Correlation of tumor volume and surface area with lymph node status in patients with multifocal/multicentric breast carcinoma

Prognostic performance of microscopic size measurements in small invasive carcinomas arising in intraductal papillary mucinous neoplasms of the pancreas

AIMS

Small invasive carcinomas arising in intraductal papillary mucinous neoplasms (IPMNs) of the pancreas can present as multiple, small foci. In such cases, there is no clear optimal measurement method for determining the invasive size for tumour staging and prognostication.

METHODS

In all, 117 small invasive IPMNs (size of largest invasive component ≤2 cm) from seven institutions (2000-2016) were reviewed, and all individual foci of invasive carcinoma were measured. T stages (AJCC 8th edition) based on the largest single focus size (LS), average size of all foci (AS), and total sum of all foci (TS) were examined in association with clinicopathologic parameters and patient outcomes.

RESULTS

The cohort comprised IPMNs with invasive tubular-type (n = 82, 70%) and colloid-type (n = 35, 30%) carcinomas. The mean LS, AS, and TS were 0.86, 0.71, and 1.32 cm, respectively. Based on the LS, AS, and TS, respectively, 48, 65, and 39 cases were classified as pT1a; 22, 18, and 11 cases as pT1b; and 47, 34, and 50 cases as pT1c. Higher pT stages based on all measurements were significantly associated with small vessel, large vessel, and perineural invasion (P < 0.05). LS-, AS-, and TS-based pT stages were not significantly associated with recurrence-free survival (RFS) or overall survival (OS) by univariate or multivariate analyses. However, among tubular-type carcinomas, higher LS-, AS-, and TS-based pT stages trended with lower RFS (based on 1-, 3-, and 5-year survival rates). All microscopic measurement methods were most predictive of RFS and OS using a 1.5-cm cutoff, with LS significantly associated with both RFS and OS by univariate and multivariate analysis.

CONCLUSIONS

For invasive tubular-type carcinomas arising in IPMN, microscopic size-based AJCC pT stages were not significant predictors of patient outcomes. However, for LS, a size threshold of 1.5 cm was optimal for stratifying both RFS and OS. The AJCC 8th ed. may not be applicable for stratifying small invasive IPMNs with colloid-type histology that generally portend a more favourable prognosis.

A nomogram model for predicting the risk of axillary lymph node metastasis in patients with early breast cancer and cN0 status

Axillary staging is commonly performed via sentinel lymph node biopsy for patients with early breast cancer (EBC) presenting with clinically negative axillary lymph nodes (cN0). The present study aimed to investigate the association between axillary lymph node metastasis (ALNM), clinicopathological characteristics of tumors and results from axillary ultrasound (US) scanning. Moreover, a nomogram model was developed to predict the risk for ALNM based on relevant factors. Data from 998 patients who met the inclusion criteria were retrospectively reviewed. These patients were then randomly divided into a training and validation group in a 7:3 ratio. In the training group, receiver operating characteristic curve analysis was used to identify the cutoff values for continuous measurement data. R software was used to identify independent ALNM risk variables in the training group using univariate and multivariate logistic regression analysis. The selected independent risk factors were incorporated into a nomogram. The model differentiation was assessed using the area under the curve (AUC), while calibration was evaluated through calibration charts and the Hosmer-Lemeshow test. To assess clinical applicability, a decision curve analysis (DCA) was conducted. Internal verification was performed via 1000 rounds of bootstrap resampling. Among the 998 patients with EBC, 228 (22.84%) developed ALNM. Multivariate logistic analysis identified lymphovascular invasion, axillary US findings, maximum diameter and molecular subtype as independent risk factors for ALNM. The Akaike Information Criterion served as the basis for both nomogram development and model selection. Robust differentiation was shown by the AUC values of 0.855 (95% CI, 0.817-0.892) and 0.793 (95% CI, 0.725-0.857) for the training and validation groups, respectively. The Hosmer-Lemeshow test yielded P-values of 0.869 and 0.847 for the training and validation groups, respectively, and the calibration chart aligned closely with the ideal curve, affirming excellent calibration. DCA showed that the net benefit from the nomogram significantly outweighed both the 'no intervention' and the 'full intervention' approaches, falling within the threshold probability interval of 12-97% for the training group and 17-82% for the validation group. This underscores the robust clinical utility of the model. A nomogram model was successfully constructed and validated to predict the risk of ALNM in patients with EBC and cN0 status. The model demonstrated favorable differentiation, calibration and clinical applicability, offering valuable guidance for assessing axillary lymph node status in this population.

Current understanding and distinct features of multifocal and multicentric breast cancers

BACKGROUND

Multifocal (MF) and multicentric (MC) breast cancers are referred to as synchronous, multiple ipsilateral breast cancers; however, the definitions vary among the literature, which has made understanding and analyzing these diseases challenging.

RECENT FINDINGS

The incidence ranges from 1% to 60%, with a higher prevalence in pre-menopausal women. MF and MC breast cancers, compared with unifocal breast cancers, tend to be more aggressive and are associated with lower survival rates, higher recurrence, and lymph node metastasis. Typically, patients with MF/MC breast cancers are treated with radical surgery, while breast conservation therapy may also be considered. Investigations have focused on elucidating the distinct biological features of MF/MC breast cancers, including the clonality of the cancers, the genetic alterations, and the impact of these features on disease aggressiveness and patient prognosis.

CONCLUSION

These findings will broaden the understanding of these breast cancer subtypes and aid in the development of more tailored treatment plans for patients.

A Model to Predict the Risk of Lymph Node Metastasis in Breast Cancer Based on Clinicopathological Characteristics

Background

Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) may cause lymphatic and nervous system side effects in patients with breast cancer. It is imperative to develop a model to evaluate the risk of sentinel lymph node metastasis to avoid unnecessary operation.

Patients and Methods

A total of 2705 cases of female breast cancer patients enrolled in this retrospective study. We divided into the training group (SLNB group) and the validation group (ALND group) to analyze the relathionship between lymph node metastasis and clinical-pathological factors. Logistic regression analysis was performed to verify the variables which involved in ALN metastasis and established a prediction model. ROC curves were employed to evaluate the predictive ability of the model.

Results

In the SLNB group, 9 variables, including pathological type, histological grade, tumor size, hormone receptor, HER-2, Ki-67, multifocality, and molecular subtypes, were related to breast cancer ALN metastasis. Clinically negative lymph nodes, favorable histologic type, tumor size <2 cm, and Ki-67 <15% were at very low risk for lymph node metastasis. The AUC of the validation group was 0.786.

Conclusion

We successfully establish a mathematics model to predict lymph node metastasis of breast cancer. Axillary surgery should be individual with preoperative clinical characteristics, especially for patients with a longer life expectancy.

Associated Features with Non-Sentinel Lymph Node Involvement in Early Stage Breast Cancer Patients who Have Positive Macrometastatic Sentinel Lymph Node

Objective

The main goal of this study is to determine the clinico-pathological factors that correlate non-sentinel lymph nodes (LNs) involvement in clinically node negative breast cancer (BC) patients with positive macrometastatic sentinel lymph node (SLN) in order to derive future evidence to define a subgroup where completion axillary lymph node dissection (cALND) might not be recommended.

Materials and Methods

Total 289 SLN biopsies were performed in clinically node negative BC patients between March 2014 and April 2017. Seventy patients who performed cALND due to positive macrometastatic SLN were retrospectively selected and classified into two groups, according to non-SLN involvement (NSLNI). Clinico-pathological features of patients were examined computerized and documentary archives.

Results

Extracapsular extension (ECE) of SLN, number of harvested SLNs, metastatic rate of SLNs, absence of ductal carcinoma in situ (DCIS) and presence of multilocalization were significantly associated with the likelihood of non-SLN involvement after univariate analysis (p<0,05). Absence of DCIS and presence of multilocalization were found to be significant after multivariate analysis.

Conclusion

Careful examination of clinico-pathological features can help to decide avoiding cALND if enough LNs are removed and the rate of SLN metastases is low, particularly in case DCIS accompanying invasive cancer in patients without multi localized tumour.

Timescale of tumor volume of a young breast cancer patient with luminal B subtype: A case report

RATIONALE

It is largely unknown about the tumor growth of breast cancer naturally. We devised and analyzed an appropriate mathematical tool of the equations that describe how fast tumors grow without treatment on the basis of the ellipsoid shape of solid breast cancer.

PATIENT CONCERNS

A 31-year-old woman presented with a painless palpable lump in her left breast for 5 months.

DIAGNOSIS

Infiltrated ductal breast cancer (histologic grade II) of luminal B INTERVENTIONS:: The patient did not receive any therapy due to her private reasons for 2 years, the analysis of the tumor volume growth was done regarding the growth rate of the tumor in the absence of intervention.

OUTCOMES

After 2 years of diagnosis of breast cancer, the tumor mass occupied the whole left breast with skin implanted and nipple abnormality. As this case indicated that the tumor's early growth rate was very slow. When the tumor volume reached 300 cm, its fast growth began without treatment. Later growth approached the maximum, when the tumor volume was more than 800 cm.

LESSONS

The tumor growth is segmental without therapy. Early diagnosis and treatment is the key to good prognosis for every breast cancer patient.

Sonographic Volumetric Assessment Is a More Accurate Measure Than Maximum Diameter Alone in Papillary Thyroid Cancer

Background

Tumor size is an important prognostic factor in papillary thyroid cancer (PTC). Management guidelines, staging systems, and pathological definitions use maximum diameter (Dmax) as a surrogate marker of tumor size. However, PTC nodules are three-dimensional (3D) structures, with behavior reflective of tumor cell count, which is directly proportional to volume. We explored the relationship between sonographically determined Dmax, volume, and lymph node status (LNS) in a cohort of patients with PTC.

Methods

All patients treated for PTC between 2003 and 2015 in our institution who had sonographic 3D nodule measurements available were evaluated. We examined the relationship between diameter, volume, and LNS.

Results

A total of 159 nodules in 153 patients met the inclusion criteria. Mean nodule dimensions were 2.4 × 1.9 × 1.5 cm, giving “ideal” nodule dimensions of y × 0.78y × 0.62y, where y is the Dmax. Observed volumes differed from predicted nodule volumes by an average of 26.2%. For PTC ≤2 cm, the coefficient of variation was 26.7%. Dmax did not correlate with the presence of lymph node metastases (Pearson coefficient 0.08), whereas volume very weakly correlated with LNS (Pearson coefficient 0.22). However, both Dmax and volume correlated very strongly with the number of nodal metastases (Pearson coefficients 0.93 and 0.89, respectively).

Conclusions

PTC nodules demonstrated significant volume heterogeneity, rendering Dmax an inaccurate marker of true tumor size. Although there was little difference between Dmax and volume in predicting nodal status or nodal disease burden, we propose that a prospective, randomized trial might demonstrate a clear clinical advantage of 3D sonographic nodule measurement over Dmax alone.

The Prognostic Impact of Synchronous Ipsilateral Multiple Breast Cancer: Survival Outcomes according to the Eighth American Joint Committee on Cancer Staging and Molecular Subtype

BACKGROUND

In the current American Joint Committee on Cancer staging system of breast cancer, only tumor size determines T-category regardless of whether the tumor is single or multiple. This study evaluated if tumor multiplicity has prognostic value and can be used to subclassify breast cancer.

METHODS

We included 5,758 patients with invasive breast cancer who underwent surgery at Samsung Medical Center, Seoul, Korea, from 1995 to 2012.

RESULTS

Patients were divided into two groups according to multiplicity (single, n = 4,744; multiple, n = 1,014). Statistically significant differences in lymph node involvement and lymphatic invasion were found between the two groups (p < .001). Patients with multiple masses tended to have luminal A molecular subtype (p < .001). On Kaplan-Meier survival analysis, patients with multiple masses had significantly poorer disease-free survival (DFS) (p = .016). The prognostic significance of multiplicity was seen in patients with anatomic staging group I and prognostic staging group IA (p = .019 and p = .032, respectively). When targeting patients with T1-2 N0 M0, hormone receptor-positive, and human epidermal growth factor receptor 2 (HER2)-negative cancer, Kaplan-Meier survival analysis also revealed significantly reduced DFS with multiple cancer (p = .031). The multivariate analysis indicated that multiplicity was independently correlated with worse DFS (hazard ratio, 1.23; 95% confidence interval, 1.03 to 1.47; p = .025). The results of this study indicate that tumor multiplicity is frequently found in luminal A subtype, is associated with frequent lymph node metastasis, and is correlated with worse DFS.

CONCLUSIONS

Tumor multiplicity has prognostic value and could be used to subclassify invasive breast cancer at early stages. Adjuvant chemotherapy would be necessary for multiple masses of T1-2 N0 M0, hormone-receptor-positive, and HER2-negative cancer.

Ultrasound Features of Breast Cancer for Predicting Axillary Lymph Node Metastasis

OBJECTIVES

The purpose of this study was to assess the clinical value of ultrasound (US) features of breast lesions for predicting the risk of axillary lymph node metastasis in patients with breast cancer.

METHODS

In this retrospective study, 425 patients with breast cancer were recruited, and their preoperative US features and postoperative pathologic results were collected. The association of these US features of breast cancer with axillary lymph node metastasis was determined by univariate and multivariate analyses.

RESULTS

Among the 425 patients, 200 (47.1%) had axillary lymph node metastasis, and 225 (52.9%) did not. The parameters of tumor shape, color Doppler flow imaging grades, histologic grade, and E-cadherin level were significantly and independently associated with axillary lymph node metastasis (P < .05 for all).

CONCLUSIONS

Axillary lymph node metastasis was prone to happen in patients with US features of an irregular tumor shape and higher color Doppler flow imaging grades. Ultrasound imaging provides a promising tool for predicting axillary lymph node metastasis in patients with breast cancer.

Phyllodes Tumor of the Breast: Ultrasound-Pathology Correlation

OBJECTIVE

The purpose of this study is to evaluate the sonographic and histopathologic features distinguishing benign from borderline and malignant phyllodes tumors.

MATERIALS AND METHODS

The ultrasound examinations of women with pathologically proven phyllodes tumors from 2004 to 2011 were retrospectively reviewed. The sonographic features of benign, borderline, and malignant phyllodes tumors were compared and analyzed using the American College of Radiology's BI-RADS ultrasound lexicon. Fisher exact test and Wilcoxon rank sum test were used for statistical analysis.

RESULTS

Fifty-nine women were included in the study; 28 benign (47%), 19 malignant (32%), and 12 borderline (20%) phyllodes tumors were identified. Significant univariate predictors of increased risk of borderline or malignant phyllodes tumors were patient age greater than 55 years (p = 0.014), irregular lesion shape (p = 0.011), and longest lesion dimension greater than 7 cm (p = 0.0022) at sonography. No significant differences were observed in lesion margins, boundaries, echo patterns, or posterior acoustic features.

CONCLUSION

There is substantial overlap in the sonographic features of benign and borderline or malignant phyllodes tumors. Understanding the clinical and sonographic features of phyllodes tumors may aid the radiologist in predicting biological behavior, including the likelihood of benign versus borderline or malignant phyllodes tumors at pathologic analysis.

A feasibility study of neoadjuvant talazoparib for operable breast cancer patients with a germline BRCA mutation demonstrates marked activity

This study was undertaken to determine the feasibility of enrolling breast cancer patients on a single-agent-targeted therapy trial before neoadjuvant chemotherapy. Specifically, we evaluated talazoparib in patients harboring a deleterious BRCA mutation (BRCA+). Patients with a germline BRCA mutation and ≥1 cm, HER2-negative primary tumors were eligible. Study participants underwent a pretreatment biopsy, 2 months of talazoparib, off-study core biopsy, anthracycline, and taxane-based chemotherapy ± carboplatin, followed by surgery. Volumetric changes in tumor size were determined by ultrasound at 1 and 2 months of therapy. Success was defined as 20 patients accrued within 2 years and <33% experienced a grade 4 toxicity. The study was stopped early after 13 patients (BRCA1 + n = 10; BRCA2 + n = 3) were accrued within 8 months with no grade 4 toxicities and only one patient requiring dose reduction due to grade 3 neutropenia. The median age was 40 years (range 25–55) and clinical stage included I (n = 2), II (n = 9), and III (n = 2). Most tumors (n = 9) were hormone receptor-negative, and one of these was metaplastic. Decreases in tumor volume occurred in all patients following 2 months of talazoparib; the median was 88% (range 30–98%). Common toxicities were neutropenia, anemia, thrombocytopenia, nausea, dizziness, and fatigue. Single-agent-targeted therapy trials are feasible in BRCA+ patients. Given the rapid rate of accrual, profound response and favorable toxicity profile, the feasibility study was modified into a phase II study to determine pathologic complete response rates after 4–6 months of single-agent talazoparib.

An investigational PARP inhibitor seems safe and possibly effective when given ahead of surgery to women with BRCA-mutated breast cancer. Jennifer Litton and colleagues from the University of Texas MD Anderson Cancer Center in Houston, USA, conducted a small feasibility study to see if patients with stage I-III breast cancer and inherited mutations in BRCA1 or BRCA2 would put off their standard course of chemotherapy ahead of surgery to first receive two months of talazoparib, an experimental inhibitor of poly ADP ribose polymerase (PARP), an enzyme involved in DNA damage repair. The trial was a resounding success. In fact, owing to rapid patient enrollment, decreases in tumor volume among all 13 participants and few signs of serious side effects, the researchers amended the study protocol to give talazoparib for longer and test for therapeutic efficacy.

A longitudinal MRI study on lymph nodes histiocytosis of a xenograft cancer model

BACKGROUND

Efforts are continuously made to detect and investigate the pivotal processes and interplay between the response of sentinel lymph node and malignant cells from a primary tumor. Conversely, some frequently used tumor animal models, such as human cancer xenografts, rarely feature metastasis. Therefore, lymph node alterations are seldom assessed. We consider that studying lymph node response could contribute to the understanding of host reaction to cancer. In the present study, we explored the presence of regional lymph node alterations in parallel with tumor growth using a pancreatic tumor xenograft model which does not develop metastasis.

METHODS AND FINDINGS

We established an animal cancer model by the subcutaneous inoculation of PANC-1 (a metastatic human pancreatic cancer cell line) in the left upper flank of athymic nude mice. Tumor animals, along with controls (n = 7 / group) were subjected to Magnetic Resonance Imaging (MRI) in order to follow tumor growth and brachial and axillary lymph nodes alterations over several weeks. Further histological analyses were performed at the end of the study. The individual average of the different lymph nodes sizes was 15-40% larger in the tumor animals compared to control animals at week 8 to week 20. The tumor size and lymph node size were not correlated. Histological analysis of the lymph nodes showed paracortical histiocytosis. No metastasis to lymph nodes could be detected by histology. In tumor bearing animals, histiocytosis was associated with isolated apoptotic bodies and migration of human tumoral cells was confirmed by specific immunostaining of human origin markers.

CONCLUSIONS

The lack of metastasis as well as the pathological manifestation of the lymph node alteration in this pre-clinical model established here parallels findings in patients with sinus histiocytosis that is correlated with improved survival.

Intratumoral heterogeneity and subclonal diversification of early breast cancer

Heterogeneity has long been recognized as a feature of some primary breast cancers manifesting as mixed histopathological subtypes or variable expression of the therapeutic targets ER, PgR and HER2. The recent emergence of next generation sequencing (NGS) technologies has revolutionized our understanding of the extent and nature of subclonal diversification. Careful examination of primary breast cancers often reveals multiple genomically distinct subclones that may contain driver alterations that follow spatial patterns of segregation. Subclonality is of clinical relevance as it forms the substrate of selection and can give rise to aggressive clinical features such as invasiveness, metastasis and treatment resistance. However, spatial and temporal intra-tumoral heterogeneity pose fundamental challenges to representative sampling and consequently the feasibility of a personalized medicine approach. Fundamental clinical and biological questions are starting to be addressed by applying NGS to the study of intra-tumoral heterogeneity and the insights that it provides should be used to better inform the prospective design of clinico-genomics trials.

Multifocal Invasive Ductal Cancer: Distinguishing Independent Tumor Foci From Multiple Satellites

Patients with multifocal breast cancers (MBCs) have a poorer prognosis than patients with unifocal breast cancers. Studies have attributed this to tumor size underestimation in MBC. An alternative hypothesis is that some MBCs behave in a fashion analogous to the "satellite" and "in-transit metastasis" observed in melanoma and, thereby, are more clinically aggressive. We identified 79 cases of MBC, which we classified into 2 groups: study cases defined as ≥2 morphologically similar tumor foci with ≥1 focus without in situ carcinoma (n = 21); and a control group defined as ≥2 morphologically similar or dissimilar foci with associated in situ carcinoma in all foci (n = 58). The odds of being a study case is 1.86 (95% confidence interval [CI] 1.26-2.74) times greater per unit increase in number of tumor foci (median of 4 tumor foci; P = .002). Study cases were 73.33 (95% CI = 8.91-603.16) times more likely to have lymphovascular invasion (LVI) and 14.72 (95% CI = 4.37-49.61) times more likely to have nodal metastases. Grade I/II tumors were 0.20 (95% CI = 0.07-0.59) times less likely to be study cases. There was a significant positive interaction ( P < 0.001) indicated by the relationship of LVI status and nodal status with the study case and control group. We conclude that there is a subset of MBC that presents with more numerous tumor foci and a higher rate of nodal metastasis. The aggressive behavior of these cases may be attributed to their proclivity for LVI.

Three-Dimensional Assessment of Automated Breast Volume Scanner Compared with Handheld Ultrasound in Pre-Operative Breast Invasive Ductal Carcinomas: A Pilot Study of 51 Cases

The aim of the work described here was to compare the accuracy of conventional handheld ultrasound (HHUS) with that of an automated breast volume scanner (ABVS) in 3-D assessment of pre-operative invasive ductal carcinomas. HHUS and ABVS were used in 51 patients to obtain the largest tumor diameter, tumor volume and tumor surface area. The volumetric measurement was also obtained from ABVS data with medical software. With tumor size and volume on pathology as the gold standard, Bland-Altman analysis was used to compare variability. Correlation coefficients and receiver operating characteristic curves were established for all measurements for T2 classification. The correlation coefficients of all ABVS measurements were stronger than those of HHUS measurements, with the ABVS volumetric measurement significantly different with a higher accuracy of 88.24% (45/51) and predicting T-classification with higher area under the receiver operating characteristic curves (0.936). Therefore, 3-D measurements provide stronger correlations with pathology in tumor size measurement. However, more clinical trials are needed to confirm our findings.

Predicting discordant HER2 results in ipsilateral synchronous invasive breast carcinomas: experience from a single institution

With the emergence of multiple lines of highly effective Human Epidermal Growth Factor Receptor 2 (HER2) directed therapy, accurate identification of HER2 positive tumour has become a critical aspect in the histopathological analysis of breast cancers. Multifocal invasive breast carcinomas are relatively common, and given the aggressive inherent biology of HER2 positive disease, identification of even small tumours with HER2 positive status may be of importance for treatment planning. There are currently no clear guidelines as to whether all of these foci should be tested for HER2 status. We reviewed the results of 172 patients in whom HER2 in situ hybridisation (ISH) testing was performed on at least two ipsilateral synchronous invasive carcinomas. Discordant results in different invasive foci were relatively uncommon and occurred in only eight (5%) of the 172 patients. This showed a statistically significant correlation with similarly discordant oestrogen receptor (ER) results. In addition HER2 discordance was more likely amongst different tumour foci if these arose in distinct and separate areas of DCIS. An algorithm based on a combination of College of American Pathologists (CAP) recommendation for HER2 testing, differing ER status and background DCIS profile may be useful in detecting these discordant cases.

Is Pre-Operative Axillary Staging with Ultrasound and Ultrasound-Guided Fine-Needle Aspiration Reliable in Invasive Lobular Carcinoma of the Breast?

Axillary ultrasound (US) with US-guided fine-needle aspiration (US-FNA) for suspicious lymph nodes is important for pre-operative staging and planning of surgical management. Invasive lobular carcinoma (ILC) metastases were previously thought to be difficult to detect, but with a limited amount of evidence. This study investigated the ability of US and US-FNA to detect ILC metastases by assessing 142 patients with ILC. The sensitivity of US in detection of metastasis was 52.3%, and US was able to exclude 96% of N2 and N3 axillary metastases. The false-negative rate of US-FNA in detection of metastasis for suspicious lymph nodes on US was 34.8%, and lymph nodes with longer maximal dimensions were associated with false-negative US-FNA results. Multiplicity of breast lesions and maximal cortical thickness ≥3.1 mm of lymph nodes were independently associated with metastasis. Although pre-operative US in ILC can reliably exclude advanced axillary nodal disease, US-FNA results should be carefully interpreted.

Impact of stress and levels of corticosterone on the development of breast cancer in rats

Stress is experienced during cancer, and impairs the immune system’s ability to protect the body. Our aim was to investigate if isolation stress has an impact on the development of tumors in rats, and to measure the size and number of tumors and the levels of corticosterone. Breast cancer was induced in two groups of female rats (N=20) by administration of a single dose of N-methyl-N-nitrosourea 50 mg/kg. Rats in the control group (cancer induction condition) were allowed to remain together in a large cage, whereas in the second group, rats were also exposed to a stressful condition, that is, isolation (cancer induction and isolation condition, CIIC). The CIIC group displayed anxious behavior after 10 weeks of isolation. In the CIIC group, 16 tumors developed, compared with only eleven tumors in the control cancer induction condition group. In addition, compared with the control group, the volume of tumors in the CIIC group was greater, and more rats had more than one tumor and cells showed greater morphological damage. Levels of corticosterone were also significantly different between the two groups. This study supports the hypothesis that stress can influence the development of cancer, but that stress itself is not a sufficient factor for the development of cancer in rats. The study also provides new information for development of experimental studies and controlled environments.

Pathologic Evaluation and Reporting of Intraductal Papillary Mucinous Neoplasms of the Pancreas and Other Tumoral Intraepithelial Neoplasms of Pancreatobiliary Tract: Recommendations of Verona Consensus Meeting

BACKGROUND

There are no established guidelines for pathologic diagnosis/reporting of intraductal papillary mucinous neoplasms (IPMNs).

DESIGN

An international multidisciplinary group, brought together by the Verona Pancreas Group in Italy-2013, was tasked to devise recommendations.

RESULTS

(1) Crucial to rule out invasive carcinoma with extensive (if not complete) sampling. (2) Invasive component is to be documented in a full synoptic report including its size, type, grade, and stage. (3) The term "minimally invasive" should be avoided; instead, invasion size with stage and substaging of T1 (1a, b, c; ≤ 0.5, > 0.5-≤ 1, > 1 cm) is to be documented. (4) Largest diameter of the invasion, not the distance from the nearest duct, is to be used. (5) A category of "indeterminate/(suspicious) for invasion" is acceptable for rare cases. (6) The term "malignant" IPMN should be avoided. (7) The highest grade of dysplasia in the non-invasive component is to be documented separately. (8) Lesion size is to be correlated with imaging findings in cysts with rupture. (9) The main duct diameter and, if possible, its involvement are to be documented; however, it is not required to provide main versus branch duct classification in the resected tumor. (10) Subtyping as gastric/intestinal/pancreatobiliary/oncocytic/mixed is of value. (11) Frozen section is to be performed highly selectively, with appreciation of its shortcomings. (12) These principles also apply to other similar tumoral intraepithelial neoplasms (mucinous cystic neoplasms, intra-ampullary, and intra-biliary/cholecystic).

CONCLUSIONS

These recommendations will ensure proper communication of salient tumor characteristics to the management teams, accurate comparison of data between analyses, and development of more effective management algorithms.

[Relevance of the sentinel lymph node biopsy in breast multifocal and multicentric cancer]

OBJECTIVES

The sentinel lymph node biopsy is a gold standard in the management of breast cancer. Its role in multifocal or multicentric tumors is still evolving. The aim of this study is to assess the feasibility and pertinence of sentinel lymph node biopsy in multifocal and multicentric tumors based on a systematic review of literature.

METHODS

A systematic review was conducted searching in the following electronic databases PubMed using "sentinel lymph node biopsy", "breast cancer", "multifocal tumor", "multicentric tumor" and "multiple tumor" as keywords. We included original articles published between 2000 and 2014, both French and English, studying feasibility of sentinel lymph node biopsy in invasive breast cancer, multicentric and/or multifocal tumors. The first end point was success rate and false negative rate.

RESULTS

Twenty-six articles were included in this literature review, with 2212 cases (782 multifocal, 737 multicentric and 693 multiple tumors). Percentage of tumors whose stage was higher than stage T2 ranged from 0 to 86.3%. Success rate average was 83.1%. False negative average was 8.2%. False negative rate was less than 10% in 15 articles. Mean of sentinel lymph node biopsy was 2 (1-9). The average rate of sentinel lymph node positive was 50.6%. Axillary recurrence rate was 0.5%.

CONCLUSION

Despite the methodological biases of the studies included in this review of literature, the false negative rate of sentinel node biopsy in multifocal and multicentric breast cancers are less than 10% with a low rate of axillary recurrence. Despite the lack of randomized study, this procedure can be routinely performed in accordance with rigorous technical process.

Total surface area is useful for differentiating between aggressive and favorable multifocal papillary thyroid carcinomas

PURPOSE

The purpose of the present study was to identify more useful parameters for predicting behaviors of multifocal papillary thyroid carcinoma (PTC).

MATERIALS AND METHODS

We investigated dominant tumor diameter (TD), total tumor diameter (TTD), and total surface area (TSA) in tumors from 588 patients and evaluated their usefulness as parameters for assessment of tumor behaviors in multifocal PTCs.

RESULTS

In 588 PTCs, tumor multifocality was found in 179 PTCs (30.4%). Multifocal tumors were significantly associated with extrathyroidal extension, lymph node metastasis, and higher tumor stage grouping (p<0.001, p<0.001, and p<0.001, respectively). The rates of nodal metastasis increased with greater TSA and TTD in PTCs. Multifocal papillary thyroid microcarcinomas (mPMCs) with TSA >3.14 cm² had higher rates of nodal metastasis than mPMCs with TSA ≤3.14 cm² (p=0.038); however, there was no significant difference between mPMCs with TTD >1.0 cm and with TTD ≤1.0 cm (p=0.325). In addition, nodal metastasis was more frequent in mPMCs with TSA >3.14 cm² than in unifocal papillary thyroid microcarcinomas (uPMCs) (TD ≤1.0 cm) (p=0.002), but not overt unifocal PTCs (TD >1.0 cm) (p=0.244).

CONCLUSION

Our results suggest that mPMCs with TSA >3.14 cm² show more aggressive behavior than uPMCs and mPMCs with TSA ≤3.14 cm². TSA could be useful in distinguishing aggressive mPMCs from favorable cases.

"Clinical significance of multifocal and multicentric breast cancers and choice of surgical treatment: a retrospective study on a series of 1158 cases"

Background

The biological and clinical significance of multifocal and multicentric (MF/MC) breast cancers and the choice of appropriate surgical treatment for these tumors are still debated.

Methods

1158 women operated on for a stage I-III breast cancer were included in this retrospective study; clinical and pathological data were obtained from the institutional database of the Department of Oncology of the University of Siena, Italy. The impact of MF/MC breast cancers on patterns of recurrence and breast cancer specific survival (BCSS) was investigated in relation to the type of surgical treatment.

Results

MF and MC cancers were present in 131 cases (11.3%) and 60 cases (5.2%) respectively and were more frequently treated with mastectomy (55 MF and 60 MC cancers, 81.2%) than with breast conserving surgery (36 MF cancers, 18.9%; p < 0.001). MF and MC breast cancers were associated with a worse prognosis with a BCSS of 154 months compared to 204 months of unicentric cancers (p < 0.001). In multivariate analysis, MF/MC cancers were independent prognostic factors for BCSS together with higher number of metastatic axillary nodes, absence of estrogen receptors and high proliferative activity. MF and MC cancers were related to a significantly shorter BCSS in patients submitted to mastectomy as well as those submitted to breast conserving surgery. Relapse at any site was higher in the subgroup of MF and MC cancers but the incidence of loco-regional and distant recurrences did not differ between patients treated with mastectomy or breast conserving surgery.

Conclusions

Our results indicate that MF/MC cancers have a negative impact on prognosis and are related to higher loregional and distant relapse independently from the type of surgery performed. Adjuvant therapies did not modify the poorer outcome, but in patients receiving adjuvant anthacyclines, the differences with unicentric tumors were reduced. Our data support the hypothesis that MF/MC tumors may have a worse biological behavior and that the presence of multiple foci should be considered in planning adjuvant treatments.

Complexities and challenges in the pathologic assessment of size (T) of invasive breast carcinoma

Size (the "T" in the TNM System) of invasive breast carcinoma is a proven independent prognostic factor; however, its accurate determination can be challenging. The purpose of this review is to discuss the complexities inherent in determining "T"-including those encountered in the clinical measurement ("cT", ie, physical and radiologic assessment) as well as pathologic determination (pT) of invasive breast carcinomas. Pathologic estimation of tumor size, macroscopic, as well as microscopic, can be problematic due to the complexity of multiple situations, seeming confusion regarding staging guidelines, and interobserver variation in interpretation. Additional problematic scenarios in determination of "T" include those incurred in excisions performed after the performance of needle core biopsies, and in cases wherein there are multiple foci of invasive carcinoma, as well as in carcinomas status post-neoadjuvant chemotherapy. It can also be difficult to determine "T" in certain types of invasive carcinoma, particularly those of the lobular type. In this communication, some of the complexities and challenges in determing "T" are discussed, and modest suggestions are offered to assist in optimizing such assessments.

Preoperative prediction of cosmetic results in breast conserving surgery

BACKGROUND

Preoperative objective predictions of cosmetic result after breast conserving surgery (BCS) has the potential to aid in surgical treatment decision making. Our aim was to investigate the predictive value of tumor volume in relation to breast volume (TV/BV ratio) for cosmetic result.

METHODS

Sixty-nine invasive breast cancer women with preoperative MRI and treated by BCS and radiotherapy in 2007-2012 were prospectively included. Simple excision or basic oncoplastic techniques were used, but no volume displacement. TV/BV ratio was measured in the MRI while 3D-projected in virtual reality environment (I-Space). Cosmetic result was assessed by patient questionnaire, panel evaluation, and breast retraction assessment (BRA). Quality-of-life was assessed by EORTC QLQ-C30 and BR23.

RESULTS

Intraobserver and interobserver correlation coefficients for tumor and breast volume were all >0.95. Increasing TV/BV ratio correlated with decreasing cosmetic result as determined by patient, panel, and BRA. TV/BV ratio was a significant independent predictor for the panel evaluation (P=0.028), as was tumor location (P<0.05), and together they constituted a good prediction model (AUC 0.83).

CONCLUSIONS

TV/BV ratio was a precise and independent predictor for cosmetic result determined by a panel and can be used as preoperative prediction tool to enable more informed surgical treatment decision making.

The clinical value of hybrid sentinel lymphoscintigraphy to predict metastatic sentinel lymph nodes in breast cancer

PURPOSE

Hybrid imaging techniques can provide functional and anatomical information about sentinel lymph nodes in breast cancer. Our aim in this study was to evaluate which imaging parameters on hybrid sentinel lymphoscintigraphy predicted metastatic involvement of sentinel lymph nodes (SLNs) in patients with breast cancer.

METHODS

Among 56 patients who underwent conventional sentinel lymphoscintigraphy, 45 patients (age, 53.1 ± 9.5 years) underwent hybrid sentinel lymphoscintigraphy using a single-photon emission computed tomography (SPECT)/computed tomography (CT) gamma camera. On hybrid SPECT/CT images, we compared the shape and size (long-to-short axis [L/S] ratio) of the SLN, and SLN/periareolar injection site (S/P) count ratio between metastatic and non-metastatic SLNs. Metastatic involvement of sentinel lymph nodes was confirmed by pathological biopsy.

RESULTS

Pathological biopsy revealed that 21 patients (46.7 %) had metastatic SLNs, while 24 (53.3 %) had non-metastatic SLNs. In the 21 patients with metastatic SLNs, the SLN was mostly round (57.1 %) or had an eccentric cortical rim (38.1 %). Of 24 patients with non-metastatic SLNs, 13 patients (54.1 %) had an SLN with a C-shape rim or eccentric cortex. L/S ratio was 2.04 for metastatic SLNs and 2.38 for non-metastatic SLNs. Seven (33 %) patients had T1 primary tumors and 14 (66 %) had T2 primary tumors in the metastatic SLN group. In contrast, 18 (75 %) patients had T1 primary tumors and six (25 %) had T2 tumors in the non-metastatic SLN group. S/P count ratio was significantly lower in the metastatic SLN group than the non-metastatic SLN group for those patients with a T1 primary tumor (p = 0.007).

CONCLUSIONS

Hybrid SPECT/CT offers the physiologic data of SPECT together with the anatomic data of CT in a single image. This hybrid imaging improved the anatomic localization of SLNs in breast cancer patients and predicted the metastatic involvement of SLNs in the subgroup of breast cancer patients with T1 primary tumors.

Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB.

METHODS

Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed.

RESULTS

Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %.

CONCLUSIONS

Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.

Axillary lymph node status in multicentric breast tumors and breast tumors with nipple involvement

BACKGROUND

Axillary lymph node dissection plays an important role in breast cancer management in terms of staging, prediction of prognosis, determination of adjuvant therapy, and local control of the primary tumor. The objective of this study was to evaluate the axillary lymph node involvement in multicentric breast tumors and breast tumors with nipple involvement in comparison with unifocal tumors.

PATIENTS AND METHODS

We reviewed the records of 267 patients with stage I or IIA disease. The rates of axillary lymph node metastasis (ALNM) in patients with unifocal tumors, multicentric tumors, or nipple involvement were compared.

RESULTS

209 (78%) patients had unifocal tumors, 24 (8%) had multicentric tumors, and 34 (12%) had nipple involvement. The incidence of ALNM was 9.76% in patients with unifocal tumors, 24.84% in patients with multicentric tumors, and 36.71% in patients with nipple involvement. Hence, the incidence of ALNM was significantly higher in patients with nipple involvement or multicentric tumors than in patients with unifocal tumors.

CONCLUSION

Our data suggest that compared to unifocal tumors, breast tumors with nipple involvement or multiple foci show a significantly higher incidence of ALNM which is a predictor of a poor prognosis.

Effect of multiple invasive foci on breast cancer outcomes according to the molecular subtypes: a report from the Korean Breast Cancer Society

BACKGROUND

In this study, the prognostic impact of the presence of the multifocal or multicentric tumor (MMT) and its association with molecular subtypes were investigated.

PATIENTS AND METHODS

We investigated the breast cancer metastasis and survival in patients with multifocal or multicentric invasive foci in the same breast. The study population includes 2882 patients in the Seoul National University Hospital Breast Care Center (SNUHBCC) dataset and 41 179 patients in Korean Breast Cancer Registry (KBCR) dataset.

RESULTS

From SNUHBCC dataset, we observed a significant role of MMT in developing distant metastasis and death when the tumors were triple-negative subtype. This subtype-specific prognostic importance of MMT in overall survival was also seen in KBCR dataset (HR, 1.32; 95% CI, 1.02-1.69). In tumors <2 cm, the hazard ratios (HRs) for node metastasis and death were similar along the tumor size change in triple-negative subtype, while other subtypes showed a stepwise increment, suggesting the biologic importance of small invasive foci in this subtype.

CONCLUSIONS

Our results demonstrate the prognostic importance of MMT in patients with triple-negative breast cancers. Small additional invasive foci in triple-negative breast cancer patients should be considered as clinically relevant tumor deposits.

Clinical and pathologic features of multifocal and multicentric breast cancer in chinese women: a retrospective cohort study

Purpose

This study aims to analyze the clinical-pathological characteristics of multifocal and multicentric breast cancer (MMBC) in Chinese women.

Methods

Sixty-seven cases with MMBC were randomly collected and reviewed at seven hospitals in representative districts of China during 1999 to 2008.

Results

The incidence of MMBC in breast cancer in China was 1.75%. Compared to those with unifocal breast cancer, women with MMBC were more likely to have larger tumor size, lymph node metastasis (59.70% vs. 45.62%) and stage III to IV (46.26% vs. 21.10%). The peak age at onset of MMBC was 40 to 49 years old and has been gradually increasing during 1999 to 2008. Most of the MMBC women were treated with surgery and adjuvant therapy.

Conclusion

In China, the incidence of MMBC in breast cancer is significantly lower than that in Western countries. Compared to unifocal breast cancer, MMBC is biologically more aggressive. Most MMBC women underwent mastectomy, instead of breast conservation surgery.

Comparison of the sentinel node procedure between patients with multifocal and unifocal breast cancer in the EORTC 10981-22023 AMAROS Trial: identification rate and nodal outcome

INTRODUCTION

Multifocal breast cancer is associated with a higher risk of nodal involvement compared to unifocal breast cancer and the drainage pattern from multifocal localisations may be different. For this reason, the value of the sentinel node biopsy (SNB) procedure for this indication is debated. The aim of the current analysis was to evaluate the sentinel node identification rate and nodal involvement in patients with a multifocal tumour in the EORTC 10981-22023 AMAROS trial.

PATIENTS AND METHODS

From the first 4000 registered patients, 342 were identified with a multifocal tumour on histological examination and compared to a randomly selected control group of 684 patients with a unifocal tumour. The outcome of the SNB was assessed.

RESULTS

The sentinel node was identified in 96% of the patients with a multifocal tumour and in 98% of those with unifocal disease. In the multifocal group, 51% had a metastasis in the sentinel node compared to 28% in the unifocal group; and further nodal involvement after a positive sentinel node was found in 40% (38/95) and 39% (39/101) respectively.

CONCLUSION

In this prospective international multicentre study, the 96% detection rate indicates that the SNB procedure can be highly effective in patients with a multifocal tumour. Though the tumour-positive rate of the sentinel node was twice as high in the multifocal group compared to the unifocal group, further nodal involvement after a positive sentinel node was similar in both groups. This suggests that the SNB procedure is safe in patients with multifocal breast cancer.

3D Pathology Volumetric Technique: A Method for Calculating Breast Tumour Volume from Whole-Mount Serial Section Images

Tumour size, most commonly measured by maximum linear extent, remains a strong predictor of survival in breast cancer. Tumour volume, proportional to the number of tumour cells, may be a more accurate surrogate for size. We describe a novel “3D pathology volumetric technique” for lumpectomies and compare it with 2D measurements. Volume renderings and total tumour volume are computed from digitized whole-mount serial sections using custom software tools. Results are presented for two lumpectomy specimens selected for tumour features which may challenge accurate measurement of tumour burden with conventional, sampling-based pathology: (1) an infiltrative pattern admixed with normal breast elements; (2) a localized invasive mass separated from the in situ component by benign tissue. Spatial relationships between key features (tumour foci, close or involved margins) are clearly visualized in volume renderings. Invasive tumour burden can be underestimated using conventional pathology, compared to the volumetric technique (infiltrative pattern: 30% underestimation; localized mass: 3% underestimation for invasive tumour, 44% for in situ component). Tumour volume approximated from 2D measurements (i.e., maximum linear extent), assuming elliptical geometry, was seen to overestimate volume compared to the 3D volumetric calculation (by a factor of 7x for the infiltrative pattern; 1.5x for the localized invasive mass).

Multifocality and multicentricity in breast cancer and survival outcomes

BACKGROUND

The clinicopathological characteristics and the prognostic significance of multifocal (MF) and multicentric (MC) breast cancers are not well established.

PATIENTS AND METHODS

MF and MC were defined as more than one lesion in the same quadrant or in separate quadrants, respectively. The Kaplan-Meier product limit was used to calculate recurrence-free survival (RFS), breast cancer-specific survival (BCSS), and overall survival (OS). Cox proportional hazards models were fit to determine independent associations of MF/MC disease with survival outcomes.

RESULTS

Of 3924 patients, 942 (24%) had MF (n = 695) or MC (n = 247) disease. MF/MC disease was associated with higher T stages (T2: 26% versus 21.6%; T3: 7.4% versus 2.3%, P < 0.001), grade 3 disease (44% versus 38.2%, P < 0.001), lymphovascular invasion (26.2% versus 19.3%, P < 0.001), and lymph node metastases (43.1% versus 27.3%, P < 0.001). MC, but not MF, breast cancers were associated with a worse 5-year RFS (90% versus 95%, P = 0.02) and BCSS (95% versus 97%, P = 0.01). Multivariate analysis shows that MF or MC did not have an independent impact on RFS, BCSS, or OS.

CONCLUSIONS

MF/MC breast cancers were associated with poor prognostic factors, but were not independent predictors of worse survival outcomes. Our findings support the current TNM staging system of using the diameter of the largest lesion to assign T stage.

Comparison of the subgross distribution of the lesions in invasive ductal and lobular carcinomas of the breast: a large-format histology study

To compare the lesion distribution and the extent of the disease in ductal and lobular carcinomas of the breast, we studied 586 ductal and 133 lobular consecutive cancers. All cases were documented on large-format histology slides. The invasive component of ductal carcinomas was unifocal in 63.3% (371/586), multifocal in 35.5% (208/586), and diffuse in 1.2% (7/586) of the cases. The corresponding figures in the lobular group were 27.8% (37/133), 45.9% (61/586), and 26.3% (35/133), respectively. When the distribution of the in situ and invasive component in the same tumors was combined to give an aggregate pattern, the ductal carcinomas were unifocal in 41.6% (244/586), multifocal in 31.6% (185/586), and diffuse in 26.8% (157/586) of the cases. The corresponding figures in the lobular category were 15.0% (20/133), 54.2% (72/133), and 30.8% (41/133), respectively. Ductal cancers were extensive in 45.7% (268/586), lobular in 65.4% (87/133) of the cases. All these differences were statistically highly significant (P < 0.0001). While the histological tumor type itself (ductal versus lobular) did not influence the lymph node status, multifocal and diffuse distribution of the lesions were associated with significantly increased risk of lymph node metastases in both ductal and lobular cancers.

Prognostic Factors for Patients with Breast Cancer: Traditional and New

At the time of breast cancer diagnosis, multiple features of the tumor are routinely assessed to evaluate for prognostic and predictive factors. Prognostic factors provide information about the patient's likely clinical course and include tumor stage (composed of lymph node status, tumor size, and presence of chest wall involvement), tumor histologic type and grade, estrogen and progesterone receptor expression, and HER2 status. These traditional prognostic factors are reviewed with particular attention to problematic areas in classification. Several newer prognostic tests may be able to provide information beyond the traditional prognostic factors and are presented.

Multicentric/multifocal breast cancer with a single histotype: is the biological characterization of all individual foci justified?

BACKGROUND

Invasive multiple breast cancers with a single histological feature (MBCSH) are routinely assessed for biological parameters to indicate adjuvant treatments only in the largest invasive carcinomas. However, the heterogeneity of individual foci in multiple carcinomas has not been widely studied. We analyzed whether such biological features are differently expressed in different MBCSH foci.

PATIENT AND METHODS

One hundred and thirteen invasive MBCSH were tested over a 5-year period. The expression of estrogen (ER) and progesterone (PgR) receptors, Ki-67 proliferative index, expression of HER2 and tumor grading were prospectively determined in each tumor focus, and mismatches among foci were recorded.

RESULTS

Mismatches in ER status were present in 5 (4.4%) cases and PgR in 18 (15.9%) cases. Mismatches in tumor grading were present in 21 cases (18.6%), proliferative index (Ki-67) in 17 (15%) cases and HER2 status in 11 (9.7%) cases.

CONCLUSIONS

In our experience, invasive MBCSH showed heterogeneity among foci. In our clinical practice, such assessment led to 14 (12.4%) patients receiving different adjuvant treatments compared with what would have been indicated if we had only taken into account the biologic status of the primary tumor.

Axillary lymph node status in unifocal, multifocal, and diffuse breast carcinomas: differences are related to macrometastatic disease

BACKGROUND

Multifocality in breast carcinoma is associated with an increased propensity to metastasis. However, it is not clear whether this propensity manifests in the form of macrometastases or as presumably less-significant low-volume metastatic disease.

METHODS

A total of 948 cases of invasive breast carcinoma documented in large-format histology sections and assessed with detailed radiologic-pathologic correlation were categorized as unifocal, multifocal, or diffuse on the basis of the subgross distribution of the invasive component. Rates of macrometastases (>2 mm), micrometastases (0.2-2 mm), and isolated tumor cells (<0.2 mm) in these categories were compared. The influence of tumor size and histology grade on lymph node positivity rates was also tested.

RESULTS

Macrometastases were present in 20.4% (112 of 550) of unifocal, 48.3% (172 of 356) of multifocal, and 61.9% (26 of 42) of diffuse cases (P < 0.0001). Among the macrometastatic cases, more than three nodes were involved in 18.9% (21 of 112) of unifocal, 35.5% (61 of 172) of multifocal, and 50.0% (13 of 26) of diffuse cases. The rates of micrometastases (5.1, 5.1, and 2.4% unifocal, multifocal, and diffuse, respectively) and isolated tumor cells (4.5, 3.7, and 2.4% unifocal, multifocal, and diffuse, respectively) were low and similar in all examined categories. The relative risk (RR) of having macrometastatic disease was approximately doubled (RR 2.3726, P < 0.0001) in multifocal and tripled (RR 3.0562, P < 0.0001) in diffuse compared to unifocal cases. The findings were similar for all size categories, tumor grade categories, and sentinel lymph nodes, as well as all examined lymph nodes.

CONCLUSIONS

The significantly increased lymph node positivity rates in multifocal and diffuse invasive breast carcinomas results from large-volume macrometastatic disease.

Radiologic assessment of response to therapy: comparison of RECIST Versions 1.1 and 1.0

Improvements in radiologic imaging technology and therapeutic options available for management of tumors have necessitated the revision of guidelines for the imaging-based assessment of tumor response to therapy. The purpose of this article is to familiarize radiologists with the modifications to the Response Evaluation Criteria in Solid Tumors (RECIST) that have been incorporated in the latest version of the guidelines, RECIST 1.1. The most important differences between this version and the previous one, RECIST 1.0, include reductions in the maximum number of lesions per patient and per organ that may be targeted for measurement, augmentation of the criteria defining progressive disease, additional guidelines for reporting findings of lesions that are too small to measure and for measuring lesions that appear to have fragmented or coalesced at follow-up imaging, new criteria for characterizing lymphadenopathy, new criteria for selecting bone lesions and cystic lesions as targets for measurement, and the inclusion of findings at positron emission tomography among the indicators of disease response.

True local recurrences do not metastasize

Generally, the limits of local tumor control are in part connected with the term "field cancerization" and are known from oral, lung, prostate, or mammary cancer. With the example of breast cancer (BC), the problem of ipsilateral breast tumor recurrences (IBTR) after breast-conserving surgery will be reviewed. Three types of local recurrences are distinguished: true recurrences, new primaries, or residual tumors. Good data for BC allow the description of the time-dependent risk of these three types, relative to the diagnosis of the primary tumor, because the time of initiation and the growth duration of the IBTR can be estimated. Two hypotheses explain the data: first, local recurrences may be initiated years before the diagnosis of a primary tumor (PT) and can then appear as multifocal PT at diagnosis, and second, true local recurrences probably do not metastasize. The generalizability of these hypotheses for other tumors will be discussed.

A simple nomogram to evaluate the risk of nonsentinel node metastases in breast cancer patients with minimal sentinel node involvement

BACKGROUND

Tumor-positive sentinel node biopsy (SNB) suggests a risk of nonsentinel node metastases in breast cancer. This risk is lower after micrometastasis or isolated tumor cells (ITC) in the sentinel node (SN), and recent studies suggest that completion axillary lymph node dissection (ALND) might not improve outcome in these patients. We aim to validate existing predictive models and to develop a new model for micrometastatic and ITC patients.

METHODS

A series of 484 patients with micrometastases or ITC in SN followed by ALND was used to evaluate factors affecting nonsentinel node involvement. Logistic regression analysis was performed to construct a predictive model, which was validated by a separate series of 51 patients.

RESULTS

Only 7.2% of patients had additional metastases on completion ALND. Tumor diameter and multifocality associated with nonsentinel status on multivariate analysis. A predictive model was constructed showing good [area under the curve (AUC) 0.791] discrimination in the validation series. Previously published models performed poorly in our patient population.

CONCLUSIONS

Nonsentinel node metastases are rare with micrometastasis or ITC in SN. Most published predictive models for nonsentinel node involvement perform poorly in the present patient population. We developed a new predictive model which seems to perform well in discriminating patients with more than 10% risk of additional metastases. However, the presented nomogram needs to be validated with an independent patient series to evaluate its accuracy, especially for high-risk patients.

The hormone receptor, human epidermal growth factor receptor 2, and molecular subtype status of individual tumor foci in multifocal/multicentric invasive ductal carcinoma of breast

Multifocal/multicentric breast cancers are common. However, investigations of biomarkers such as estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 in individual tumor foci of such cancers are rare. This study was designed to evaluate the status of the hormone receptors, human epidermal growth factor receptor 2, and its molecular subtypes in individual foci of multifocal/multicentric invasive ductal carcinoma of the breast and to identify the factors associated with the different phenotypes of individual foci. We performed immunohistochemical analyses of the estrogen receptor, progesterone receptor, cytokeratin 5/6, epidermal growth factor receptor, and p53 and fluorescence in situ hybridization of human epidermal growth factor receptor 2 in individual foci of 65 cases of multifocal/multicentric invasive ductal carcinoma and the associated ductal carcinoma in situ components using tissue microarrays. The estrogen receptor status differed in 2 (3%) of the 65 invasive ductal carcinomas, progesterone receptor status in 7 (11%), human epidermal growth factor receptor 2 status in 4 (6%), and molecular subtypes in 5 (8%). The presence of different molecular subtypes in the invasive tumor foci was associated with differences in histologic features (P = .005), high histologic and nuclear grade (P = .012 and P = .021, respectively), p53 overexpression (P = .006), and mixed molecular subtypes in the ductal carcinoma in situ components (P = .011). Multifocal/multicentric invasive ductal carcinomas usually have a single phenotype in terms of hormone receptors, human epidermal growth factor receptor 2, and molecular subtypes; and thus, immunohistochemical analyses of the index tumor may be sufficient in routine practice. However, if multifocal/multicentric invasive ductal carcinomas are of high grade, of different histologic features, or of heterogeneous ductal carcinoma in situ component, biomarkers of the various foci need to be evaluated separately.

Tumor size and survival in multicentric and multifocal breast cancer

PURPOSE

Current AJCC/UICC staging of early breast cancer defines tumor stage using the largest focus, adding the suffix "(m)" to indicate multiplicity. This method may underestimate the total tumor burden in multifocal and multicentric breast cancer (MMBC). This study examines other measures of tumor size in MMBC to determine which provides the best fit in a multivariate model for survival outcomes.

PATIENTS AND METHODS

This prospective cohort study used data from the Australian Capital Territory and New South Wales Breast Cancer Treatment Group database to identify 812 women with ipsilateral invasive breast cancer; 141 of these women had MMBC. The pathology slides of all women with MMBC were reviewed and all foci of invasive breast cancer were re-measured. The measures of interest were the diameter of the largest deposit, the aggregate diameter and the aggregate volume. These measures of tumor size were included with other clinicopathological features of MMBC in a multivariate analysis to assess their relationship with progression-free survival (PFS) and overall survival (OS).

RESULTS

Tumor size was associated with PFS and OS in MMBC using any of the three measures; however, the diameter of the largest deposit provided the best fit in the multivariate model for OS.

CONCLUSION

Tumor size is an important prognostic factor for MMBC, and the diameter of the largest deposit provides a better fit in a multivariate model for OS than aggregate diameter and aggregate volume. Therefore, tumor size in MMBC should continue to be measured using the diameter of the largest deposit.