401
|
|
402
|
Brown AS, Hunt KK, Shen J, Huo L, Babiera GV, Ross MI, Meric-Bernstam F, Feig BW, Kuerer HM, Boughey JC, Ching CD, Gilcrease MZ. Histologic changes associated with false-negative sentinel lymph nodes after preoperative chemotherapy in patients with confirmed lymph node-positive breast cancer before treatment. Cancer 2010; 116:2878-83. [PMID: 20564394 DOI: 10.1002/cncr.25066] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND A wide range of false-negative rates has been reported for sentinel lymph node (SLN) biopsy after preoperative chemotherapy. The purpose of this study was to determine whether histologic findings in negative SLNs after preoperative chemotherapy are helpful in assessing the accuracy of SLN biopsy in patients with confirmed lymph node-positive disease before treatment. METHODS Eighty-six patients with confirmed lymph node-positive disease at presentation underwent successful SLN biopsy and axillary dissection after preoperative chemotherapy at a single institution between 1994 and 2007. Available hematoxylin and eosin-stained sections from patients with negative SLNs were reviewed, and associations between histologic findings in the negative SLNs and SLN status (true negative vs false negative) were evaluated. RESULTS Forty-seven (55%) patients had at least 1 positive SLN, and 39 (45%) patients had negative SLNs. The false-negative rate was 22%, and the negative predictive value was 67%. The negative SLNs from 17 of 34 patients with available slides had focal areas of fibrosis, some with associated foamy parenchymal histiocytes, fat necrosis, or calcification. These histologic findings occurred in 15 (65%) of 23 patients with true-negative SLNs and in only 2 (18%) of 11 patients with false-negative SLNs (P = .03, Fisher exact test, 2-tailed). The lack of these histologic changes had a sensitivity and specificity for identifying a false-negative SLN of 82% and 65%, respectively. CONCLUSIONS Absence of treatment effect in SLNs after chemotherapy in patients with lymph node-positive disease at initial presentation has good sensitivity but low specificity for identifying a false-negative SLN.
Collapse
|
403
|
Jakub JW, Bryant K, Huebner M, Hoskin T, Boughey JC, Reynolds C, Degnim AC. The Number of Axillary Lymph Nodes Involved with Metastatic Breast Cancer Does not Affect Outcome as Long as All Disease is Confined to the Sentinel Lymph Nodes. Ann Surg Oncol 2010; 18:86-93. [DOI: 10.1245/s10434-010-1202-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2009] [Indexed: 01/02/2023]
|
404
|
Ansari B, Boughey JC. Sentinel Lymph Node Surgery in Uncommon Clinical Circumstances. Surg Oncol Clin N Am 2010; 19:539-53. [DOI: 10.1016/j.soc.2010.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
405
|
Degnim AC, Frost MH, Radisky DC, Anderson SS, Vierkant RA, Boughey JC, Pankratz VS, Ghosh K, Hartmann LC, Visscher DW. Pseudoangiomatous stromal hyperplasia and breast cancer risk. Ann Surg Oncol 2010; 17:3269-77. [PMID: 20567920 DOI: 10.1245/s10434-010-1170-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pseudoangiomatous stromal hyperplasia (PASH) is a benign localized fibrotic lesion in which clusters of spindle cells form cleftlike spaces, resembling ectatic vessels. Its relationship to breast cancer risk has not been characterized. MATERIALS AND METHODS Histological presence of PASH was evaluated by review of archival slides in a single institution cohort of women who underwent benign excisional breast biopsy from 1967 to 1991. Relative risks for subsequent breast cancer were estimated using standardized incidence ratios (SIR), comparing the observed number of cancers with those expected based on Iowa SEER data (mean follow-up 18.5 years). RESULTS PASH was identified in 579 of 9065 biopsies (6.4%). Women with PASH were younger, more likely to have a palpable mass as indication for biopsy, and had less lobular involution compared with those without PASH (all P < 0.001), while they did not differ by family history of breast cancer or degree of epithelial proliferation. Breast cancers occurred in 34 women with PASH (5.9%) and 789 without (8.8%). Women with PASH had lower risk of breast cancer (SIR 1.03, 95% confidence interval [95% CI] 0.71-1.44) than those without PASH (SIR 1.54, 95% CI 1.43-1.65), P = 0.01. Lower levels of breast cancer risk for the PASH group persisted in analyses stratified by age, family history, epithelial proliferation, and involution. The cancers in the PASH group occurred predominantly in the ipsilateral breast more than 5 years after biopsy. CONCLUSIONS Despite clinical concern generated by palpable density often associated with PASH, this relatively uncommon histological finding does not connote increased risk of subsequent breast cancer.
Collapse
|
406
|
Zendejas B, Hoskin TL, Degnim AC, Reynolds CA, Farley DR, Boughey JC. Predicting four or more metastatic axillary lymph nodes in patients with sentinel node-positive breast cancer: assessment of existent risk scores. Ann Surg Oncol 2010; 17:2884-91. [PMID: 20429038 DOI: 10.1245/s10434-010-1077-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with metastases in four or more axillary lymph nodes (≥4+ALN) represent a subset of patients with breast cancer who are at increased risk of local recurrence and who benefit from postmastectomy radiation. Risk prediction models designed to identify such patients have been published by Rivers et al., Chagpar et al., and Katz et al. We sought to evaluate and compare the performance of these models in an independent patient population. METHODS We reviewed 454 patients with breast cancer with one to three positive sentinel lymph nodes who underwent completion axillary lymph node dissection at our institution. Each of the three published models was applied to our sample as described in the respective publications. The models' performances were analyzed with the Hosmer-Lemeshow goodness-of-fit test and with the area under the curve (AUC). Sensitivity, specificity, and false-negative percentages were calculated for clinically meaningful cutoff points of each score. RESULTS Of 454 eligible patients, 87 (19.2%) had four or more positive axillary nodes. The Rivers, Chagpar, and Katz models demonstrated good calibration in our population based on the Hosmer-Lemeshow test (p = 0.82, p = 0.73, p = 0.71, respectively). Assessment of discriminatory ability for the models resulted in AUCs of 0.81, 0.73, and 0.81, respectively. CONCLUSIONS The Rivers and Katz models performed well in our patient population and may be clinically useful to predict patients with ≥4+ALN. However, their clinical utility is limited by the current controversy surrounding the use of postmastectomy radiation for all node-positive patients.
Collapse
|
407
|
Boughey JC, Donohue JH, Jakub JW, Lohse CM, Degnim AC. Number of lymph nodes identified at axillary dissection. Cancer 2010; 116:3322-9. [DOI: 10.1002/cncr.25207] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
408
|
Scow JS, Reynolds CA, Degnim AC, Petersen IA, Jakub JW, Boughey JC. Primary and secondary angiosarcoma of the breast: the Mayo Clinic experience. J Surg Oncol 2010; 101:401-7. [PMID: 20119983 DOI: 10.1002/jso.21497] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Angiosarcoma of the breast can be divided into primary and secondary. The objective was to determine clinicopathologic factors associated with breast angiosarcoma and to compare primary versus secondary angiosarcoma. METHODS Breast angiosarcoma cases at Mayo Clinic from 1960 to 2008 were identified. Clinicopathologic factors were reviewed. Characteristics of primary and secondary angiosarcoma were compared. RESULTS Twenty-seven cases of primary angiosarcoma and 14 cases of secondary angiosarcoma were identified. The median age of primary angiosarcoma patients was lower than that of secondary angiosarcoma--43 years versus 73 years (P < 0.0001). Primary angiosarcoma more frequently presented with a mass, whereas secondary angiosarcoma presented with a rash (P < 0.0001). Median time from radiation to secondary angiosarcoma diagnosis was 6.8 years. Median tumor size was 7.0 cm for primary angiosarcoma and 5.0 cm for secondary angiosarcoma (P = 0.7). Tumors were high grade in 33% of primary angiosarcoma and 82% of secondary angiosarcoma (P = 0.02). Five-year survival for primary and secondary angiosarcoma was 46% and 69%, respectively (P = 0.8). CONCLUSION Primary angiosarcoma occurs in younger patients than secondary and more frequently presents with a mass. Mastectomy is the mainstay of treatment for breast angiosarcoma. Breast angiosarcoma is a rare malignancy with poor long-term prognosis.
Collapse
|
409
|
Degnim AC, Zakaria S, Boughey JC, Sookhan N, Reynolds C, Donohue JH, Farley DR, Grant CS, Hoskin T. Axillary Recurrence in Breast Cancer Patients with Isolated Tumor Cells in the Sentinel Lymph Node [AJCC N0(i+)]. Ann Surg Oncol 2010; 17:2685-9. [DOI: 10.1245/s10434-010-1062-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Indexed: 01/20/2023]
|
410
|
Jakub JW, Gray RJ, Degnim AC, Boughey JC, Gardner M, Cox CE. Current status of radioactive seed for localization of non palpable breast lesions. Am J Surg 2010; 199:522-8. [DOI: 10.1016/j.amjsurg.2009.05.019] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 05/26/2009] [Accepted: 05/26/2009] [Indexed: 11/16/2022]
|
411
|
Goetz MP, Hoskin TL, Boughey JC, Degnim AC. Reply to S.L. Gomez et al. J Clin Oncol 2010. [DOI: 10.1200/jco.2009.26.2972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
412
|
Pockaj BA, Wasif N, Dueck AC, Wigle DA, Boughey JC, Degnim AC, Gray RJ, McLaughlin SA, Northfelt DW, Sticca RP, Jakub JW, Perez EA. Metastasectomy and surgical resection of the primary tumor in patients with stage IV breast cancer: time for a second look? Ann Surg Oncol 2010; 17:2419-26. [PMID: 20232163 DOI: 10.1245/s10434-010-1016-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Indexed: 12/17/2022]
Abstract
Patients with metastatic or stage IV breast cancer have limited therapeutic options, and the mainstay of treatment remains systemic chemotherapy. Traditionally, the role of surgery has been confined to strict palliation. Improvements in the efficacy of chemotherapeutic regimens, coupled with the use of hormonal and targeted therapy, have resulted in an expansion of surgical resection beyond simple palliation. Several single-institution studies have reported improved survival and even long-term cures after surgical resection for oligometastatic stage IV breast cancer. Similarly, provocative new data suggest that removal of the primary tumor in some patients may confer a survival advantage. The aim of this review is to summarize studies in the medical literature pertaining to the use of surgical resection in patients with stage IV breast cancer. We believe there is enough evidence to challenge conventional thinking about the role of surgery in stage IV breast cancer and to consider a new multimodality treatment paradigm to optimize patient outcomes. It is time to conduct a carefully designed randomized trial to see whether surgery in stage IV breast cancer does indeed warrant a second look.
Collapse
|
413
|
Boughey JC, Moriarty JP, Degnim AC, Gregg MS, Egginton JS, Long KH. Cost modeling of preoperative axillary ultrasound and fine-needle aspiration to guide surgery for invasive breast cancer. Ann Surg Oncol 2010; 17:953-8. [PMID: 20127185 DOI: 10.1245/s10434-010-0919-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Indexed: 02/05/2023]
Abstract
PURPOSE Preoperative axillary lymph node ultrasound (US) and fine-needle aspiration (FNA) biopsy can identify a proportion of node-positive patients and avoid sentinel lymph node (SLN) surgery and direct surgical treatment. We compared the costs with preoperative US/FNA to without US/FNA (standard of care) for invasive breast cancer. METHODS Using decision-analytic software we constructed a model to assess the costs associated with the two preoperative strategies. Diagnostic test sensitivities and specificities were obtained from literature review. Costs were derived from Medicare payment rates and actual resource utilization. Base-case results were fully probabilistic to capture parameter uncertainty in economic results. RESULTS Base-case results estimate total mean costs per patient of $10,947 ("$" indicates US dollars throughout) with the US/FNA strategy and $10,983 with standard of care, an incremental cost savings of $36, on average, per patient [95% confidence interval (CI) of cost difference: -$248 to $179]. Most (63%) of the simulations resulted in cost saving with axillary US/FNA. One-way sensitivity analyses suggest that results are sensitive to assumed diagnostic and surgical costs and selected diagnostic test parameters. US/FNA approach was similar in costs or cost saving relative to the standard of care for all tumor stages. CONCLUSIONS The additional cost of performing axillary US with possible FNA in every patient is balanced, on average, by the savings from avoiding SLN in cases where metastasis can be documented preoperatively. Routine use of preoperative axillary US with FNA to guide surgical planning can decrease the overall cost of patient care for invasive breast cancer.
Collapse
|
414
|
McKian KP, Reynolds CA, Visscher DW, Nassar A, Radisky DC, Vierkant RA, Degnim AC, Boughey JC, Ghosh K, Anderson SS, Minot D, Caudill JL, Vachon CM, Frost MH, Pankratz VS, Hartmann LC. Novel breast tissue feature strongly associated with risk of breast cancer. J Clin Oncol 2009; 27:5893-8. [PMID: 19805686 PMCID: PMC2793038 DOI: 10.1200/jco.2008.21.5079] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2008] [Accepted: 06/25/2009] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Accurate, individualized risk prediction for breast cancer is lacking. Tissue-based features may help to stratify women into different risk levels. Breast lobules are the anatomic sites of origin of breast cancer. As women age, these lobular structures should regress, which results in reduced breast cancer risk. However, this does not occur in all women. METHODS We have quantified the extent of lobule regression on a benign breast biopsy in 85 patients who developed breast cancer and 142 age-matched controls from the Mayo Benign Breast Disease Cohort, by determining number of acini per lobule and lobular area. We also calculated Gail model 5-year predicted risks for these women. RESULTS There is a step-wise increase in breast cancer risk with increasing numbers of acini per lobule (P = .0004). Adjusting for Gail model score, parity, histology, and family history did not attenuate this association. Lobular area was similarly associated with risk. The Gail model estimates were associated with risk of breast cancer (P = .03). We examined the individual accuracy of these measures using the concordance (c) statistic. The Gail model c statistic was 0.60 (95% CI, 0.50 to 0.70); the acinar count c statistic was 0.65 (95% CI, 0.54 to 0.75). Combining acinar count and lobular area, the c statistic was 0.68 (95% CI, 0.58 to 0.78). Adding the Gail model to these measures did not improve the c statistic. CONCLUSION Novel, tissue-based features that reflect the status of a woman's normal breast lobules are associated with breast cancer risk. These features may offer a novel strategy for risk prediction.
Collapse
|
415
|
Scow JS, Degnim AC, Hoskin TL, Reynolds C, Boughey JC. Simple Prediction Models for Breast Cancer Patients with Solitary Positive Sentinel Nodes--are they Valid? Breast J 2009; 15:610-4. [PMID: 19824998 DOI: 10.1111/j.1524-4741.2009.00837.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
416
|
Scow JS, Degnim AC, Hoskin TL, Reynolds C, Boughey JC. Assessment of the performance of the Stanford Online Calculator for the prediction of nonsentinel lymph node metastasis in sentinel lymph node-positive breast cancer patients. Cancer 2009; 115:4064-70. [PMID: 19517477 DOI: 10.1002/cncr.24469] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Several models for the prediction of nonsentinel lymph node (NSLN) metastasis in sentinel lymph node (SLN)-positive breast cancer patients have been proposed. In this study, the authors evaluate the Stanford Online Calculator (SOC), which was designed to predict the likelihood of NSLN metastasis using only 3 variables: primary tumor size, SLN metastasis size, and angiolymphatic invasion status. They compared it with the Mayo and Memorial Sloan-Kettering Cancer Center (MSKCC) nomograms. METHODS The SOC was used to calculate the probability of NSLN metastasis in 464 breast cancer patients with SLN metastasis who underwent completion axillary lymph node dissection at the Mayo Clinic. The area under the receiver operating characteristic curve (AUC) was calculated for each model. Mean probabilities of patients with and without NSLN metastasis were compared. Patients with <or=5%, <or=10%, and 100% NSLN metastasis probabilities were examined. RESULTS The AUCs of the Stanford, MSKCC, and Mayo models were 0.72, 0.74, and 0.77, respectively (P=.13). The mean Stanford probabilities for patients with and without NSLN metastasis were 0.75 (range, 0.06-1.0) and 0.50 (range, 0.05-1.0), respectively (P<.0001). The false-negative rates for patients with a Stanford probability of <or=5% and <or=10% were 0% and 13%, respectively. Of the patients with a Stanford probability of 100%, 26% did not have NSLN metastasis. CONCLUSIONS Despite using only 3 variables, the Stanford nomogram appears to perform on a par with, but not better than, the MSKCC and Mayo nomograms. Further validation in other patient populations is needed.
Collapse
|
417
|
Throckmorton AD, Hoskin T, Boostrom SY, Boughey JC, Holifield AC, Stobbs MM, Baddour LM, Degnim AC. Complications associated with postoperative antibiotic prophylaxis after breast surgery. Am J Surg 2009; 198:553-6. [DOI: 10.1016/j.amjsurg.2009.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Revised: 06/14/2009] [Accepted: 06/14/2009] [Indexed: 10/20/2022]
|
418
|
Boughey JC, Goravanchi F, Parris RN, Kee SS, Frenzel JC, Hunt KK, Ames FC, Kuerer HM, Lucci A. Improved postoperative pain control using thoracic paravertebral block for breast operations. Breast J 2009; 15:483-8. [PMID: 19624418 DOI: 10.1111/j.1524-4741.2009.00763.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Thoracic paravertebral block (PVB) in breast surgery can provide regional anesthesia during and after surgery with the potential advantage of decreasing postoperative pain. We report our institutional experience with PVB over the initial 8 months of use. All patients undergoing breast operations at the ambulatory care building from September 09, 2005 to June 28, 2005 were reviewed. Comparison was performed between patients receiving PVB and those who did not. Pain scores were assessed immediately, 4 hours, 8 hours and the morning after surgery. 178 patients received PVB and 135 patients did not. Patients were subdivided into three groups: Group A-segmental mastectomy only (n = 89), Group B-segmental mastectomy and sentinel node surgery (n = 111) and Group C-more extensive breast surgery (n = 113). Immediately after surgery there was a statistically significant difference in the number of patients reporting pain between PVB patients and those without PVB. At all time points up until the morning after surgery PVB patients were significantly less likely to report pain than controls. Patients in Group C who received PVB were significantly less likely to require overnight stay. The average immediate pain scores were significantly lower in PVB patients than controls in both Group B and Group C and approached significance in Group A. PVB in breast surgical patients provided improved postoperative pain control. Pain relief was improved immediately postoperatively and this effect continued to the next day after surgery. PVB significantly decreased the proportion of patients that required overnight hospitalization after major breast operations and therefore may decrease cost associated with breast surgery.
Collapse
|
419
|
Katipamula R, Degnim AC, Hoskin T, Boughey JC, Loprinzi C, Grant CS, Brandt KR, Pruthi S, Chute CG, Olson JE, Couch FJ, Ingle JN, Goetz MP. Trends in mastectomy rates at the Mayo Clinic Rochester: effect of surgical year and preoperative magnetic resonance imaging. J Clin Oncol 2009; 27:4082-8. [PMID: 19636020 DOI: 10.1200/jco.2008.19.4225] [Citation(s) in RCA: 280] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Recent changes have occurred in the presurgical planning for breast cancer, including the introduction of preoperative breast magnetic resonance imaging (MRI). We sought to analyze the trends in mastectomy rates and the relationship to preoperative MRI and surgical year at Mayo Clinic, Rochester, MN. PATIENTS AND METHODS We identified 5,405 patients who underwent surgery between 1997 and 2006. Patients undergoing MRI were identified from a prospective database. Trends in mastectomy rate and the association of MRI with surgery type were analyzed. Multiple logistic regression was used to assess the effect of surgery year and MRI on surgery type, while adjusting for potential confounding variables. RESULTS Mastectomy rates differed significantly across time (P < .0001), and decreased from 45% in 1997% to 31% in 2003, followed by increasing rates for 2004 to 2006. The use of MRI increased from 10% in 2003% to 23% in 2006 (P < .0001). Patients with MRI were more likely to undergo mastectomy than those without MRI (54% v 36%; P < .0001). However, mastectomy rates increased from 2004 to 2006 predominantly among patients without MRI (29% in 2003% to 41% in 2006; P < .0001). In a multivariable model, both MRI (odds ratio [OR], 1.7; P < .0001) and surgical year (compared to 2003 OR: 1.4 for 2004, 1.8 for 2005, and 1.7 for 2006; P < .0001) were independent predictors of mastectomy. CONCLUSION After a steady decline, mastectomy rates have increased in recent years with both surgery year and MRI as significant predictors for type of surgery. Further studies are needed to evaluate the role of MRI and other factors influencing surgical planning.
Collapse
|
420
|
Throckmorton AD, Boughey JC, Boostrom SY, Holifield AC, Stobbs MM, Hoskin T, Baddour LM, Degnim AC. Postoperative Prophylactic Antibiotics and Surgical Site Infection Rates in Breast Surgery Patients. Ann Surg Oncol 2009; 16:2464-9. [DOI: 10.1245/s10434-009-0542-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 05/13/2009] [Accepted: 05/15/2009] [Indexed: 11/18/2022]
|
421
|
Pockaj BA, Degnim AC, Boughey JC, Gray RJ, McLaughlin SA, Dueck AC, Perez EA, Halyard MY, Frost MH, Cheville AL, Sloan JA. Quality of life after breast cancer surgery: What have we learned and where should we go next? J Surg Oncol 2009; 99:447-55. [PMID: 19418493 DOI: 10.1002/jso.21151] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Treatment options for women with newly diagnosed breast cancer include breast conservation therapy and mastectomy with or without reconstruction, which provide equivalent cancer outcomes in properly selected patients. Although multiple studies have evaluated breast surgery quality-of-life outcomes, the data are inconsistent. This factor is important to consider when counseling patients and defining surgical quality measures.
Collapse
|
422
|
Boughey JC, Goravanchi F, Parris RN, Kee SS, Kowalski AM, Frenzel JC, Bedrosian I, Meric-Bernstam F, Hunt KK, Ames FC, Kuerer HM, Lucci A. Prospective randomized trial of paravertebral block for patients undergoing breast cancer surgery. Am J Surg 2009; 198:720-5. [PMID: 19427625 DOI: 10.1016/j.amjsurg.2008.11.043] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Revised: 11/21/2008] [Accepted: 11/21/2008] [Indexed: 01/04/2023]
Abstract
BACKGROUND The goal of the current study was to evaluate the effect of regional anesthesia using paravertebral block (PVB) on postoperative pain after breast surgery. METHODS Patients undergoing unilateral breast surgery without reconstruction were randomized to general anesthesia (GA) only or PVB with GA and pain scores assessed. RESULTS Eighty patients were randomized (41 to GA and 39 to PVB with GA). Operative times were not significantly different between groups. Pain scores were lower after PVB compared to GA at 1 hour (1 vs 3, P = .006) and 3 hours (0 vs 2, P = .001) but not at later time points. The overall worst pain experienced was lower with PVB (3 vs 5, P = .02). More patients were pain-free in the PVB group at 1 hour (44% vs 17%, P = .014) and 3 hours (54% vs 17%, P = .005) postoperatively. CONCLUSIONS PVB significantly decreases postoperative pain up to 3 hours after breast cancer surgery.
Collapse
|
423
|
Wagner J, Boughey JC, Garrett B, Babiera G, Kuerer H, Meric-Bernstam F, Singletary E, Hunt KK, Middleton LP, Bedrosian I. Margin assessment after neoadjuvant chemotherapy in invasive lobular cancer. Am J Surg 2009; 198:387-91. [PMID: 19362281 DOI: 10.1016/j.amjsurg.2009.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 01/07/2009] [Accepted: 01/15/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal surgical management of patients with invasive lobular carcinoma (ILC) who undergo neoadjuvant chemotherapy (NAC) is unknown. We evaluated optimal margin distance and local recurrence (LR) rates for these patients. METHODS Ninety-three (30%) of 311 patients with ILC received NAC. We examined margin status, residual disease after re-excision, and clinical outcomes. RESULTS Margin positivity rates after the final operative procedure were similar between the NAC and surgery-first group (P > .05). The proportion of patients, stratified by margin status, who were taken back for re-excision was not different between the 2 groups, and, similarly, there were no differences in frequency of residual disease (all P > .05). At a median follow-up of 3.1 years, 1 patient in the NAC group and 2 in the surgery-first group developed LR (P = 1.0). CONCLUSIONS Patients with ILC who have undergone NAC and have margins >1 mm have a low probability of residual disease and LR.
Collapse
|
424
|
Boughey JC, Hartmann LC, Pankratz VS. In Reply. J Clin Oncol 2009. [DOI: 10.1200/jco.2008.21.2498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
425
|
Boughey JC, Wagner J, Garrett BJ, Harker L, Middleton LP, Babiera GV, Meric-Bernstam F, Lucci A, Hunt KK, Bedrosian I. Neoadjuvant chemotherapy in invasive lobular carcinoma may not improve rates of breast conservation. Ann Surg Oncol 2009; 16:1606-11. [PMID: 19280264 DOI: 10.1245/s10434-009-0402-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Revised: 02/02/2009] [Accepted: 02/03/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with invasive lobular carcinoma (ILC) experience a lower pathological complete response rate to neoadjuvant chemotherapy than patients with invasive ductal carcinoma. This study was intended to evaluate the impact of neoadjuvant chemotherapy in ILC on breast-conserving surgery (BCS) rates. METHODS Two-hundred eighty-four consecutive patients with pure ILC treated between May 1998 and September 2006 were reviewed. Surgical procedures and long-term outcomes were compared between patients receiving neoadjuvant chemotherapy and those receiving surgery first. RESULTS Neoadjuvant chemotherapy was administered to 84 patients; 200 patients underwent surgery first. The mean tumor size in the neoadjuvant group (4.9 cm) was significantly larger than in patients who underwent surgery first (2.5 cm, p < 0.0001). In the neoadjuvant group, clinical complete response was seen in 10% and partial response in 59%. Overall BCS rates were 17% in the neoadjuvant group compared with 43% in the surgery-first group (p < 0.0001). When controlled for initial tumor size, there was no difference (all p > 0.05) between the groups in terms of (1) the proportion of patients who underwent an initial attempt at BCS, (2) rate of failure of BCS or (3) the proportion of patients undergoing BCS as their final procedure. With a mean follow-up of 47 months, local recurrence (LR) rates were similar between the two groups (1.2% versus 0.5%, p = 0.5). CONCLUSION The use of neoadjuvant chemotherapy does not increase the rates of breast conservation in patients with pure ILC.
Collapse
|
426
|
Degnim AC, Hoskin TL, Cheville AL, Miller JP, Gamble GL, Baddour LM, Donohue JH, Thomsen KM, Maloney SD, Boughey JC. Skin thickness as a measure of breast lymphedema. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Abstract #3103
Introduction: Lymphedema is well-known in the arm but can also occur in the breast. Diagnosis is currently non-standardized and based on clinical impression. We sought to determine if skin thickness could serve as a useful measure in the diagnosis of breast lymphedema (BLE).
 Methods: Patients undergoing unilateral non-mastectomy procedures were enrolled on this prospective clinical study preoperatively and evaluated for signs and symptoms of lymphedema in the operated breast in the postoperative period. Patients with established BLE were also studied. BLE diagnosis was independent of ultrasound findings and was based on a graded physical exam targeting clinical signs of edema and erythema. Skin thickness was measured with ultrasound at the 6 o'clock position of both breasts. Differences in skin thickness were assessed by the ratio of skin thickness in the operated and contralateral breasts, with comparison of means by two-sample t-test. Receiver operating characteristic curves were constructed to estimate the area under the curve (AUC) and to determine optimal cutpoints.
 Results: Ninety-seven women were studied; 85 were enrolled preoperatively and 12 postoperatively after a diagnosis of BLE. Median length of follow-up overall was 8 months. Of the 97 women, 46 had BLE at one or more follow-up visit with median time to first diagnosis of 3 months. Mean measured skin thickness was 2.3 ± 0.5mm in unaffected breasts and 3.2 ± 1.0 mm in operated breasts. Women with BLE had significantly greater skin thickness in the operated breast compared to the contralateral breast, with a mean skin thickness ratio of 1.83 ± 0.57 in patients with BLE compared to 1.18 ± 0.40 among those without BLE (p<0.0001). Skin thickness ratio provided excellent discrimination for BLE, with an area under the curve (AUC) of 0.86. At a ratio of 1.32 or greater (32% greater skin thickness in operated versus contralateral breast), sensitivity and specificity for diagnosing BLE were 81% and 82% respectively. A single measure of skin thickness in the operated breast also correlated well with diagnosis of BLE, with skin thickness of 3.2 mm or greater demonstrating sensitivity of 78% and specificity of 82%, AUC 0.82.
 Conclusions: Breast lymphedema results in skin edema and increased skin thickness that can be quantified with ultrasound. Measuring breast skin thickness- either as a single reading or as a ratio to the unaffected breast- may be useful in the diagnosis of breast lymphedema.
Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3103.
Collapse
|
427
|
Sookhan N, Boughey JC, Walsh MF, Degnim AC. Nipple-sparing mastectomy--initial experience at a tertiary center. Am J Surg 2008; 196:575-7. [PMID: 18809066 DOI: 10.1016/j.amjsurg.2008.06.022] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2008] [Revised: 06/01/2008] [Accepted: 06/01/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Nipple-sparing mastectomy (NSM) combines skin-sparing mastectomy with preservation of the nipple-areolar dermis and intraoperative pathologic assessment of the nipple core. We evaluated our initial experience with NSM in terms of clinical outcomes. METHODS An Institutional Review Board-approved retrospective review of patients undergoing NSM between November 2005 and June 2007 was performed. RESULTS Eighteen NSM and two areola-sparing mastectomies were performed. Indications for surgery were invasive cancer (n = 4), ductal carcinoma in situ (DCIS) (n = 5), pseudoangiomatous stromal hyperplasia (n = 3), and risk reduction (n = 8). The average distance of tumor from the nipple on imaging was 4.8 cm (range 4 to 5.7). Nipple cores were all benign, and 2 patients developed self-limited superficial desquamation of the nipple. At a mean follow up of 10.8 months, all nipple-areolar complexes were intact, and there were no local or systemic recurrences. CONCLUSIONS NSM can be successfully achieved with low morbidity in appropriately selected patients.
Collapse
|
428
|
Pankratz VS, Hartmann LC, Degnim AC, Vierkant RA, Ghosh K, Vachon CM, Frost MH, Maloney SD, Reynolds C, Boughey JC. Assessment of the accuracy of the Gail model in women with atypical hyperplasia. J Clin Oncol 2008; 26:5374-9. [PMID: 18854574 DOI: 10.1200/jco.2007.14.8833] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE An accurate estimate of a woman's breast cancer risk is essential for optimal patient counseling and management. Women with biopsy-confirmed atypical hyperplasia of the breast (atypia) are at high risk for breast cancer. The Gail model is widely used in these women, but has not been validated in them. PATIENTS AND METHODS Women with atypia were identified from the Mayo Benign Breast Disease (BBD) cohort (1967 to 1991). Their risk factors for breast cancer were obtained, and the Gail model was used to predict 5-year-and follow-up-specific risks for each woman. The predicted and observed numbers of breast cancers were compared, and the concordance between individual risk levels and outcomes was computed. RESULTS Of the 9,376 women in the BBD cohort, 331 women had atypia (3.5%). At a mean follow-up of 13.7 years, 58 of 331 (17.5%) patients had developed invasive breast cancer, 1.66 times more than the 34.9 predicted by the Gail model (95% CI, 1.29 to 2.15; P < .001). For individual women, the concordance between predicted and observed outcomes was low, with a concordance statistic of 0.50 (95% CI, 0.44 to 0.55). CONCLUSION The Gail model significantly underestimates the risk of breast cancer in women with atypia. Its ability to discriminate women with atypia into those who did and did not develop breast cancer is limited. Health care professionals should be cautious when using the Gail model to counsel individual patients with atypia.
Collapse
|
429
|
Throckmorton AD, Askegard-Giesmann J, Hoskin TL, Bjarnason H, Donohue JH, Boughey JC, Degnim AC. Sclerotherapy for the treatment of postmastectomy seroma. Am J Surg 2008; 196:541-4. [DOI: 10.1016/j.amjsurg.2008.06.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 06/04/2008] [Accepted: 06/04/2008] [Indexed: 12/01/2022]
|
430
|
Hruska CB, Boughey JC, Phillips SW, Rhodes DJ, Wahner-Roedler DL, Whaley DH, Degnim AC, O'Connor MK. Scientific Impact Recognition Award: Molecular breast imaging: a review of the Mayo Clinic experience. Am J Surg 2008; 196:470-6. [PMID: 18723155 DOI: 10.1016/j.amjsurg.2008.06.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Revised: 06/12/2008] [Accepted: 06/12/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Molecular breast imaging (MBI) depicts functional uptake of targeted radiotracers in the breast using dedicated gamma cameras. METHODS MBI studies were performed under several institutional protocols evaluating the use of MBI in screening and diagnosis. RESULTS By using a single-head system, sensitivity for breast cancer detection was 85% (57 of 67) overall and 29% for tumors 5 mm or less in diameter. Sensitivity improved to 91% (117 of 128) overall and 69% for tumors 5 mm or less using a dual-head system. In 650 high-risk patients undergoing breast cancer screening, MBI detected 7 cancers, 5 of which were missed on mammography. In 24 of 149 (16%) breast cancer patients MBI detected additional disease not seen on mammography. The sensitivity of MBI was 88% (83 of 94) for invasive ductal carcinoma, 79% (23 of 29) for invasive lobular carcinoma, and 89% (25 of 28) for ductal carcinoma in situ. CONCLUSIONS MBI can detect invasive ductal carcinoma, ductal carcinoma in situ, and invasive lobular carcinoma. It has a promising role in evaluating the extent of disease and multifocal disease in the breast for surgical treatment planning.
Collapse
|
431
|
Boughey JC, Cormier JN, Xing Y, Hunt KK, Meric-Bernstam F, Babiera GV, Ross MI, Kuerer HM, Singletary SE, Bedrosian I. Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy. Cancer 2008; 110:2542-50. [PMID: 17932905 DOI: 10.1002/cncr.23067] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patients who have invasive breast cancer identified after prophylactic mastectomy (PM) require axillary lymph node dissection (ALND) for lymph node staging (ie, directed ALND). Because the majority of these patients will be lymph node negative, sentinel lymphadenectomy (SLND) has been advocated at the time of PM to avoid the sequelae of unnecessary ALND. The objective of this study was to compare the efficacy of 2 surgical strategies, routine SLND versus directed ALND, in PM patients. METHODS A decision-analytic model was created to compare the 2 surgical strategies. Model estimates were derived from a systematic literature review. The endpoints that were examined to compare the 2 strategies were the number of SLNDs performed per breast cancer detected, the number of SLNDs attempted to avoid 1 ALND in a lymph node-negative patient with occult invasive cancer, and the number of axillary complications associated with each strategy. RESULTS The prevalence of invasive cancer in patients undergoing PM was estimated at 1.9%. At this rate, 37 SLNDs were performed per 1 breast cancer detected, and 73 SLNDs were required to avoid 1 ALND in a lymph node-negative PM patient. In 1 model scenario, the probability of complications per breast cancer detected was 9-fold greater with the SLND strategy than with the directed ALND strategy (2.7 vs 0.3). The complication rates for the 2 strategies become equivalent in the model scenario when the prevalence of occult invasive cancer was projected to 28%. CONCLUSIONS Routine SLND for patients undergoing PM is not warranted given the large number of procedures required to benefit 1 patient and the potential complications associated with performing SLND in all patients.
Collapse
|
432
|
|
433
|
Boughey JC, Buzdar AU, Hunt KK. Recent Advances in the Hormonal Treatment of Breast Cancer. Curr Probl Surg 2008; 45:13-55. [DOI: 10.1067/j.cpsurg.2007.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
434
|
Boughey JC, Middleton LP, Harker L, Garrett B, Fornage B, Hunt KK, Babiera GV, Dempsey P, Bedrosian I. Utility of ultrasound and fine-needle aspiration biopsy of the axilla in the assessment of invasive lobular carcinoma of the breast. Am J Surg 2007; 194:450-5. [PMID: 17826054 DOI: 10.1016/j.amjsurg.2007.06.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 06/27/2007] [Accepted: 06/28/2007] [Indexed: 12/13/2022]
Abstract
BACKGROUND The unique growth pattern of invasive lobular carcinoma (ILC) poses a challenge for preoperative assessment of disease extent within the breast. Whether it similarly limits lymph node staging by ultrasound (US) and fine-needle aspiration (FNA) biopsy was the subject of the current study. METHODS A total of 217 patients with ILC who underwent axillary US were reviewed. FNA biopsy was performed when US findings were suspicious or indeterminate. Findings were compared to literature reports of US in invasive ductal carcinoma (IDC) patients. RESULTS Axillary US was negative in 137 patients (63%) and suspicious or indeterminate in 80 patients (37%). FNA biopsy was positive in 62% (47/76 patients). Preoperative US and FNA biopsy identified 43 of 111 (39%) node-positive patients. Sensitivity of US with FNA biopsy correlated with primary tumor and nodal metastasis size. Similar results were seen in IDC populations. CONCLUSION US with FNA biopsy appears to be similarly useful in axillary staging of ILC and IDC patients.
Collapse
|
435
|
Pruthi S, Boughey JC, Brandt KR, Degnim AC, Dy GK, Goetz MP, Perez EA, Reynolds CA, Schomberg PJ, Ingle JN. A multidisciplinary approach to the management of breast cancer, part 2: therapeutic considerations. Mayo Clin Proc 2007; 82:1131-40. [PMID: 17803883 DOI: 10.4065/82.9.1131] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
New approaches to breast cancer treatment have enhanced clinical outcomes and patient care. These approaches include advances in breast irradiation and hormonal and systemic adjuvant therapies. In addition to the identification of new drug targets and targeted therapeutics (eg, trastuzumab), there is renewed re-emphasis in the development of biomarkers for the prediction of response to therapy. One example is the pharmacogenetics of tamoxifen metabolism and the individualization of hormonal therapy. The current treatment of breast cancer continues to evolve rapidly, with new scientific and clinical achievements constantly changing the standard of care and leading to substantial reductions in breast cancer mortality. The goal of this article is to provide clinicians who care for women with breast cancer a multidisciplinary, state-of-the art approach to the treatment of these patients.
Collapse
|
436
|
Izaddoost S, Boughey JC, Williams SA, Gilcrease M, Ames F. An unusual presentation of locally recurrent breast cancer: a case report. Breast J 2007; 13:294-6. [PMID: 17461906 DOI: 10.1111/j.1524-4741.2007.00425.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Recurrent breast carcinoma is usually detected by imaging studies and biopsy. We present a case with unusual clinical presentation and discuss the diagnosis and treatment. While core needle biopsy and fine-needle aspiration are important in the diagnosis of early-stage breast cancer, physical examination and close follow-up are important in the absence of a diagnosis.
Collapse
|
437
|
Boughey JC, Hunt KK. Expanding the indications for sentinel lymph node surgery in breast cancer. Future Oncol 2007; 3:9-14. [PMID: 17280496 DOI: 10.2217/14796694.3.1.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
438
|
Boughey JC, Khakpour N, Meric-Bernstam F, Ross MI, Kuerer HM, Singletary SE, Babiera GV, Arun B, Hunt KK, Bedrosian I. Selective use of sentinel lymph node surgery during prophylactic mastectomy. Cancer 2006; 107:1440-7. [PMID: 16955504 DOI: 10.1002/cncr.22176] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use. METHODS Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. RESULTS A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2-9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of invasive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). CONCLUSIONS The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.
Collapse
|
439
|
Boughey JC, Peintinger F, Meric-Bernstam F, Perry AC, Hunt KK, Babiera GV, Singletary SE, Bedrosian I, Lucci A, Buzdar AU, Pusztai L, Kuerer HM. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg 2006; 244:464-70. [PMID: 16926572 PMCID: PMC1856540 DOI: 10.1097/01.sla.0000234897.38950.5c] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the effect of preoperative chemotherapy on the volume of tissue excised and the number of breast operations in patients undergoing breast-conserving therapy (BCT). SUMMARY BACKGROUND DATA Preoperative chemotherapy is increasingly being used for breast cancer and increases rates of BCT. Its impact on the extent of surgery and the number of surgical procedures in BCT has never been fully defined. The extent of surgery in BCT directly affects cosmesis. METHODS We reviewed the records of 509 consecutive patients with T1-T3, N0-N2 breast cancer who were treated in prospective randomized clinical trials of chemotherapy between 1998 and 2005. We analyzed the final surgical procedure (BCT or mastectomy), the number of operations, and, in patients who underwent BCT, re-excision rates, and the total volume of breast tissue excised [4Pi/3(width/2 x length/2 x height/2)]. RESULTS A total of 241 patients underwent BCT, and 268 patients underwent mastectomy. Among BCT patients who had initial tumor size >2.0 cm, patients who received preoperative chemotherapy had significantly smaller volumes of breast tissue excised compared with patients who received postoperative chemotherapy (113 cm vs. 213 cm, P = 0.004). The re-excision rate and total number of breast operations did not significantly differ between the groups. Among BCT patients who had initial tumor size < or = 2 cm, preoperative chemotherapy had no impact on volume of breast tissue excised, re-excision rate, or number of breast operations (P > 0.05). CONCLUSIONS Among patients treated with BCT for larger breast tumors, patients treated with preoperative chemotherapy have less extensive resection, with no change in rates of re-excision.
Collapse
|
440
|
Boughey JC, Bedrosian I, Meric-Bernstam F, Ross MI, Kuerer HM, Akins JS, Giordano SH, Babiera GV, Ames FC, Hunt KK. Comparative Analysis of Sentinel Lymph Node Operation in Male and Female Breast Cancer Patients. J Am Coll Surg 2006; 203:475-80. [PMID: 17000390 DOI: 10.1016/j.jamcollsurg.2006.06.014] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 06/14/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Male breast cancer accounts for < 1% of breast cancers. Sentinel lymph node (SLN) operation is commonly used in the evaluation of female breast cancer patients. The purpose of this study was to determine whether SLN operation is as feasible and accurate in male patients compared with female patients. STUDY DESIGN Between 1999 and 2005, 30 men and 2,784 women underwent SLN operation. Clinical and pathologic data were reviewed and statistical analysis performed. RESULTS Men presented at an older age (p = 0.005) and with larger tumors than women (p = 0.04). The SLN was identified in 100% of men and in 98.3% of women (p = NS). The mean number of SLNs harvested was 3.5 in men and 3.0 in women (p = NS). The incidence of positive SLNs was higher in men (37.0% versus 22.3%), although this did not reach statistical significance (p = 0.1). In patients with a positive SLN there were additional non-SLNs positive in 62.5% of men, compared with 20.7% in women (p = 0.01). The median size of the largest lymph node metastasis was 10 mm in men and 3 mm in women (p = 0.03). CONCLUSIONS SLN operation in clinically node-negative men is feasible and accurate. Male breast cancer patients present at an older age and with larger tumors than female breast cancer patients. Male patients have higher nodal tumor burden reflected in a larger size of nodal metastasis and increased risk of harboring additional disease in axillary lymph nodes when the SLN is positive. Intraoperative SLN evaluation should be considered in the surgical management of male breast cancer.
Collapse
|
441
|
Peintinger F, Kuerer HM, Anderson K, Boughey JC, Meric-Bernstam F, Singletary SE, Hunt KK, Whitman GJ, Stephens T, Buzdar AU, Green MC, Symmans WF. Accuracy of the Combination of Mammography and Sonography in Predicting Tumor Response in Breast Cancer Patients After Neoadjuvant Chemotherapy. Ann Surg Oncol 2006; 13:1443-9. [PMID: 17028770 DOI: 10.1245/s10434-006-9086-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2006] [Revised: 05/15/2006] [Accepted: 05/18/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Residual tumor size after neoadjuvant chemotherapy is an important consideration in surgical planning. We examined the accuracy of the combination of mammography and sonography in predicting pathologic residual tumor size. METHODS Tumor size was evaluated by physical examination, mammography, and sonography at diagnosis and before surgery in 162 breast cancer patients who received neoadjuvant chemotherapy. Agreement between the predicted and the pathologic responses and the predicted and the pathologic tumor sizes was calculated. The effect of invasive lobular carcinoma, high nuclear grade, hormone receptor positivity, and the presence of an extensive intraductal component on the accuracy of mammography and sonography in predicting pathologic residual tumor size was analyzed. RESULTS Forty-two patients (25.9%) had a pathologic complete response (pCR). Overall agreement between predicted and pathologic responses was 53% for physical examination, 67% for mammography plus sonography, and 63% for physical examination plus mammography and sonography. The sensitivity of mammography and sonography in predicting pCR was 78.6%, and the specificity was 92.5%; the accuracy was 88.9%. Residual tumor size determined by mammography and sonography correlated with pathologic residual tumor size (r = .662); pathologic tumor size was within .5 cm of predicted in 69.1% of patients. Multivariate analysis showed that pathologic residual tumor size was underestimated for lobular carcinoma and overestimated for poorly differentiated tumors. CONCLUSIONS The combination of mammography and sonography has a high accuracy in predicting pCR after neoadjuvant chemotherapy. Agreement of residual tumor size in mammography and sonography with pathologic residual tumor size was moderate.
Collapse
|
442
|
Boughey JC, Ross MI, Babiera GV, Bedrosian I, Feig BW, Hwang RF, Kuerer HM, Hunt KK. Sentinel Lymph Node Surgery in Locally Recurrent Breast Cancer. Clin Breast Cancer 2006; 7:248-53. [PMID: 16942642 DOI: 10.3816/cbc.2006.n.037] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Patients with locally recurrent breast cancer can also harbor regional nodal disease. Sentinel lymph node (LN; SLN) surgery is an accepted method for LN evaluation in early-stage breast cancer. We sought to evaluate the feasibility of SLN surgery in patients with locally recurrent breast cancer. PATIENTS AND METHODS Patients undergoing SLN surgery at the time of treatment for recurrent breast cancer were identified. Clinical, pathologic, and operative details of initial and recurrent breast cancer events were analyzed. RESULTS From 2001 to 2005, 21 patients underwent SLN surgery for locally recurrent breast cancer. Previous breast procedures included segmental mastectomy in 17 patients and mastectomy in 4 patients. Previous axillary procedures included axillary LN dissection in 12 patients, SLN surgery in 5 patients, and no axillary surgery in 4 patients. Twelve patients had received breast irradiation. The SLN was identified and excised in 13 patients (62%). Six patients had drainage to nodal basins outside of the axilla (internal mammary and/or contralateral axilla). As the number of axillary nodes removed at primary surgery increased, the incidence of alternative lymphatic drainage increased: no previous axillary surgery, 0; 1-10 LNs removed, 30%; > 10 LNs removed, 50%. CONCLUSION Sentinel LN surgery is feasible in patients with locally recurrent breast cancer regardless of previous axillary node surgery or radiation. The incidence of alternative lymphatic drainage is increased in patients with > 10 axillary LNs removed at original operation or when radiation was part of the previous treatment. Sentinel LN surgery is a tool for guiding local-regional management of patients with locally recurrent breast cancer.
Collapse
|
443
|
Peintinger F, Symmans WF, Gonzalez-Angulo AM, Boughey JC, Buzdar AU, Yu TK, Hunt KK, Singletary SE, Babiera GV, Lucci A, Meric-Bernstam F, Kuerer HM. The safety of breast-conserving surgery in patients who achieve a complete pathologic response after neoadjuvant chemotherapy. Cancer 2006; 107:1248-54. [PMID: 16862596 DOI: 10.1002/cncr.22111] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objectives of this study were to determine the locoregional recurrence (LRR) rate and to evaluate the correlation between surgical resection volume (RV) and LRR in patients with breast cancer who underwent segmental mastectomy after achieving a pathologic complete response (pCR) on neoadjuvant chemotherapy. METHODS The authors reviewed the outcomes of all 109 patients who underwent segmental mastectomy after the complete eradication of invasive disease by neoadjuvant chemotherapy at their institution between 1987 and 2002. LRRs were recorded, and RVs after segmental mastectomy were calculated and categorized as small, medium, or large. RESULTS At a median follow-up of 6.6 years, 3 patients (2.7%) developed LRR. In 2 of those patients, the recurrence was located in the ipsilateral breast; in the other patient, the recurrence was located in the supraclavicular lymph nodes with synchronous distant metastases. The median RV was 73.12 cm3 (range, 2.82-451.51 cm3). Large RVs (>125 cm3) were less common than small RVs (up to 70 cm3) or medium RVs (between 70 cm3 and 125 cm3; P = .009 and P<.0001, respectively). One patient with a small RV had an LRR at 4 years, and 2 patients with medium RVs had LLRs at 2.3 years and 6 years, respectively. The 5-year and 10-year LRR-free survival rates were 98.1% and 96.5%, respectively, and the corresponding overall survival rates were 96% and 92%, respectively. CONCLUSIONS Segmental mastectomy was associated with excellent locoregional control in patients who achieved a pCR after neoadjuvant chemotherapy. Prospective studies are needed to examine whether decreasing the RVs in this patient population leads to an increased LRR rate.
Collapse
|
444
|
|
445
|
Boughey JC, Emovon OE, Afzal F, Baliga P, Rogers J, Lin A, Chavin K, Rajagopalan PR. Living donor transplantation of a pelvic kidney. Clin Transplant 2004; 18:336-8. [PMID: 15142058 DOI: 10.1111/j.1399-0012.2004.00166.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pelvic kidneys are uncommon anomalies rarely utilized in kidney transplantation. We describe a successful case of living-donor transplantation using a pelvic kidney in a 17-month-old infant with congenital renal dysplasia. The recipient had exhausted all options for renal replacement therapy, and urgent transplantation was considered a life saving treatment.
Collapse
|
446
|
Boughey JC, Yost MJ, Bynoe RP. Diabetes Insipidus in the Head-Injured Patient. Am Surg 2004. [DOI: 10.1177/000313480407000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Diabetes insipidus (DI) is an uncommon but important complication in the head-injured population. A retrospective review of all trauma patients admitted to the intensive care unit (ICU) during a 4-year period who developed DI was undertaken. The incidence of DI was 1.3 per cent in ICU trauma admissions and 2.9 per cent in traumatic head injuries admitted to the ICU. The overall mortality was 69 per cent (18/26). The mean onset time of DI in nonsurvivors (1.5 ± 0.7 days) was shorter compared to survivors (8.9 ± 10.2 days) ( P < 0.001). All patients who died developed DI within the first 3 days of hospitalization. Patients who develop DI early in their course have a higher mortality than those who develop DI later in their hospital course. The development of diabetes insipidus after head injury carries a 69 per cent mortality rate, and if the onset is within the first 3 days after injury, mortality rate rises to 86 per cent.
Collapse
|
447
|
Boughey JC, Yost MJ, Bynoe RP. Diabetes insipidus in the head-injured patient. Am Surg 2004; 70:500-3. [PMID: 15212402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Diabetes insipidus (DI) is an uncommon but important complication in the head-injured population. A retrospective review of all trauma patients admitted to the intensive care unit (ICU) during a 4-year period who developed DI was undertaken. The incidence of DI was 1.3 per cent in ICU trauma admissions and 2.9 per cent in traumatic head injuries admitted to the ICU. The overall mortality was 69 per cent (18/26). The mean onset time of DI in nonsurvivors (1.5 +/- 0.7 days) was shorter compared to survivors (8.9 +/- 10.2 days) (P < 0.001). All patients who died developed DI within the first 3 days of hospitalization. Patients who develop DI early in their course have a higher mortality than those who develop DI later in their hospital course. The development of diabetes insipidus after head injury carries a 69 per cent mortality rate, and if the onset is within the first 3 days after injury, mortality rate rises to 86 per cent.
Collapse
|
448
|
Boughey JC, Ewart CJ, Yost MJ, Nottingham JM, Brown JJ. Chloride/phosphate ratio in primary hyperparathyroidism. Am Surg 2004; 70:25-8. [PMID: 14964541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
The chloride/phosphate (Cl:PO4) ratio is known to help distinguish between the hypercalcemia of primary hyperparathyroidism (HPT) and hypercalcemia from other causes. The Cl:PO4 ratio of 106 patients with surgically proven primary HPT was compared with that of 126 normocalcemic healthy outpatients to examine its usefulness as a confirmatory test for primary HPT. The Cl:PO4 ratio was significantly higher in patients with HPT (42.5 +/- 7.0) compared with healthy controls (28.7 +/- 4.6). Patients with HPT and mild renal insufficiency (serum creatinine, 1.5-2.4 mg/dL) also showed a significant increase in the Cl:PO4 ratio (37.3 +/- 6.6) as did those with HPT with borderline elevations in serum calcium (calcium < 11; Cl:PO4, 40.3 +/- 5.6). A Cl:PO4 ratio > or = 33 is a reliable diagnostic test for primary HPT when compared with a normal population. The Cl:PO4 ratio is also of value in the evaluation of the patient with suspected HPT and borderline calcium elevation and those with mild renal impairment. These data suggest that an inexpensive Cl:PO4 ratio might replace serum parathormone assay as a confirmatory test in the evaluation of suspected primary HPT, especially for those patients in whom a localizing study (sestamibi scan) is obtained before neck exploration.
Collapse
|
449
|
Boughey JC, Bowen PA, Gifford RR. Renal transplantation in patients with hypercoagulable states. JOURNAL OF THE SOUTH CAROLINA MEDICAL ASSOCIATION (1975) 2003; 99:372-4. [PMID: 14983528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Early vascular thrombotic complications in renal transplantation frequently result in loss of the allograft with an increased long-term incidence of renal dysfunction from venous and arterial thrombosis. Hypercoagulable states are recognized risk factors of allograft thrombosis but are seldom discussed in the literature. This is the first report of preemptive heparin anticoagulation of two hypercoagulable patients undergoing renal transplantation, resulting in long term allograft success with warfarin anticoagulation. We recommend that any hemodialysis patient who has had recurrent dialysis graft thrombosis with a few months' time be evaluated for possible hypercoagulable state. Our experience suggests that appropriate management of such patients includes warfarin therapy. Renal transplantation can be successful in such patients provided heparin is given before, during, and after surgery followed by reinstitution of warfarin prior to discharge from the hospital.
Collapse
|
450
|
Boughey JC, Nottingham JM. Indications for ERCP and sphincterotomy without cholecystectomy. CURRENT SURGERY 2003; 60:112-6. [PMID: 15214320 DOI: 10.1016/s0149-7944(02)00757-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
|