Breast radiotherapy (RT) using tangential fields (TgF): a prospective evaluation of the dose distribution in the sentinel lymph node (SLN) area as determined intraoperatively by clip placement

BACKGROUND

Randomized trials have established that patients with limited involvement of sentinel lymph node (SLN) do not require axillary lymph node dissection (ALND). The similar outcome in patients with ≤2 positive SLN with or without additional ALND is attributed, in part, to tangential fields (TgF) RT. We evaluated the dose distribution in the SLN biopsy area (SLNBa) as determined intraoperatively by clips placement for radiotherapy (RT) optimization.

METHODS

This prospective study included 25 patients who had breast conservation. Titanium clips were used intraoperatively to mark the SLNBa. All patients had 3D-conformal RT using standard (STgF) or high tangential fields (HTgF). Axillary levels, SLNBa, and organs at risk were contoured on a CT scan. Dose distribution and overlap between TgF and target volumes were analyzed.

RESULTS

The average doses delivered to axilla levels I-III and SLNBa were 25, 5, 2, and 33 Gy, respectively. The average dose delivered to SLNBa was higher using HTgF with better coverage of the axilla. Only 12 of 25 patients (48 %) had their SLNBa completely covered by the TgF. There was no impact of TgF size on ipsilateral lung dose. The mean heart dose delivered using STgF was lower than HTgF.

CONCLUSIONS

In the era of SLNB, axilla and SNLBa RT technique has to be standardized to deliver adequate dose. We recommend the use of HTgF or direct axillary RT techniques (such as in AMAROS trial) in patients with metastases in SLN without ALND completion, when only TgF are expected to cure potential residual disease in the axilla.

Positive margins following breast cancer tumorectomy. Can we predict the occurrence of residual disease?

AIMS AND BACKGROUND

In conservative early stage breast cancer surgery, the sample's margins are directly related to relapse, and positive or close margins indicate the need for additional surgery. Since the range of residual disease in secondary surgeries and the related pathological factors are highly variable, we intended to evaluate the number of additional surgeries due to compromised margins and identify the percentage of residual disease and factors related to it.

METHODS

We retrospectively analyzed the clinical records of 659 tumorectomy or needle localization surgery patients with breast carcinoma at the Hospital Universitario Austral in Buenos Aires, Argentina, between December 2000 and December 2012. The variables considered were age, type of surgery, type of margin, tumor size, histological grade, extensive intraductal component and immunohistochemical profile. We investigated how they related to the presence of residual disease.

RESULTS

We identified 68 patients (10%) who were reoperated because of positive (75%) or close (25%) margins. Residual disease was identified in 68% of them; the positive (66%) and close (70%) margin ratio was similar. The individual analysis of variables was statistically significant only for tumors larger than 3 cm (Pearson's chi square [1] = 6.7194; P = 0.0095; relative risk = 1.56 [95% CI 1.09-2.21]) with an association between age and tumor size: Pearson's chi square (1) = 3.8984; P = 0.0483; relative risk = 1.56 (95% CI 1.09-2.21).

CONCLUSIONS

The need for second surgery due to compromised margins is not common, with variable residual tumor identifying ranges. Some pathological factors can predict the persistence of residual disease. In our series, tumor size >3 cm was the variable identified as an independent predictor.

Extranodal extension on sentinel lymph node dissection: why should we treat it differently?

American College of Surgeons Oncology Group Z0011 concluded that axillary lymph node dissection (ALND) may be avoided in selected patients with breast cancer with limited axillary nodal metastasis on sentinel lymph node dissection (SLND). However, patients with extranodal extension (ENE) were excluded to the follow existing standard of care, which is completion ALND. The significance of ENE detected on SLND is not well defined. Our objective was to determine the impact of ENE found on SLND on nonsentinel lymph node (NSLN) metastasis, recurrence, and overall mortality. We evaluated patients with breast cancer treated at a tertiary cancer center from 2005 to 2012. SLND was performed in 655 patients. Of those, 478 of 655 (73.0%) patients had no SLN metastases, 124 of 655 (18.9%) had SLN metastases without ENE (SLN-ENE), and 53 of 655 (8.1%) had SLN metastases with ENE (SLN+ENE). Of patients undergoing ALND, NSLN metastasis was detected in 37 of 84 (44.0%) of patients in the SLN-ENE group and 26 of 45 (57.8%) patients in the SLN+ENE group (P = 0.14). On adjusted analyses, ENE was associated with increased disease recurrence (odds ratio [OR], 5.48; 95% confidence interval [CI], 1.23 to 24.48; P = 0.03) as well as increased overall mortality (OR, 8.16; 95% CI, 1.72 to 38.63; P = 0.01). In conclusion, ENE is associated with increased overall axillary nodal burden, disease recurrence, and overall mortality.

Long-term follow-up of breast-conserving therapy in patients with inflammatory breast cancer treated with neoadjuvant chemotherapy

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer. Currently, multimodality treatment is recommended, but the optimal surgical management has not been fully elucidated. In this study, we investigated the long-term outcomes of using breast-conserving therapy in patients with IBC undergoing neoadjuvant chemotherapy (NAC). Twenty-four patients with IBC were treated from 2002 to 2006. NAC was initiated with doxorubicin and cyclophosphamide followed by paclitaxel. In addition, HER2/neu-positive patients received trastuzumab, whereas HER2/neu-negative patients received bevacizumab. Clinical response was assessed by dynamic contrast-enhanced magnetic resonance imaging before surgery and pathologic response after surgery. A partial mastectomy with sentinel lymph node biopsy and/or axillary lymph node dissection or a modified radical mastectomy was performed based on the surgeon's recommendations and patient's preference. All patients received adjuvant radiation. Of the 24 patients, seven (29%) underwent a partial mastectomy and 17 (71%) underwent a mastectomy. The overall survival rate for partial mastectomy and for mastectomy patients was 59 and 57 per cent (P = 0.49), respectively, at a median follow-up of 60 months (range, 48 to 92 months). Breast-conserving therapy can be considered in a selected group of patients who demonstrate a good response to NAC.

Prone breast intensity modulated radiation therapy: 5-year results

PURPOSE

To report the 5-year results of a technique of prone breast radiation therapy delivered by a regimen of accelerated intensity modulated radiation therapy with a concurrent boost to the tumor bed.

METHODS AND MATERIALS

Between 2003 and 2006, 404 patients with stage I-II breast cancer were prospectively enrolled into 2 consecutive protocols, institutional trials 03-30 and 05-181, that used the same regimen of 40.5 Gy/15 fractions delivered to the index breast over 3 weeks, with a concomitant daily boost to the tumor bed of 0.5 Gy (total dose 48 Gy). All patients were treated after segmental mastectomy and had negative margins and nodal assessment. Patients were set up prone: only if lung or heart volumes were in the field was a supine setup attempted and chosen if found to better spare these organs.

RESULTS

Ninety-two percent of patients were treated prone, 8% supine. Seventy-two percent had stage I, 28% stage II invasive breast cancer. In-field lung volume ranged from 0 to 228.27 cm(3), mean 19.65 cm(3). In-field heart volume for left breast cancer patients ranged from 0 to 21.24 cm(3), mean 1.59 cm(3). There was no heart in the field for right breast cancer patients. At a median follow-up of 5 years, the 5-year cumulative incidence of isolated ipsilateral breast tumor recurrence was 0.82% (95% confidence interval [CI] 0.65%-1.04%). The 5-year cumulative incidence of regional recurrence was 0.53% (95% CI 0.41%-0.69%), and the 5-year overall cumulative death rate was 1.28% (95% CI 0.48%-3.38%). Eighty-two percent (95% CI 77%-85%) of patients judged their final cosmetic result as excellent/good.

CONCLUSIONS

Prone accelerated intensity modulated radiation therapy with a concomitant boost results in excellent local control and optimal sparing of heart and lung, with good cosmesis. Radiation Therapy Oncology Group protocol 1005, a phase 3, multi-institutional, randomized trial is ongoing and is evaluating the equivalence of a similar dose and fractionation approach to standard 6-week radiation therapy with a sequential boost.

Conserving surgery - balance between good cosmetic aspect and local disease control in incipient breast cancer

New acquisitions in the study of breast cancer, based on several retrospective and prospective studies, have led over the past decades to the possibility of applying conserving methods of treatment for breast cancer (breast conserving therapy -BCT) in incipient stages. Starting with 1996, a single surgical team, among others at the Bucharest Oncology Institute,performed BCT in 497 patients out of the total 2,256 cases of breast cancer treated. Work protocol consisted of tumour excision with safety margins, intraoperative histology exam,samples from all the walls of the remaining cavity, with intraoperative histology exam, axillary lymphadenectomy, followed by mandatory irradiation of the entire breast, associated or not with systemic or hormonal adjuvant treatment. 38 patients developed local disease recurrences, 14 of which in the first 5 years. In this paper we present the results obtained through BCT, as a means of supporting this type of treatment adequate for patients with initial stage breast cancer, with cosmetic results visibly superior to those of mastectomy.

Radioactive seed localization of nonpalpable breast lesions in an academic comprehensive cancer program community hospital setting

Wire localized excision (WLE) has been a long-standing method for localization of nonpalpable breast lesions. Disadvantages of this method include difficulty locating the wire tip in relation to borders of the lesion, imprecise placement of the wire, and the need to place the wire shortly before scheduled surgery. These shortcomings may lead to a high positive margin rate requiring re-excision to obtain clear margins for breast cancer. Radioactive seed localized excision (RSLE) of nonpalpable breast lesions has been advocated as a safe and effective alternative to WLE. The primary endpoints of the study were to compare re-excision rates between WLE and RSLE of nonpalpable breast lesions and to determine if there were any differences in volume of tissue removed. One hundred three patients were included in a retrospective review of localized breast excisions done by a single surgeon. Forty-four patients underwent WLE between April 2007 and February 2009. Fifty-nine patients underwent RSLE between September 2009 and January 2012. Margins were considered to be clear if at least 1 mm of normal tissue was obtained from the circumferential periphery of the lesion in question. RSLE resulted in a re-excision rate of 17 versus 55 per cent re-excision rate for wire localization (P < 0.001). Excision volume was greater for patients having wire localization (P = 0.074). RSLE is an effective technique for excision of nonpalpable breast lesions in the community setting. This technique allows for accurate localization and appears to allow for smaller volume of tissue to be excised.

[Lymph node metastasis and prognostic analysis of 354 cases of T1 breast cancer]

OBJECTIVE

To analyze the characteristics of lymph node metastasis and prognosis in patients with T1 breast cancer.

METHODS

The clinicopathological data of 354 patients with T1 breast cancer after standard treatment from March 2007 to September 2011 were collected to analyze the relationship between the clinical characteristics of T1 breast cancer, lymph node metastasis and prognostic features.

RESULTS

In the 354 patients with T1 breast cancer, 105 patients (29.7%) had lymph node metastasis, among them 73 cases (69.5%) had 1-3 lymph node metastasis, and 32 cases (30.5%) had more than 4 lymph node metastasis. The lymph node metastasis rate was 8.3% in T1a patients, 39.7% in T1b patients, and 30.4% in T1c cases (P = 0.005). Pairwise comparison showed that the difference of lymph node metastasis rate between T1a, T1b and T1c patients was statistically significant (P = 0.001 and P = 0.006, respectively). The difference of lymph node metastasis rates in T1b and T1c patients was statistically insignificant (P = 0.171). In the 354 patients of T1 breast cancer, 92 patients had vascular tumor thrombi and their lymph node metastasis rate was 71.7%, while the lymph node metastasis rate in 262 patients without vascular tumor thrombus was 14.9% (P < 0.001). The median follow-up was 49 months (range 27-81 months). 12 patients developed recurrence, and 3 patients died, one of them died of cerebrovascular accident. The 4-year disease-free survival for all patients was 96.6%, and the 4-year overall survival rate was 99.2%.

CONCLUSIONS

There is a correlation between vascular tumor thrombus, tumor size and lymph node metastasis rate. The lymph node metastasis rate is lower in T1a patients and relatively higher in T1b/c patients. Compared with patients without vascular tumor thrombus, the T1 breast cancer patients with vascular tumor thrombi have a higher lymph node metastasis rate. Generally speaking, there is a still good prognosis in patients with T1 breast cancer.

PD-1(+) immune cell infiltration inversely correlates with survival of operable breast cancer patients

The programmed death-1 (PD-1) molecule is mainly expressed on functionally "exhausted" CD8(+) T cells, dampening the host antitumor immune response. We evaluated the ratio between effective and regulatory T cells (Tregs) and PD-1 expression as a prognostic factor for operable breast cancer patients. A series of 218 newly diagnosed invasive breast cancer patients who had undergone primary surgery at Ruijin Hospital were identified. The influence of CD8(+) cytotoxic T lymphocytes, FOXP3(+) (Treg cell marker), and PD-1(+) immune cell counts on prognosis was analyzed utilizing immunohistochemistry. Both PD-1(+) immune cells and FOXP3(+) Tregs counts were significantly associated with unfavorable prognostic factors. In bivariate, but not multivariate analysis, high tumor infiltrating PD-1(+) cell counts correlated with significantly shorter patient survival. Our results suggest a prognostic value of the PD-1(+) immune cell population in such breast cancer patients. Targeting the PD-1 pathway may be a feasible approach to treating patients with breast cancer.

Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer

PURPOSE

To convene a multidisciplinary panel of breast experts to examine the relationship between margin width and ipsilateral breast tumor recurrence (IBTR) and develop a guideline for defining adequate margins in the setting of breast conserving surgery and adjuvant radiation therapy.

METHODS AND MATERIALS

A multidisciplinary consensus panel used a meta-analysis of margin width and IBTR from a systematic review of 33 studies including 28,162 patients as the primary evidence base for consensus.

RESULTS

Positive margins (ink on invasive carcinoma or ductal carcinoma in situ) are associated with a 2-fold increase in the risk of IBTR compared with negative margins. This increased risk is not mitigated by favorable biology, endocrine therapy, or a radiation boost. More widely clear margins than no ink on tumor do not significantly decrease the rate of IBTR compared with no ink on tumor. There is no evidence that more widely clear margins reduce IBTR for young patients or for those with unfavorable biology, lobular cancers, or cancers with an extensive intraductal component.

CONCLUSIONS

The use of no ink on tumor as the standard for an adequate margin in invasive cancer in the era of multidisciplinary therapy is associated with low rates of IBTR and has the potential to decrease re-excision rates, improve cosmetic outcomes, and decrease health care costs.

Surgery for breast cancer liver metastases - factors determining results

BACKGROUND/AIM

The results of the surgical treatment of liver metastases from breast cancer (BCLMs) may be determined by various factors. The aim of the present study was to specify the risk factors for surgical treatment of BCLM.

PATIENTS AND METHODS

Twenty-four female patients with BCLMs were treated with liver resection or radiofrequency ablation (RFA). We evaluated the effects of patient age, time interval between the breast cancer and BCLM surgery, the type of surgical procedure, histopathological findings of the primary tumor, the number and overall diameter of BCLMs, the presence of resectable extra-hepatic metastases, and local tumor recurrence after breast cancer surgery on patients' overall (OS) and progression-free survival (PFS).

RESULTS

Age <50 years and shorter interval between breast and liver surgery were risk factors for poorer OS (p<0.02 and p<0.01, respectively) and for PFS (p<0.01 and p<0.01, respectively). The presence of extra-hepatic metastases was a risk factor for OS (p<0.005). An overall diameter of BCLM ≥3.5 cm and a negative status of both estrogen (ER) and progesterone receptors (PR) in the primary tumor were risk factors for poorer PFS (p<0.009 and p<0.0003, respectively).

CONCLUSION

The risk factors for surgery for BCLMs are age <50 years, the presence of extra-hepatic metastases, hormone receptor negativity of the primary tumor and an overall BCLM diameter ≥3.5 cm.

Accuracy of mammography, digital breast tomosynthesis, ultrasound and MR imaging in preoperative assessment of breast cancer

AIM

To define the accuracy of digital breast tomosynthesis (DBT) and magnetic resonance imaging (MRI) added to digital mammography (DM) and ultrasound (US) in the preoperative assessment of breast cancer.

PATIENTS AND METHODS

We performed a prospective study of 200 consecutive women with histologically-proven breast cancer using the above imaging techniques. Accuracy measurements were estimated using a lesion-by-lesion analysis for unifocal, multifocal/multicentric, bilateral and all carcinomas. We also calculated sensitivity according to breast density.

RESULTS

DBT had higher sensitivity than DM (90.7% vs. 85.2%). Combined DM and DBT with US yielded a 97.7% sensitivity; despite high sensitivity of MRI (98.8%), the addition of MRI to combined DM with DBT and US did not significantly improve sensitivity. Overall accuracy did not significantly differ between MRI and DM with DBT and US (92.3% vs. 93.7%). Breast density affected sensitivity of DM and DBT (statistically significant difference for DM), not MRI.

CONCLUSION

There is little gain in sensitivity and no gain in overall accuracy, by performing MRI for patients who have been evaluated with DM with DBT and US.

Evaluation of expert criteria for preoperative magnetic resonance imaging of newly diagnosed breast cancer

Despite 2 randomized trials reporting no reduction in operations or local recurrence at 1 year, preoperative magnetic resonance imaging (MRI) is increasingly used in diagnostic workup of breast cancer. We evaluated 5 utilization criteria recently proposed by experts. Of women (n = 340) newly diagnosed with unilateral breast cancer who underwent bilateral MRI, most (69.4%) met at least 1 criterion before MRI: mammographic density (44.4%), under consideration for partial breast irradiation (PBI) (19.7%), genetic-familial risk (12.9%), invasive lobular carcinoma (11.8%), and multifocal/multicentric disease (10.6%). MRI detected occult malignant lesion or extension of index lesion in 21.2% of index, 3.3% of contralateral, breasts. No expert criterion was associated with MRI-detected malignant lesion, which associated instead with pre-MRI plan of lumpectomy without PBI (48.2% of subjects): Odds Ratio 3.05, 95% CI 1.57-5.91 (p adjusted for multiple hypothesis testing = 0.007, adjusted for index-vs-contralateral breast and covariates). The expert guidelines were not confirmed by clinical evidence.

Management of breast lobular carcinoma in situ: radio-pathological correlation, clinical implications, and follow-up

PURPOSE OF INVESTIGATION

To show management of patients with breast lobular carcinoma in situ (LCIS).

MATERIALS AND METHODS

This study is the retrospective review of 65 patients, between 1996 and 2012, with isolated LCIS of the breast, evaluated through clinical examination, ultrasound, and mammography at the first examination and follow-up.

RESULTS

In 53 patients (81.54%), clinical examination was negative. In 14/65 (21.54%) cases, ultrasound was positive and led to biopsy. The clusters of tiny calcifications were the predominant mammographic pattern (45 cases, 69.23%). Forty-six patients (70.77%) underwent surgical biopsy after guided stereotactic placement of metallic marker (hook-wire), 12 (18.46%) by stereotactic vacuum biopsy (SVB), 5 (7.69%) by core needle biopsy (CNB) under ultrasound guidance, two (3.08%) patients CNB with clinically palpable nodules. Fourteen (21.54%) women underwent a quadrantectomy or total mastectomy after the first diagnosis; in this latter group follow-up was negative. Among the 51 patients (78.46%) who did not undergo quadrantectomy or total mastectomy, five relapses occurred, respectively, three LCIS and two infiltrating ductal carcinomas (IDC). Follow-up ranged from 12 to 144 months.

CONCLUSION

LCIS is a risk factor for invasive carcinoma and should be managed with careful follow-up, but if there is a discrepancy between pathology and imaging, surgical excision is mandatory.

Prognostic significance of Ki-67 in chemotherapy-naive breast cancer patients with 10-year follow-up

BACKGROUND/AIM

In order to define accurate survival outcome in breast cancer, 10-year follow-up is required and such long-term survival information are few and difficult to gather.

PATIENTS AND METHODS

We recruited 253 breast cancer patients who undertook operation with no prior chemotherapy. Ten-year survival outcomes were evaluated by clinicopathological factors.

RESULTS

Significant univariate prognostic factors were: T factor, N factor, preoperative values of tumor markers, and biological factors. T-factor, CEA, hormone receptor, and Ki-67 were the final independent prognostic factors of recurrence-free survival through multivariate analysis. The Luminal A group except for the Ki-67-positive cases showed the best survival outcomes, while the HER2-positive or triple-negative (TN) groups showed worse prognosis than the Luminal A group, and Ki-67 was shown to be an excellent prognostic factor in each stage (p<0.01).

CONCLUSION

Ki-67 has a great potential as a prognostic biomarker while prognostic information of this sort could be beneficial for development of novel therapeutic strategies.

Increased oxidative damage to membrane lipids following surgery for breast cancer

OBJECTIVES

To evaluate the level of oxidative damage to membrane lipids due to the breast cancer surgery in the early postoperative period.

PATIENTS AND METHODS

Blood samples were collected on the preoperative day and 24 hours postoperatively in 71 women operated for breast cancer, and preoperatively in 38 female patients with benign breast tumour. Lipid peroxidation (LPO) in the blood samples was estimated by measuring the concentrations of malondialdehyde+4-hydroxyalkenals (MDA+4-HDA) with spectrophotometry.

CLINICAL DATA INCLUDED

tumour site, tumour histological findings, cancer stage, grade, tumour volume, state of lymph nodes, type of surgery for breast, type of surgery for axilla.

RESULTS

Blood LPO level was similar in breast cancer patients and benign tumour patients (2.01±0.46 nmol/ml vs. 1.92±0.39 nmol/ml, respectively; p>0.05). In cancer patients, MDA+4-HDA increased on the first postoperative day, i.e. from 2.01±0.46 nmol/ml to 2.58±0.98 nmol/ml (p=0.0001). In women with benign breast tumour, LPO did not relate to the histological finding (p=0.8915). In the breast cancer group, preoperative LPO did not correlate with age, tumour volume and number of metastatic lymph nodes. Level of MDA+4-HDA was similar in stages I/II (2.03±0.46 nmol/ml) compared to stages III/IV (1.69±0.26 nmol/ml, p=0.1521). Consequently, levels of MDA+4-HDA did not relate to disease stage (p=0.1364).

CONCLUSIONS

Surgery for breast cancer causes peripheral increase in oxidative damage to macromolecules in the early postoperative period. Therefore, perioperative antioxidant supplementation should be considered.

Papillary lesions on core breast biopsy: excisional biopsy for all patients?

Excisional biopsy has been recommended for papillary lesions diagnosed on core needle biopsy (CNB) because a significant proportion of cases are upstaged to in situ/invasive cancer after surgical excision. The study goals were to identify patients at lowest risk of upstaging in whom excisional biopsy may potentially be avoided. We retrospectively evaluated 46 patients with a papillary lesion on CNB. Six patients were upstaged overall (13%), to intraductal papillary carcinoma (7%), invasive papillary carcinoma (4%), and mixed invasive ductal/lobular carcinoma (2%). The upstaging rate for patients with atypia on CNB was higher than for patients without atypia (33 vs 3%, P = 0.011). No patient younger than 65 years was upstaged to in situ or invasive carcinoma, and the mean lesion size was also higher among patients who were upstaged (P > 0.05). Patients younger than 65 years with small papillary lesions lacking atypia on CNB may therefore represent a low-risk group that may be offered close clinical and radiologic follow-up.

[A case of metastatic breast carcinoma of the cervical muscles]

A 57-year-old woman was referred to another hospital with bilateral breast masses. Incisional biopsy findings indicated bilateral breast invasive lobular carcinoma, with positive estrogen receptor(ER)status and negative human epidermal growth factor receptor 2(HER2)status. Close inspection did not show the presence of distant metastasis, but lymphadenopathy was noted in the left supraclavicular region, and bilateral TxN3M0, Stage IIIC breast cancer was diagnosed. We performed a simple, double mastectomy, and endocrine therapy was initiated. Treatment with anastrozole followed by tamoxifen resulted in a temporary response. Because of progression after both treatments, chemotherapy was initiated. Complete response was observed in the left supraclavicular lymph node metastases after 4 courses of docetaxel and cyclophosphamide. Two years after treatment was discontinued, metastatic breast carcinoma in the stomach was diagnosed. Immediately after fulvestrant administration, the patient complained of neck stiffness. Several examinations revealed thickening of the cervical muscles with an abnormal signal. Core needle biopsy of the cervical muscle lesion revealed the presence of metastatic adenocarcinoma, with negative ER status and negative HER2 status. Chemotherapy with capecitabine was initiated, and this resulted in stable disease.

Atypical lobular hyperplasia and lobular carcinoma in situ at core breast biopsy: use of careful radiologic-pathologic correlation to recommend excision or observation

PURPOSE

To assess the utility of precise radiologic and pathologic correlation for establishing imaging-histologic concordance or discordance as a method to limit the number of patients requiring surgical excision when atypical lobular hyperplasia (ALH) or lobular carcinoma in situ (LCIS) is diagnosed at core biopsy.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The pathology database was searched from 2000 to 2010 for core biopsies yielding ALH or LCIS devoid of any additional lesion that independently necessitated excision. All cases had to have either subsequent surgical excision or a minimum of 2 years of imaging follow-up. This yielded 50 cases from 49 women aged 40-73 years (mean age, 59 years). The authors performed detailed radiologic-pathologic analysis while blinded to subsequent follow-up information, comparing all biopsy-related images with the histologic findings at core biopsy and then designating each core biopsy finding as concordant or discordant. Then, results of subsequent surgery or extended follow-up for each case were unblinded and compared with original concordant or discordant designations. Outcomes and confidence intervals (CIs) were calculated.

RESULTS

Of the 43 benign concordant core biopsy findings, none were upgraded at surgery (n = 38) or extended follow-up (n = 5) (95% CI: 0%, 8%). Of the seven discordant biopsy findings, two were upgraded to ductal carcinoma in situ at surgery (n = 5); none of the cases were upgraded at follow-up (n = 2).

CONCLUSION

When careful radiologic-pathologic correlation is performed and concordance is achieved, women with ALH or LCIS at core biopsy can be observed.

Usefulness of magnetic resonance in patients with invasive cancer eligible for breast conservation: a comparative study

BACKGROUND

The role of magnetic resonance imaging (MRI) in newly detected breast cancer remains controversial. We investigated the impact of preoperative MRI on surgical management of infiltrating breast carcinoma (IBC).

METHODS

We reviewed data of 237 patients with IBC who were suitable for breast-conserving surgery (BCS) between 2009 and 2011. Of these patients, 109 underwent preoperative MRI (46%; MRI group) and 128 did not (54%; no-MRI group). We analyzed MRI-triggered changes in surgical plan and compared differences in rates of positive margins and mastectomy.

RESULTS

Tumor size was larger in the MRI group (16.8 mm vs. 13.9 mm; P < .001). MRI changed the initial surgical planning in 18 of 109 patients (16.5%) because of detection of larger tumor diameter requiring wider resection (8 patients [7.3%]) or additional malignant lesions in the ipsilateral (9 patients [8.2%]) or contralateral breast (1 patient [0.9%]). MRI-triggered treatment changes included mastectomy (n = 12), wider excision (n = 5), and contralateral BCS (n = 1). Reoperation rates for positive margins after BCS appeared higher in the no-MRI group (4.1% vs. 8.6%), but the difference missed statistical significance (P = .9). Overall mastectomy rates were higher in the MRI group (13.7% vs. 7.0%; P < .05). The likelihood of having a change of treatment resulting from MRI was significantly higher for patients with tumors > 15 mm and for those with positive lymph nodes.

CONCLUSION

Lymph node positivity and tumor size > 15 mm may predict an MRI-triggered change in surgical plan. Preoperative MRI resulted in higher mastectomy rates justified by biopsy-proven additional foci of carcinoma and did not significantly reduce reoperation rates for positive margins.

[Analysis of influencing factors to metastasis in sentinel lymph nodes and non-sentinel lymph nodes in breast cancer]

OBJECTIVE

To explore the relevant factors influencing sentinel and non-sentinel lymph node (SLNM, NSLNM) metastases in breast cancer.

METHODS

The clinicopathological data of 283 women with breast cancer who underwent sentinel lymph node biopsy from July 2010 to August 2011 in the Cancer Institute and Hospital at Chinese Academy of Medical Sciences were reviewed retrospectively, and the relevant factors affecting sentinel and non-sentinel lymph node metastases were analyzed.

RESULTS

Univariate analysis showed that age, menopause status, tumor size, pathological type and intravascular tumor thrombus were associated with SLNM metastasis (all P < 0.05). Multivariate analysis showed that age, tumor size and intravascular tumor thrombus were associated with SLNM (all P < 0.05) . No risk factors were found in either univariate or multivariate analysis of NSLNM.

CONCLUSIONS

Age, tumor size and intravascular tumor thrombus are independent influencing factors associated with SLNM, and age is a protective factor. Whether ER, pathological type and pathological grade are associated with SLNM or not is still controversial.

Rate of re-excision after breast-conserving surgery for invasive lobular carcinoma

Invasive lobular carcinoma (ILC) accounts for approximately 5 to 20 per cent of all breast cancers and is often multicentric. Despite pre- and intraoperative assessments to achieve negative margins, ILC is reported to be associated with higher rates of positive margin. This cross-sectional study examined patients with breast cancer treated at our institution from 2000 to 2010. The objective was to investigate the rate of re-excision resulting from positive or close margin (1 mm or less) in patients who underwent breast-conserving surgery (BCS) for ILC compared with invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). Of the 836 patients treated, 416 patients underwent BCS. The rate of re-excision after BCS for ILC was 35.1 versus 17.7 per cent for IDC and 20.0 per cent for DCIS (P = 0.04). Re-excisions were more often performed for positive margin in patients with ILC (11 of 37 [29.7%]) versus IDC (36 of 334 [10.8%]) and DCIS (five of 45 [11.1%];(P = 0.004). In this single-institution review, BCS for ILC had significantly higher rates of re-excision as a result of positive margins when compared with IDC and DCIS. Tumor size greater than 2 cm and lymph node involvement were identified as factors associated with positive surgical margin in ILC. The higher possibility of positive margins and the need for additional procedures should be discussed with patients undergoing BCS for ILC.

Postmastectomy reconstruction is associated with improved survival in patients with invasive breast cancer: a single-institution study

Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.

Pleomorphic lobular carcinoma with lipid-producing activity: a report of 2 cases

This case report presented 2 cases of pleomorphic lobular carcinoma (PLC) of the breast with lipid-producing activity, a type of cancer that has not been previously reported in the literature. The patients were 2 Japanese women aged 67 and 57 years, respectively, who presented with the chief complaint of an indolent tumor mass of the left breast. Both patients underwent breast conserving surgery and axillary sentinel node biopsy. Pathological analysis of breast tissue specimens revealed carcinoma cells, most of which contained abundant granular or foamy cytoplasm, enlarged round nuclei with prominent nucleoli, and intracytoplasmic lumens (ICLs). Digested periodic acid-Schiff (PAS) staining revealed diastase-resistant PAS staining in the ICLs, while Sudan III and oil -red -O staining revealed lipid granules in the cytoplasm. Immunohistochemically, the carcinoma cells from both cases tested negative for E-cadherin but positive for gross cystic disease fluid protein-15, cytokeratin, and mucin 1. Consideration of these findings led to a diagnosis of PLC with lipid-producing activity.

t(8;16) AML developed subsequent to breast cancer therapy

We report a breast cancer patient who developed acute myeloid leukemia (AML) one year following her adjuvant chemotherapy consisting of cyclophosphamide, adriamycin and 5-fluorouracil. Cytogenetic examination of bone marrow samples resulted in t(8;16)(p11.2;p13.3), which is a chromosome rearrangement observed in de novo and treatment related AML M4/M5 with a poor prognosis.

[Invasive lobular carcinoma of basal-like subtype of breast: a clinicopathologic analysis]

OBJECTIVE

To investigate the clinicopathologic features, clinical progress and prognosis of the basal-like subtype of invasive lobular carcinoma (ILC) of the breast.

METHODS

Four cases of ILC were analyzed by detailed histopathologic observation and immunohistochemical staining for E-cadherin, p120 catenin, ER, PR, HER2, CK5/6, EGFR, p63, p53, Ki-67 using MaxVision method. The follow-up and clinical data were analyzed.

RESULTS

Morphologically, one case was mixed ILC and three cases were pleomorphic ILC. The tumor cells were negative for E-cadherin except one case with focal membrane positivity, and all showed p120 catenin cytoplasmic positivity except one case with focal membrane positivity. All cases were negative for ER, PR and HER2 (triple negative), and positive for EGFR and CK5/6. Two cases were positive for p63. The cases were partly and weakly positive for p53, and the Ki-67 positive rate was between 30% and 75%. Follow-up data showed that two cases developed chest wall metastases, and in one case, there was progression to liver and abdominal metastases.

CONCLUSIONS

ILC of the breast are ER, PR and HER2 "triple negative", CK5/6 and EGFR positive, indicative of basal-like characteristics. Basal-like subtype of ILC are peculiarly prone to metastasis and poor response to chemotherapy, suggesting that it is associated with poor prognosis.

Surgical impact of new treatments in breast cancer

Local treatment of breast cancer with tumor-free surgical margins is the standard procedure in the treatment of T1 and small T2 breast cancers. Surgery is followed by radiation therapy, and adjuvant systemic therapy is offered depending on primary tumor characteristics, such as tumor size, grade of differentiation, number of involved axillary lymph nodes, the status of estrogen (ER) and progesterone (PR) receptors, and the expression of the human epidermal growth factor 2 (HER2) receptor. Although this approach implies a higher risk of ipsilateral breast tumor recurrence, the total risk of recurrence is low (1% per year), with rates of overall survival similar to that after radical procedures. The most peripheral part of epithelial tumors, the tumor margin, is the part which is most likely to remain in loco after surgical resection. Thus, understanding the biology of the invasion front is important as these tumor cells have been reported to lose epithelial properties, such as cohesiveness and keratin expression, and to acquire features of mesenchymal cells. The parallel appearance of tumor cells in different states of cell dedifferentiation implicates a dynamic equilibrium that is determined by the induction of epithelial-mesenchymal transition (EMT). EMT has been suggested to be of prime importance for tissue and vessel invasion. Furthermore, features of EMT are associated with the activity of tumor stem cells (TSC). TSC exist in breast cancer and their appearance varies depending on the used marker profile. Consequently, intratumoral heterogeneity is reflected by the grade of EMT activation. A specific function at the invasion front is hypothesized but has not yet been proven. Nevertheless, the molecular differentiation between the tumor center and the invasion front enhances the importance of tumor-free surgical margins.

Impact of preoperative bilateral whole breast sonography in patients with invasive lobular carcinoma: results from two medical centers

PURPOSE

The purpose of this study was to evaluate the sensitivity of bilateral whole breast sonography (BWBS) combined with mammography for the detection of additional lesions, as well as index lesions, in patients with invasive lobular carcinoma (ILC) and to evaluate the impact of BWBS on surgical treatment and cancer staging strategies.

MATERIALS AND METHODS

We retrospectively reviewed mammographic and sonographic records of 97 patients with proven ILCs between November 2002 and November 2009. We evaluated the sensitivity of mammography and BWBS for the detection of additional and index lesions. We compared the impact of BWBS on surgical treatment and breast cancer staging between cases with single index lesions and with BWBS-detected additional lesions and index lesions. We compared the differences in sensitivity, surgical treatment procedures and breast cancer staging between BWBS and MRI confined to the patients underwent MRI.

RESULTS

The overall sensitivity was 74.4% (93/125 lesions) for mammography and 96.0% (120/125 lesions) for BWBS (p < 0.001). The group with additional lesions detected using US alone exhibited more frequent mastectomy (p = 0.003) and higher N staging (p = 0.051) than did the group with single index lesions. Comparing the BWBS and MRI cases, there were no significant differences in lesion staging, the sensitivity of malignant foci detection (p = 0.074).

CONCLUSION

BWBS has a higher sensitivity than does mammography for the detection of index and additional ILC. Detection of additional malignancies using BWBS could affect which strategy is chosen for surgical treatment.

The importance of pre-operative needle core breast biopsy results on resected tissue volume, margin status, and cosmesis

PURPOSE

This study aimed to evaluate the relationship between pre-operative image-guided large needle core biopsy (LNCB) histopathology results and surgical resection volumes in breast conserving surgery (BCS), with attention to both margin status and cosmetic outcome.

METHODS

Breast volumes (BV) were calculated using the elliptical cone based formula on mammography images for each patient. Initial resected volume (IRV), final resected volume (FRV), and resected volume ratio (RVR) were calculated and compared according to histopathological diagnosis and cosmetic outcomes. Final pathology results were classified as benign, high risk lesion (HRL), ductal carcinoma in situ (DCIS), or invasive cancer. The cosmetic results were graded based on the Harvard breast cosmesis grading scale.

RESULTS

A total of 217 women underwent BCS by the same experienced breast surgeon. The resected volumes (mean, cm3) were higher among patients who underwent LNCB than those who did not (54.3 vs 26.5 ;p=0.005). The LNCB diagnoses were 16% benign, 19% HRLs, 16% DCIS, and 49% invasive cancers. Reexcision rates were 15.6% and 25.8% for DCIS and invasive cancer, respectively. Cosmesis was excellent in 79.8%. Age, pathological tumor size, IRV and FRV were different among the benign, HRLs and carcinoma groups (p= 0.001).

CONCLUSION

The diagnosis of carcinoma by LNCB leads to the planning of a wider resection, but the need for reexcision is no different than less resection. HRLs are best approached with diagnostic excision, as there is no strong evidence that larger resections reduce the incidence of involved resection margins.

Pleomorphic lobular carcinoma in a male breast: a case report with review of the literature

Invasive lobular carcinoma (ILC) is a distinct type of breast carcinoma and represents 5-15% of invasive breast carcinomas in female. However, the occurrence of ILC is exceptional in male breast, and the incidence is 1.5-1.9% of male breast carcinomas. Herein, we report a case of pleomorphic lobular carcinoma in a male breast. A 76-year-old Japanese male with a history of treatment with a progestational agent for prostate cancer presented with a right breast tumor. Magnetic resonance imaging showed gynecomastia of bilateral breasts and an irregular-shaped nodule in his right breast. Histopathological study revealed infiltrative neoplastic growth of discohesive tumor cells arranged in single-filed linear cords or trabeculae. These neoplastic cells had variable-sized large nuclei containing occasional nucleoli. Immunohistochemically, these tumor cells lacked E-cadherin expression. Accordingly, an ultimate diagnosis of pleomorphic lobular carcinoma was made. This is the third documented case of pleomorphic lobular carcinoma of male breast. Our analyses of the clinicopathological features of this type of tumor revealed that patients were middle-aged or elderly men, and all cases were free from lymph node metastases or recurrence. Gynecomastia and a history of hormonal agent intake were present only in the current case. The most commonly proposed risk factor for the development of male breast cancer is elevated level of estrogen, and a possible link between the development of male breast cancer and estrogen therapy for prostate cancer has been suggested. The clinicopathological features of ILC of male breast remains unclear; therefore, additional studies are needed to clarify them.

Factors of influence on acute skin toxicity of breast cancer patients treated with standard three-dimensional conformal radiotherapy (3D-CRT) after breast conserving surgery (BCS)

PURPOSE/OBJECTIVES

Standard 3D-CRT after BCS may cause skin toxicity with a wide range of intensity including acute effects like erythema or late effects. In order to reduce these side effects it is mandatory to identify potential factors of influence in breast cancer patients undergoing standard three-dimensional conformal radiation therapy (3D-CRT) of the breast and modern systemic therapy.

MATERIALS/METHODS

Between 2006 and 2010 a total of 211 breast cancer patients (median age 52,4 years, range 24-77) after BCS consecutively treated in our institution with 3D-CRT (50 Gy whole breast photon radiotherapy followed by 16 Gy electron boost to the tumorbed) were evaluated with special focus on documented skin toxicity at the end of the 50 Gy-course. Standardized photodocumentation of the treated breast was done in each patient lying on the linac table with arms elevated. Skin toxicity was documented according to the common toxicity criteria (CTC)-score. Potential influencing factors were classified in three groups: patient-specific (smoking, age, breast size, body mass index = BMI, allergies), tumor-specific (tumorsize) and treatment-specific factors (antihormonal therapy with tamoxifen or aromatase inhibitors, chemotherapy). Uni- and multivariate statistical analyses were done using IBM SPSS version 19.

RESULTS

After 50 Gy 3D-CRT to the whole breast 28.9% of all 211 patients had no erythema, 62.2% showed erythema grade 1 (G1) and 8.5% erythema grade 2. None of the patients had grade 3/4 (G3/4) erythema.In univariate analyses a significant influence or trend on the development of acute skin toxicities (erythema G0 versus G1 versus G2) was observed for larger breast volumes (p=0,004), smoking during radiation therapy (p=0,064) and absence of allergies (p=0,014) as well as larger tumorsize (p=0,009) and antihormonal therapy (p=0.005).Neither patient age, BMI nor choice of chemotherapy showed any significant effect on higher grade toxicity. In the multivariate analysis, factors associated with higher grade skin toxicity were larger breast target volume (p=0,003), smoking (p=0,034) and absence of allergies (p=0,002).

CONCLUSION

Patients treated in this study showed less objectively documented skin toxicity after 50 Gy 3D-CRT compared to similar patient cohorts. Factors associated with higher grade skin toxicity were smoking during 3D-CRT, absence of allergies and larger breast volumes.

Clinical presentation and surgical management of invasive lobular carcinoma of the breast

Invasive lobular carcinoma is the second most common histological type of breast cancer and differs from invasive ductal carcinoma also in some clinical features. Multifocal or multicentric as well as contralateral diseases are more frequently found among patients with lobular carcinoma. Tumor size at diagnosis is larger than in patients with ductal carcinoma due to diagnostic challenges associated with lobular histology. For surgical management, breast conserving surgery followed by radiotherapy offers equal local control as mastectomy. Controversy however exists regarding risk for positive margins and subsequent need for second operations. Axillary staging can be safely performed by sentinel node biopsy if lymph nodes are clinically negative, even in multifocal or multicentric disease.

Preliminary results: double lumpectomies for multicentric breast carcinoma

The standard operation for patients with multicentric breast cancer is total mastectomy. The safety of breast-conserving surgery (BCS) for these patients is unknown but interest in BCS has recently resurfaced as a result of the detection of occult second malignancies by breast magnetic resonance imaging (MRI). We report a small number of patients who chose to undergo "double lumpectomies," defined as two separate segmental mastectomies for primary cancers in different quadrants of the same breast. Patients with multicentric breast cancer surgically managed with double lumpectomies at our institute were identified retrospectively. Clinicopathologic features are described and outcomes reported. Seven patients underwent double lumpectomies for multicentric carcinoma. Median age was 69 years (range, 61 to 80 years). In five patients, MRI identified ipsilateral second malignancies. All patients had two foci of invasive carcinoma, all tumors expressed estrogen receptor, and none showed HER-2 overexpression. Tumor sizes ranged from 0.7 to 2.9 cm. Six patients had histologically distinct tumors in the same breast: five had one invasive lobular carcinoma (ILC) and one invasive ductal carcinoma (IDC), and one had classic ILC in one quadrant and pleomorphic ILC in another. One patient had two foci of IDC in separate quadrants. All patients had sentinel lymph node biopsies and none had nodal metastasis. Median follow-up was 26 months (range, 18 to 85 months). No patient developed locoregional recurrence. This small series suggests that "double lumpectomy" may be considered for multicentric invasive breast carcinoma in carefully selected patients with favorable tumors who desire breast conservation.

Synchronous primary malignant tumors of the breast, caecum and sigma. Case report

We present the case of a patient with a double adenocarcinoma of the right colon and sigma associated with a bilateral infiltrating ductal breast carcinoma. Sigma and caecum bowel cancers were diagnosed at colonoscopy, with computerized tomography staging, while breast cancer was found with screening mammography. Following right hemicolectomy , sigmoidectomy and bilateral mastectomy the histology confirmed the presence of colonic adenocarcinoma and infiltrating and in situ lobular cancer. This case report reviews the treatment of synchronous neoplasia.

[A case of combined noninvasive ductal and lobular carcinoma]

We report a case of combined noninvasive ductal and lobular carcinoma. The patient was a 54-year-old woman with a breast tumor. The tumor was a palpable movable mass measuring 1 cm in diameter in the AC region of her breast. Mammography, ultrasonography, magnetic resonance imaging, and vacuum-assisted core-needle biopsy were performed. The histopathological diagnosis was intraductal papillary cystic lesion. However, there was also a ductal lesion. We performed lumpectomy, and the diagnosis was combined noninvasive ductal and lobular carcinoma. It was difficult to determine the range of carcinoma, and thus, we performed Bt+Ax. Combined noninvasive ductal and lobular carcinoma is rare. We should study additional cases and develop more adequate treatments.

Effect of adjuvant chemotherapy in postmenopausal patients with invasive ductal versus lobular breast cancer

BACKGROUND

On the basis of the lack of response of invasive lobular breast cancer to neoadjuvant chemotherapy, we questioned the effectiveness of adjuvant chemotherapy in relation to histology.

PATIENTS AND METHODS

Women with primary nonmetastatic invasive ductal or (mixed type) lobular breast cancer, aged 50-70 years, diagnosed between 1995 and 2008, were selected from the Netherlands Cancer Registry and followed until January 1, 2010. The patients were divided in two groups: one group receiving adjuvant hormonal therapy only and the other receiving adjuvant hormonal therapy in combination with adjuvant chemotherapy.

RESULTS

In total, 19,609 patients had ductal cancer and 3685 had lobular cancer. The 10-year overall survival rate in ductal cancer when treated with hormonal therapy alone was 69%, compared with 74% with the combination therapy (P < 0.0001). In lobular cancer, 10-year survival rates were 68% after hormonal treatment alone and 66% after the combination therapy (P = 0.45). The hazard ratio (HR) for mortality in ductal cancer after combination therapy was 0.70 [95% confidence interval (CI) 0.64-0.76; P < 0.0001], compared with hormonal treatment alone. The HR in lobular cancer was 1.00 (95% CI 0.82-1.21; P = 0.97).

CONCLUSION

Adjuvant chemotherapy seems to confer no additional beneficial effects in postmenopausal patients with pure or mixed type lobular breast cancer receiving hormonal therapy.

American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns

INTRODUCTION

The ACOSOG Z0011 trial has been described as practice-changing. The goal of this study was to determine the impact of the trial on surgeon practice patterns at our institution.

METHODS

This is a review of practice patterns comparing the year before release of Z0011 to the year after an institutional multidisciplinary meeting discussing the results. Patients meeting Z0011 inclusion criteria were identified. Clinicopathologic data were compared between the cohorts.

RESULTS

There were 658 patients with clinical T1-2 tumors planned for breast conservation: 335 in the pre-Z0011 cohort and 323 post-Z0011. Sixty-two (19 %) patients were sentinel lymph node (SLN) positive in the pre-Z0011 group versus 42 (13 %) post-Z0011 (p = 0.06). Before Z0011, 85 % (53/62) of SLN-positive patients underwent axillary node dissection (ALND) versus 24 % (10/42) after Z0011 (p < 0.001). After Z0011, surgeons were more likely to perform ALND on patients with larger tumors (2.2 vs. 1.5 cm, p = 0.09), lobular histology (p = 0.01), fewer SLNs (1 vs. 3, p = 0.09), larger SLN metastasis size (4 vs. 2.5 mm, p = 0.19), extranodal extension present (20 vs. 6 %, p = 0.16), or a higher probability of positive non-SLNs (p = 0.03). Surgeons were less likely to perform intraoperative nodal assessment post-Z0011 (26 vs. 69 %, p < 0.001) resulting in decreased median operative times for SLN-negative patients (79 vs. 92 min, p < 0.001).

CONCLUSIONS

Surgeons at our institution have implemented Z0011 results for the majority of patients; however, clinicopathologic factors still impact the decision to perform ALND. Z0011 results have significantly impacted practice by decreasing rates of ALND, use of intraoperative nodal evaluation, and operative times.

Preoperative PET/CT in early-stage breast cancer

BACKGROUND

The aim of this study was to assess the diagnostic and therapeutic impact of preoperative positron emission tomography and computed tomography (PET/CT) in the initial staging of patients with early-stage breast cancer.

PATIENTS AND METHODS

A total of 103 consecutive patients with newly diagnosed operable breast cancer with tumors ≥2 cm were independently examined preoperatively with conventional assessment (mammography, breast/axillary ultrasound, chest X-ray and blood samples) and PET/CT with no prior knowledge of the other.

RESULTS

PET/CT identified a primary tumor in all but three patients (97%). PET/CT solely detected distant metastases (ovary, bones and lung) in 6 patients and new primary cancers (ovary, lung) in another two patients, as well as 12 cases of extra-axillary lymph node involvement. In 15 patients (15%), extra-axillary malignancy was detected by PET/CT only, leading to an upgrade of initial staging in 14% (14/103) and ultimately a modification of planned treatment in 8% (8/103) of patients.

CONCLUSIONS

PET/CT is a valuable tool to provide information on extra-axillary lymph node involvement, distant metastases and other occult primary cancers. Preoperative (18)F-fluorodeoxyglucose-PET/CT has a substantial impact on initial staging and on clinical management in patients with early-stage breast cancer with tumors ≥2 cm.

Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics

OBJECTIVES

To examine whether rate of reoperation after breast conserving surgery is associated with patients' characteristics and investigate whether reoperation rates vary among English NHS trusts.

DESIGN

Cohort study using patient level data from hospital episode statistics.

SETTING

English NHS trusts.

PARTICIPANTS

Adult women who had breast conserving surgery between 1 April 2005 and 31 March 2008.

MAIN OUTCOME MEASURE

Reoperation rates after primary breast conserving surgery within 3 months, adjusted using logistic regression for tumour type, age, comorbidity, and socioeconomic deprivation. Tumours were grouped by whether a carcinoma in situ component was coded at the time of the primary breast conserving surgery.

RESULTS

55,297 women had primary breast conserving surgery in 156 NHS trusts during the three year period. 11,032 (20.0%, 95% confidence interval 19.6% to 20.3%) women had at least one reoperation. 10,212 (18.5%, 18.2% to 18.8%) had one reoperation only; of these, 5943 (10.7%, 10.5% to 11.0%) had another breast conserving procedure and 4269 (7.7%, 7.5% to 7.9%) had a mastectomy. Of the 45,793 women with isolated invasive disease, 8229 (18.0%) had at least one reoperation. In comparison, 2803 (29.5%) of the 9504 women with carcinoma in situ had at least one reoperation (adjusted odds ratio 1.9, 95% confidence interval 1.8 to 2.0). Substantial differences were found in the adjusted reoperation rates among the NHS trusts (10th and 90th centiles 12.2% and 30.2%).

CONCLUSION

One in five women who had breast conserving surgery in England had a reoperation. Reoperation was nearly twice as likely when the tumour had a carcinoma in situ component coded. Women should be informed of this reoperation risk when deciding on the type of surgical treatment of their breast cancer.

Androgen receptor expression is usually maintained in initial surgically resected breast cancer metastases but is often lost in end-stage metastases found at autopsy

Androgen receptor (AR) is expressed in approximately 70% of primary breast carcinomas (PBCs) and is a promising therapeutic target for metastatic breast carcinoma (MBC). Here, we examine AR expression in a population of initial surgically resected metastases and a separate cohort of end-stage metastases harvested at autopsy compared with their matched PBCs. Tissue microarrays of matched PBC and MBC were labeled by immunohistochemistry for AR, estrogen receptor (ER), progesterone receptor (PR), and Her2 and classified into the following previously described categories: luminal (ER/PR+/Her2-), triple negative (ER/PR/Her2-), Her2 (ER/PR-/Her2+), and luminal loss (ER/PR loss from primary to metastasis). In the cohort of surgically resected metastases (n = 16), AR was expressed in 12 of 16 PBC and maintained in 11 of 12 corresponding MBCs. Of these, 36% showed stronger AR labeling in the metastases and none showed a decrease. In the cohort of metastases harvested at autopsy (n = 16), AR was expressed in 11 of 16 primary carcinomas and maintained in only 5 of 11 corresponding metastases. Of these, none showed increased AR and 80% showed decreased AR labeling. AR expression is overwhelmingly concordant between matched PBC and MBC at initial presentation. These findings validate AR as a therapeutic target in MBC and suggest that AR may need to be reevaluated in metastases even if the primary is negative. However, similar to ER/PR, AR expression is often decreased with a trend toward complete loss in end-stage metastases, suggesting a shift of AR expression between initial and end-stage metastases. This suggests an opportunity for targeted antiandrogen therapy at an earlier stage of disease progression.

[Metastasis of breast cancer in gastointestinal tract - report of a case and review of the literature]

Metastatic breast cancer affecting the gastrointestinal tract except from the liver is very rare, however, some case reports can be found in literature, autopsy series and several retrospective studies focusing on this issue. In our surgery department we have also documented a case report of metastatic breast cancer manifesting as an obstructive tumor of small intestine.