921, p=0.011), and between KI67 and BRCA1 (r=-0.821, p=0.032). The median survival time of patients with positive expressions of p53, KI67 and BRCA1 was significantly shorter than those of patients with negative expressions.

CONCLUSION

The expressions of p53, KI67 and BRCA1 in different molecular subtypes of BC are evidently different and related to pathological features. The above protein expressions are helpful in predicting the prognosis, diagnosis, and treatment of BC.

Surgeon-led Intraoperative Ultrasound Localization for Nonpalpable Breast Cancers: Results of 5 Years of Practice

BACKGROUND

The uptake of breast screening has led to a rise in the number of nonpalpable breast cancer diagnoses. Breast conserving therapy (BCT) is the treatment of choice for early breast cancer, and this requires localization of the lesion. Commonly detection is achieved by wire-guided localization in the radiology department. This technique has complications and requires utilization of a radiologist. Intraoperative ultrasound (IOUS) has been shown to be a safe alternative, but there is little data on its use. The aim of this study is to report the use of surgeon-led IOUS over the past 5 years, assessing the ability to detect lesions and the re-excision rate for involved margins.

PATIENTS AND METHODS

A retrospective observational study was performed on consecutive patients undergoing IOUS-marked BCT between 2014 and 2018. The technique is described, and patients' records were reviewed to assess the histologic specimen reports and need for subsequent re-excision.

RESULTS

Ninety-five IOUS BCT operations were performed. Every cancer was identified by IOUS and removed. Fourteen margins were positive and required re-excision. Of these, only 2 contained residual tumor.

CONCLUSION

This is the first data from the United Kingdom for IOUS skin marking without wire localization. IOUS is a safe method of localization in BCT. It offers advantages both to the patient and the unit as it reduces pressure on the radiology department.

[Advanced-Stage Breast Cancer Discovered by Cervical Lymphadenopathy in an Elderly Patient-Report of a Case]

Breast cancer spreading beyond the regional lymph nodes from the primary lesion is considered to be difficult to cure. Although systemic therapy is common for the treatment of metastatic breast cancer, standard therapy is difficult in some cases. We encountered a case of advanced-stage breast cancer detected by cervical lymphadenopathy in an elderly patient. An 82-year-old woman consulted an otolaryngologist for left cervical lymphadenopathy. On receiving the biopsy result, she was referred for a suspected metastatic lymph node from breast cancer. The tumor was 40mm in diameter and was palpable in the CD area of her left breast, accompanied by pain. Ultrasonography showed an irregular-shaped mass. Core needle biopsy was performed, and the pathological diagnosis was invasive lobular carcinoma. Her body check-up revealed multiple enlarged lymph nodes from the left axilla to the supraclavicular and cervical areas. We diagnosed her clinical stage with T2N3cM1, stage Ⅳ(LYM). We proceeded with surgery to alleviate the symptom. Breast reduction surgery was performed for the left breast. The pathological findings from the surgically resected specimens indicated invasive lobular carcinoma. After the surgery, 5-fluorouracil(5-FU)drug was orally administered. Cervical lymphadenopathy decreased, and visceral metastasis has not appeared.