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Spoor J, Heeling E, Collewijn RC, van der Ploeg IMC, Hoornweg MJ, Russell N, van den Berg JG, Vrancken Peeters MJFTD, van Duijnhoven FH. Intraoperative frozen section of subareolar tissue in nipple-sparing mastectomy: Towards a less is more approach. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108320. [PMID: 38581755 DOI: 10.1016/j.ejso.2024.108320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 02/09/2024] [Accepted: 04/02/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Nipple preservation contributes to aesthetic outcome and quality of life in women undergoing Skin-Sparing Mastectomy (SSM) with immediate breast reconstruction for the treatment of breast cancer. Intraoperative Frozen Section (IFS) has been advocated to facilitate conversion from Nipple-Sparing Mastectomy (NSM) to SSM in cases with positive subareolar margins. This study investigated the application of IFS at our comprehensive cancer centre. METHODS In this single-centre retrospective study, for all patients who underwent therapeutic NSM with IFS from 2000 to 2021 pathological reports, patient- and tumour characteristics were retrieved. RESULTS In total 640 women were included in whom 662 intended NSMs with IFS had been performed. Sensitivity and specificity of frozen section compared with definitive histopathology were 75.2% and 98.5% respectively. In six women with a false positive result, the nipple had been removed. In 16 out of 32 women with a false negative result, the nipple was excised in a second procedure. In total 115 nipples were resected. In 40% of these nipples, no residual disease was detected. DISCUSSION IFS is a moderately sensitive and highly specific diagnostic tool to detect positive subareolar margins. An alternative approach is to omit frozen section but take intraoperative biopsies of the sub areolar margin, which are postoperatively analysed with definitive formalin-fixed paraffin-embedded histopathology. This allows for shared decision making regarding nipple excision in cases where minimal disease is found in subareolar tissue or cases with an indication for post-mastectomy radiotherapy.
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Affiliation(s)
- Jonathan Spoor
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Epidemiology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Eva Heeling
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Romy C Collewijn
- Faculty of Medicine, University of Amsterdam, Amsterdam, the Netherlands
| | - Iris M C van der Ploeg
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Marije J Hoornweg
- Department of Plastic- and Reconstructive Surgery, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Nicola Russell
- Department of Radiation Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Jose G van den Berg
- Department of Pathology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Marie-Jeanne F T D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands; Department of Surgery, Amsterdam University Medical Centre, Amsterdam, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute Antoni van Leeuwenhoek, Amsterdam, the Netherlands.
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Byon JH, Hwang S, Choi H, Choi EJ. Diagnostic Accuracy of Magnetic Resonance Imaging Features and Tumor-to-Nipple Distance for the Nipple-Areolar Complex Involvement of Breast Cancer: A Systematic Review and Meta-Analysis. Korean J Radiol 2023; 24:739-751. [PMID: 37500575 PMCID: PMC10400374 DOI: 10.3348/kjr.2022.0846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE This systematic review and meta-analysis evaluated the accuracy of preoperative breast magnetic resonance imaging (MRI) features and tumor-to-nipple distance (TND) for diagnosing occult nipple-areolar complex (NAC) involvement in breast cancer. MATERIALS AND METHODS The MEDLINE, Embase, and Cochrane databases were searched for articles published until March 20, 2022, excluding studies of patients with clinically evident NAC involvement or those treated with neoadjuvant chemotherapy. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Two reviewers independently evaluated studies that reported the diagnostic performance of MRI imaging features such as continuity to the NAC, unilateral NAC enhancement, non-mass enhancement (NME) type, mass size (> 20 mm), and TND. Summary estimates of the sensitivity and specificity curves and the summary receiver operating characteristic (SROC) curve of the MRI features for NAC involvement were calculated using random-effects models. We also calculated the TND cutoffs required to achieve predetermined specificity values. RESULTS Fifteen studies (n = 4002 breast lesions) were analyzed. The pooled sensitivity and specificity (with 95% confidence intervals) for NAC involvement diagnosis were 71% (58-81) and 94% (91-96), respectively, for continuity to the NAC; 58% (45-70) and 97% (95-99), respectively, for unilateral NAC enhancement; 55% (46-64) and 83% (75-88), respectively, for NME type; and 88% (68-96) and 58% (40-75), respectively, for mass size (> 20 mm). TND had an area under the SROC curve of 0.799 for NAC involvement. A TND of 11.5 mm achieved a predetermined specificity of 85% with a sensitivity of 64%, and a TND of 12.3 mm yielded a predetermined specificity of 83% with a sensitivity of 65%. CONCLUSION Continuity to the NAC and unilateral NAC enhancement may help predict occult NAC involvement in breast cancer. To achieve the desired diagnostic performance with TND, a suitable cutoff value should be considered.
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Affiliation(s)
- Jung Hee Byon
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Seungyong Hwang
- Department of Genetics, Stanford University, Stanford, CA, USA
| | - Hyemi Choi
- Department of Statistics and Institute of Applied Statistics, Jeonbuk National University, Jeonju, Republic of Korea.
| | - Eun Jung Choi
- Department of Radiology, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Republic of Korea.
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Long-Term Cancer Recurrence Rates Following Nipple-Sparing Mastectomy: A 10-year Follow-up Study. Plast Reconstr Surg 2022; 150:13S-19S. [PMID: 35943969 DOI: 10.1097/prs.0000000000009495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the increased utilization of nipple-sparing mastectomies (NSM), there is limited data examining long-term cancer recurrence rates in these patients. The objective of this study was to analyze breast cancer recurrence in patients who received therapeutic NSM with a median of 10 years of follow-up. METHODS All patients undergoing NSM at a single institution were retrospectively reviewed temporally to obtain a median of 10-years of follow up. Patient demographic factors, mastectomy specimen pathology, and oncologic outcomes were analyzed. Univariate analysis was performed to identify independent risk factors for locoregional recurrence. RESULTS 126 therapeutic NSM were performed on 120 patients. The most frequently observed tumor histology included invasive ductal carcinoma (48.4%) and ductal carcinoma in situ (38.1%). Mean tumor size was 1.62 cm. Multifocal or multicentric disease and lymphovascular invasion were present in 31.0% and 10.3% of NSM specimens, respectively. Sentinel lymph node biopsy was performed in 84.9% of NSM and 17.8% were positive. The rate of positive frozen subareolar biopsy was 7.3% (n=82) and permanent subareolar pathology was 9.5% (n=126). The most frequently observed pathologic tumor stages was stage I (44.6%) and stage 0 (33.9%). Incidence of recurrent disease was 3.17% per mastectomy and 3.33% per patient. Upon univariate analysis, no demographic, operative, or tumor-specific variables were independent risk factors for locoregional recurrence. CONCLUSIONS Overall recurrence rates are low in patients undergoing NSM at a median follow-up of 10-years. Close surveillance should remain a goal for patients and their providers to promptly identify potential recurrence.
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EL-Adalany MA, EL-Razek AAEKA, EL-Metwally D. Prediction of nipple-areolar complex involvement by breast cancer: role of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2021; 52:131. [DOI: 10.1186/s43055-021-00516-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/17/2021] [Indexed: 09/01/2023] Open
Abstract
Abstract
Background
Skin-sparing and nipple-sparing mastectomies were considered as alternative techniques for modified radical mastectomy. In patients who are candidates for nipple-sparing mastectomy, preoperative assessment of the nipple-areolar complex (NAC) is essential for adequate surgical planning. Breast MRI is highly sensitive for cancer detection and has an important role in disease staging. The aim of this study was to estimate the role of DCE-MRI in predicting malignant NAC invasion by underlying breast cancer and assess the best predictors on MRI that can suspect malignant NAC invasion.
Results
Out of the 125 patients with breast cancer, 33 patients (26.4%) showed malignant NAC invasion. On basis of multivariate analysis, abnormal nipple enhancement, tumor nipple enhancement, tumor nipple distance ≤ 2 cm, and abnormal and asymmetric nipple morphology were all significant predictors of malignant NAC invasion (P < 0.001) with abnormal unilateral nipple enhancement as the most important independent MRI predictor of malignant NAC invasion (odds ratio = 61.07, 95% CI 12.81–291.22, P < 0.001). When combining more than positive suspicious MRI features, DCE-MRI had 66.6% sensitivity, 76% specificity, 50% PPV, 86.4% NPV, and 73.6% accuracy in prediction of malignant NAC invasion.
Conclusion
DCE-MRI could predict malignant NAC invasion with abnormal unilateral nipple enhancement as the most important independent MRI predictor.
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Bae SJ, Cha YJ, Eun NL, Ji JH, Kim D, Lee J, Ahn SG, Son EJ, Jeong J. Diagnostic Accuracy of Nonmass Enhancement at Breast MRI in Predicting Tumor Involvement of the Nipple: A Prospective Study in a Single Institution. Radiology 2021; 301:47-56. [PMID: 34254854 DOI: 10.1148/radiol.2021204136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Although nonmass enhancement (NME) extension to the nipple at preoperative MRI frequently leads to sacrifice of the nipple-areolar complex (NAC), its correlation with pathologically confirmed NAC involvement is unclear. Purpose To evaluate the diagnostic accuracy of using NME extension to the subareolar region at breast MRI to predict pathologic nipple involvement and the eligibility for nipple-sparing mastectomy. Materials and Methods From November 2017 to November 2019, the authors prospectively enrolled participants with breast cancer and NME within 2 cm of the nipple at breast MRI who underwent surgery that included removal of the NAC. The authors evaluated NME extensions that were ipsilateral and contiguous with the biopsy-proven tumor lesions on images acquired during the early contrast phases. Pathologic nipple involvement and the distance from the nipple to the nearest cancer cell were evaluated by using serial vertical sectioning of the area extending from the entire NAC to the tumor. The primary end point was the positive predictive value (PPV) of NME, which was calculated as follows: (number with pathologic nipple invasion and NME extension to the nipple at breast MRI/number with NME extension to the nipple at breast MRI) × 100. Results Of 64 women (mean age, 52 years ± 9.8 [standard deviation]), 49 (77%) had NME extension to the nipple at breast MRI. The PPV of NME extension to the nipple was 86% (42 of 49 women; 95% CI: 73, 94). Among the 15 participants without NME extension to the nipple, only one (7%) had pathologic nipple involvement. The diagnostic accuracy of using NME extension to the nipple was 88% (56 of 64 women; 95% CI: 77, 95). The radiologic distance correlated well with the pathologic distance (Spearman correlation coefficient = 0.71, P = .003). Conclusion Nonmass enhancement extension to the nipple base at preoperative MRI has a high positive predictive value for identifying tumor involvement of the nipple, a contraindication to nipple-sparing mastectomy. © RSNA, 2021 Online supplemental material is available for this article.
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Affiliation(s)
- Soong June Bae
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Yoon Jin Cha
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Na Lae Eun
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Jung Hwan Ji
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Dooreh Kim
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Janghee Lee
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Sung Gwe Ahn
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Eon Ju Son
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
| | - Joon Jeong
- From the Departments of Surgery (S.J.B., J.H.J., D.K., J.L., S.G.A., J.J.), Pathology (Y.J.C.), and Radiology (N.L.E., E.J.S.), Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul 06273, Korea
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Coşkun Bilge A, Aydın H, Bostancı IE, Tanişman Ö, Saygılı Öz D. Comparison of the Magnetic Resonance Imaging Findings of Paget's Disease of the Breast and Malignant Tumor Invasion of the Nipple-Areola Complex. Eur J Breast Health 2021; 17:265-273. [PMID: 34263155 DOI: 10.4274/ejbh.galenos.2021.6091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/30/2021] [Indexed: 12/01/2022]
Abstract
Objective We aimed to investigate the distinction between Paget's disease of the breast (PDB) and malignant tumor invasion of nipple-areolar complex (MTION) with Magnetic resonance imaging (MRI) findings without the need for skin punch biopsy. Materials and Methods MRI findings of 16 patients with pathologically proven PDB and 11 patients with pathologically proven MTION were reviewed retrospectively. MRI images were assessed for nipple morphological changes; areolar-periareolar skin changes; thickness, classification, and kinetic characteristics of the nipple-areolar complex (NAC) enhancement; morphological pattern, size, and pathological diagnosis of concomitant malignant lesions; kinetic characteristics of the concomitant malignant lesions enhancement; continuity of enhancement between the nipple and closest concomitant malignant lesion; similarity of enhancement kinetics of the NAC and concomitant malignant lesions; and nipple-to-malignant lesion distance in both patient groups. Results Areolar-periareolar skin thickening was statistically different between the patient groups. Enhancement kinetic pattern was classified as persistent in four patients with MTION and plateau in seven patients with PDB. Moreover, NAC enhancement kinetic characteristics were statistically different between the groups. Invasive ductal carcinoma was detected in three patients with PDB and five patients with MTION. A statistically significant difference in malignant lesion pathological types was detected between the patient groups. Conclusion The significant MRI findings in patients with MTION diagnosed as invasive ductal carcinoma were areolar-periareolar skin thickening and asymmetric NAC enhancement with persistent kinetics pattern. In patients diagnosed with ductal carcinoma in situ, a plateau pattern of asymmetric NAC enhancement without any areolar-periareolar skin changes on MRI may indicate PDB.
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Affiliation(s)
- Almila Coşkun Bilge
- Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Hale Aydın
- Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Işıl Esen Bostancı
- Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Özge Tanişman
- Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
| | - Diba Saygılı Öz
- Department of Radiology, Dr Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
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Yang J, Yang Q, Mukherjee A, Lv Q. Distance Between the Tumour and Nipple as a Predictor of Axillary Lymph Node Involvement in Breast Cancer. Cancer Manag Res 2021; 13:193-199. [PMID: 33469363 PMCID: PMC7810584 DOI: 10.2147/cmar.s262413] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/14/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose The possibility of axillary node metastasis via the lymphatics might be related to a cancer’s location within the breast. Previous studies of this topic had small sample sizes, inaccuracies because of subjective differences, and the inability to depict the entire three-dimensional structure of the breast. Here, we aimed to improve upon these existing drawbacks by retrospectively analysing whether tumour location (quadrants) and tumour–nipple distance can predict axillary node positivity. Patients and Methods We identified 961 patients with invasive breast cancer between January 2000 and April 2016. The tumour–nipple distance was objectively measured intraoperatively and clinicopathological information was extracted from hospital database. The distance was measured radially from the nipple to the epicentre rather than the edge of tumour to obviate confounders resulting from tumour size variations. Results A total of 847 breast cancers (839 patients) met the eligibility criteria and were included in the statistical analysis. The tumour–nipple distance was smaller in node-positive patients (n = 307; 2.76 ± 2.07 cm) than in node-negative patients (n = 297; 3.41 ± 2.18 cm) (p < 0.001). Tumour–nipple distance was an independent predictor of axillary involvement on logistic regression analysis. However, no statistically significant relationship was detected between node positivity and breast quadrant tumour location. Conclusion Tumour–nipple distance can be used to predict axillary lymph node metastasis and assist in surgical decision-making and therapy planning. However, exploratory studies are required to increase our understanding of the mechanism.
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Affiliation(s)
- Jiqiao Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.,Clinical Research Center for Breast Disease, West China Hospital, Sichuan University and Collaborative Innovation Center, Chengdu, 610041, People's Republic of China
| | - Qianru Yang
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Arjudeb Mukherjee
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu 610041, People's Republic of China
| | - Qing Lv
- Department of Breast Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
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Atallah D, Arab W, El Kassis N, Nasser Ayoub E, Chahine G, Salem C, Moubarak M. Breast and tumor volumes on 3D-MRI and their impact on the performance of a breast conservative surgery (BCS). Breast J 2020; 27:252-255. [PMID: 33336469 DOI: 10.1111/tbj.14137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 01/11/2023]
Abstract
Breast conservation rate is being increasingly used nowadays as a marker of breast cancer care among hospitals. Searching for the ideal technique to predict the feasibility of BCS is ongoing. For this matter, the preoperative MRIs of 169 patients operated with radical or conservative surgery were reviewed. We estimated the tumor volume (TV) and breast volume (BV) on enhanced 3D-MRI and compared the tumor-to-breast volume ratio (TV/BV) in both groups. The mean ratio was 9.5% in the mastectomy group and 1.7% in the BCS group. A tumor-to-breast volume ratio less than 4% seemed to favor the adoption of a conservative option. Our data suggest that preoperative 3D-MRI can orient the surgical approach by assessing the TV/BV ratio, increasing lumpectomy rates with clear margins and good cosmetic outcome.
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Affiliation(s)
- David Atallah
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Wissam Arab
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Nadine El Kassis
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Eliane Nasser Ayoub
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Anesthesiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Georges Chahine
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Oncology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Christine Salem
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Radiology, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
| | - Malak Moubarak
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon.,Department of Gynecology and Obstetrics, Hôtel-Dieu de France University Hospital, Beirut, Lebanon
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Liu Z, Li X, Feng B, Li C, Chen Y, Yi L, Li Z, Li R, Long W. MIP image derived from abbreviated breast MRI: potential to reduce unnecessary sub-nipple biopsies during nipple-sparing mastectomy for breast cancer. Eur Radiol 2020; 31:3683-3692. [PMID: 33247343 DOI: 10.1007/s00330-020-07550-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 11/02/2020] [Accepted: 11/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the value of a maximum-intensity projection (MIP) image derived from abbreviated breast MRI for excluding occult nipple-areolar complex (NAC) involvement in patients with breast cancer. METHODS This prospective study included breast cancer patients with clinically normal NACs between April 2016 and May 2019. Abbreviated breast MRI was performed, and an MIP image was generated for each patient. MIP images were examined for the following features: asymmetric nipple enhancement, tumor-nipple distance (TND), tumor diameter, lesion type, location, and multifocality. Independent predictive MIP features for occult NAC involvement were identified by univariable and multivariable logistic regression analyses. Models based on independent predictive MIP features were developed, and their diagnostic performances were evaluated using ROC analysis. The utility of an MIP image for excluding occult NAC involvement was assessed by considering NPVs across patient subgroups. RESULTS Eight hundred forty-three patients (67 NAC-positive and 776 NAC-negative) were enrolled. On MIP images, asymmetric nipple enhancement (odds ratio, 6.098; p < 0.001) and TND (odds ratio, 0.564; p = 0.003) were independent predictors of occult NAC involvement. A parallel test model of "asymmetric nipple enhancement or TND ≤ 15 mm" yielded the highest AUC value (0.838) among prediction models. The NPV of MIP images for excluding occult NAC involvement was 99.5%, which was applicable across various patient subgroups. CONCLUSIONS A single MIP image derived from abbreviated breast MRI has utility for excluding occult NAC involvement in breast cancer patients and reducing the number of unnecessary sub-nipple biopsies in nipple-sparing mastectomy. KEY POINTS • On MIP images derived from abbreviated breast MRI, asymmetric nipple enhancement and tumor-nipple distance were independent predictors for occult nipple involvement in patients with breast cancer. • Negative findings on MIP image can help select patients at minimal risk of occult nipple involvement, for whom unnecessary intraoperative sub-nipple biopsies in nipple-sparing mastectomy can be omitted.
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Affiliation(s)
- Zhuangsheng Liu
- Department of Radiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23 Haibang Street, Jiangmen, 529000, China
| | - Xiaoping Li
- Department of Gastrointestinal Surgery, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23 Haibang Street, Jiangmen, 529000, China
| | - Bao Feng
- Department of Radiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23 Haibang Street, Jiangmen, 529000, China
- School of Electronic Information and Automation, Guilin University of Aerospace Technology, Guilin, 541004, China
| | - Changlin Li
- School of Electronic Information and Automation, Guilin University of Aerospace Technology, Guilin, 541004, China
| | - Yehang Chen
- School of Electronic Information and Automation, Guilin University of Aerospace Technology, Guilin, 541004, China
| | - Lilei Yi
- Department of Radiology, Foshan Hospital of Traditional Chinese Medicine, Foshan, 528000, China
| | - Zhiwei Li
- Department of Radiology, Sanya Central Hospital, Sanya, 572000, China
| | - Ronggang Li
- Department of Pathology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23 Haibang Street, Jiangmen, 529000, China
| | - Wansheng Long
- Department of Radiology, Jiangmen Central Hospital, Affiliated Jiangmen Hospital of Sun Yat-Sen University, No. 23 Haibang Street, Jiangmen, 529000, China.
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Lee J, Jung JH, Kim WW, Park CS, Lee RK, Kim HJ, Kim WH, Park HY. Efficacy of breast MRI for surgical decision in patients with breast cancer: ductal carcinoma in situ versus invasive ductal carcinoma. BMC Cancer 2020; 20:934. [PMID: 32993586 PMCID: PMC7526123 DOI: 10.1186/s12885-020-07443-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 09/21/2020] [Indexed: 12/26/2022] Open
Abstract
Background Preoperative breast magnetic resonance imaging (MRI) provides more information than mammography and ultrasonography for determining the surgical plan for patients with breast cancer. This study aimed to determine whether breast MRI is more useful for patients with ductal carcinoma in situ (DCIS) lesions than for those with invasive ductal carcinoma (IDC). Methods A total of 1113 patients with breast cancer underwent mammography, ultrasonography, and additional breast MRI before surgery. The patients were divided into 2 groups: DCIS (n = 199) and IDC (n = 914), and their clinicopathological characteristics and oncological outcomes were compared. Breast surgery was classified as follows: conventional breast-conserving surgery (Group 1), partial mastectomy with volume displacement (Group 2), partial mastectomy with volume replacement (Group 3), and total mastectomy with or without reconstruction (Group 4). The initial surgical plan (based on routine mammography and ultrasonography) and final surgical plan (after additional breast MRI) were compared between the 2 groups. The change in surgical plan was defined as group shifting between the initial and final surgical plans. Results Changes (both increasing and decreasing) in surgical plans were more common in the DCIS group than in the IDC group (P < 0.001). These changes may be attributed to the increased extent of suspicious lesions on breast MRI, detection of additional daughter nodules, multifocality or multicentricity, and suspicious findings on mammography or ultrasonography but benign findings on breast MRI. Furthermore, the positive margin incidence in frozen biopsy was not different (P = 0.138). Conclusions Preoperative breast MRI may provide more information for determining the surgical plan for patients with DCIS than for those with IDC.
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Affiliation(s)
- Jeeyeon Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jin Hyang Jung
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Wan Wook Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Chan Sub Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ryu Kyung Lee
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hye Jung Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Won Hwa Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ho Yong Park
- Department of Surgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea. .,Department of Surgery, Joint Institute for Regenerative Medicine, School of Medicine, Kyungpook National University, Hoguk-ro 807, Buk-gu, Daegu, 41404, Republic of Korea.
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A novel MRI-based predictive index can identify patients suitable for preservation of the nipple-areola complex in breast reconstructive surgery. Eur J Surg Oncol 2020; 47:225-231. [PMID: 32950315 DOI: 10.1016/j.ejso.2020.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/01/2020] [Accepted: 08/10/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Accurately predicting nipple-areola complex (NAC) involvement in breast cancer is necessary for identifying patients who may be candidates for a nipple-sparing mastectomy. Although multiple risk factors are indicated in the guidelines, it is difficult to predict NAC involvement (NAC-i) preoperatively even if these factors are evaluated individually. This study aimed to develop a more accurate and practical preoperative NAC-i prediction model using magnetic resonance imaging (MRI). MATERIALS AND METHODS All tumors in 252 patients were evaluated using postcontrast T1-weighted subtraction on MRI. RESULTS The receiver operating characteristic curves identified cut-off values for tumor size and tumor-to-nipple distance (TND) as 4 cm and 1.2 cm, respectively. Multivariate analysis demonstrated that TND (p < 0.001), ductal enhancement extending to the nipple (DEEN) (p < 0.001), and nipple enhancement (NE) (p = 0.005) were independent clinical risk factors for pathological NAC-i. A formula was constructed using odds ratios for these three independent preoperative risk factors in multivariate analysis: the MRI-based NAC-i predictive index (mNACPI) = TND × 4 + DEEN × 3 + NE × 1. A total score of ≤4 points was defined as low risk and ≥5 points as high risk. NAC-i rates were 2.4% in the low-risk group and 89.4% in the high-risk group; a significant correlation was observed between the risk group and permanent pathological NAC-i (p < 0.001). Assuming that the NAC was preserved in low-risk patients and resected in high-risk patients, NAC-i was verified using the mNACPI. CONCLUSION mNACPI may contribute greatly to the improvement of selecting suitable patients for NAC preservation in breast reconstructive surgery while maintaining oncological safety.
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Heinzen RN, de Barros ACSD, Carvalho FM, Aguiar FN, Nimir CDCBA, Jacomo AL. Nipple-sparing mastectomy for early breast cancer: the importance of intraoperative evaluation of retroareolar margins and intra-nipple duct removal. Gland Surg 2020; 9:637-646. [PMID: 32775253 DOI: 10.21037/gs-20-405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Nipple-sparing mastectomy (NSM) is increasingly performed for breast cancer (BC) treatment. To ensure local control with this procedure, it is important to obtain clear surgical margins. Here, we aimed to estimate the confidence in intraoperative evaluation of the retroareolar margin (IERM) and the necessity of removing the intra-nipple ducts. Methods In this retrospective cohort study, we evaluated 224 BC (infiltrating carcinoma 178, ductal carcinoma in situ 46) patients, who underwent NSM. IERM was determined via cytology and frozen sections. Following gland removal, the intra-nipple ducts were excised and embedded in paraffin for analysis. The retroareolar tissue was also paraffin-embedded and reanalyzed for definitive evaluation of retroareolar margins (DERM). The IERM predictive capacity in relation to DERM and the frequency of intra-nipple duct involvement were estimated. Results IERM classified the sub-nipple areolar complex area as cancer-free in 219 cases (97.8%). The condition of clear retroareolar margin was confirmed by DERM in 216 cases (98.6%). The IERM accuracy was estimated as 98.6%. Ductal carcinoma in situ was detected in intra-nipple ducts using paraffin sections in 1.8% of the cases, despite clear IERM (4/219). Conclusions In conclusion, IERM affords high accuracy and its results are suitable to manage the nipple-areolar complex. Nevertheless, some patients may retain residual disease in the intra-nipple ducts; thus, these ducts should ideally be removed during NSM.
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Affiliation(s)
- Rebeca Neves Heinzen
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | - Fernando Nalesso Aguiar
- Discipline of Pathologic Anatomy, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Alfredo Luiz Jacomo
- Discipline of Human Structural Topography, University of São Paulo School of Medicine, São Paulo, Brazil
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Razek AAKA, El-Adalany MA, El-Metwally D. Role of diffusion-weighted imaging in prediction of nipple-areolar complex invasion by breast cancer. Clin Imaging 2020; 69:45-49. [PMID: 32652457 DOI: 10.1016/j.clinimag.2020.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/12/2020] [Accepted: 06/26/2020] [Indexed: 11/29/2022]
Abstract
THE AIM OF THIS WORK The aim of this work was to estimate the role of diffusion-weighted imaging (DWI) in predicting malignant invasion of the nipple-areolar complex (NAC) by underlying breast cancer. MATERIAL AND METHODS This prospective study included 70 female patients with breast cancer with a mean age of 45.8 years (range: 28-68). DWI of the breast was done for all patients. Apparent diffusion coefficient (ADC) maps were automatically constructed. The mean ADC values of NAC were independently measured by two observers who are experts in breast imaging and correlated with the results of histopathological examinations. RESULTS Both observers found a significantly lower ADC value of malignant NAC invasion (n = 18) when compared with free NAC (n = 52), with mean ADC value for malignant NAC invasion was 0.86 ± 0.35 × 10-3 mm2/s and 0.84 ± 0.08 × 10-3 mm2/s for observer one and two respectively versus mean ADC value of 1.34 ± 0.25 × 10-3 mm2/s and 1.4 ± 0.26 × 10-3 mm2/s for free NAC by observer one and two respectively (P-value =0.001). Observer one found that a cutoff ADC value of 1.05 × 0-3 mm2/s can predict malignant NAC invasion with 0.975 AUC, 92.8% accuracy, 94.4% sensitivity, and 92.3% specificity. Observer two found that a cutoff ADC value of 0.95 × 10-3 mm2/s can predict malignant NAC invasion with 0.992 AUC, 95.7% accuracy, 88.9% sensitivity, and 98.1% specificity. CONCLUSION DWI can predict malignant NAC invasion in patients with breast cancer.
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Affiliation(s)
| | | | - Dina El-Metwally
- Department of Diagnostic Radiology, Mansoura Faculty of Medicine, Mansoura, Egypt
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MRI diagnostic features for predicting nipple-areolar-complex involvement in breast cancer. Eur J Radiol 2020; 122:108754. [DOI: 10.1016/j.ejrad.2019.108754] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 09/19/2019] [Accepted: 11/18/2019] [Indexed: 11/21/2022]
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Lim S, Park G, Choi HJ, Kwon WJ, Kang BS, Bang M. Use of preoperative mammography, ultrasonography, and MRI to predict nipple areolar complex involvement in breast cancer. Br J Radiol 2019; 92:20190074. [PMID: 31317763 DOI: 10.1259/bjr.20190074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To identify the predictive factors of cancer invading into the nipple. METHODS Patients with breast cancer undergoing mastectomy between May 2009 and March 2019 were reviewed retrospectively. Of these, those with breast cancer within 2 cm of the nipple areolar complex on ultrasonography were included in this study. Clinicopathological data of the primary tumor and imaging findings from mammography, ultrasonography, and MRI were compared between cases with and without nipple involvement by cancer. RESULTS In total, 156 of the 821 patients identified were included in the analysis. Of them, 29 had nipple involvement by cancer. Univariate analysis revealed that the following imaging results were significantly associated with nipple involvement: perineural invasion, lymphovascular invasion, lymph node metastasis; relation type between the tumor and the nipple on ultrasonography; periareolar skin thickening on mammography; and short tumor-nipple distance, continuous enhancement between the nipple and tumor, skin enhancement, and nipple enhancement on MRI. However, on multivariate logistic regression analysis, only invasion type of tumor on ultrasonography and nipple enhancement and short tumor-nipple distance on MRI were significantly correlated with nipple involvement by cancer. CONCLUSION Imaging findings on preoperative mammography, ultrasonography and MRI are effective predictors for nipple involvement by cancer. ADVANCES IN KNOWLEDGE Preoperative mammography, ultrasonography, and MRI help predict nipple involvement by breast cancer.
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Affiliation(s)
- Soyeoun Lim
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Gyeongmin Park
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Hye-Jeong Choi
- Department of Pathology, Ulsan University Hosptial, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Woon Jung Kwon
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Byeong Seong Kang
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Minseo Bang
- Department of Radiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
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