Identifying patients at risk of compromised margins following breast conservation for lobular carcinoma

The role of contrast-enhanced mammography in the preoperative evaluation of invasive lobular carcinoma of the breast

AIM

To assess the performance of contrast-enhanced mammography (CEM) in the preoperative staging of invasive lobular carcinoma (ILC) of the breast.

MATERIALS AND METHODS

The present study was a multicentre, multivendor, multinational retrospective study of women with a histological diagnosis of ILC who had undergone CEM from December 2013 to December 2021. Index lesion size and multifocality were recorded for two-dimensional (2D) mammography, CEM, and when available magnetic resonance imaging (MRI). Comparison with histological data was undertaken for women treated by primary surgical excision. Pearson correlation coefficients and Bland-Altman's analysis of agreement were used to assess differences with a significance level of 0.05.

RESULTS

One hundred and fifteen ILC lesions were included, 46 (40%) presented symptomatically and 69 were screening detected. CEM demonstrated superior sensitivity when compared to standard mammography. The correlation between the histological size measured on the surgical excision specimen size was greater than with standard mammography (r=0.626 and 0.295 respectively, p=0.001), with 19% of lobular carcinomas not visible without a contrast agent. The sensitivity of CEM for multifocal disease was greater than standard mammography (70% and 20% respectively, p<0.0001). CEM overestimated tumour size by an average of 1.5 times, with the size difference increasing for larger tumour. When MRI was performed (n=22), tumour size was also overestimated by an average of 1.3 times. The degree of size overestimation was similar for both techniques, with the tumour size on CEM being on average 0.5 cm larger than MRI.

CONCLUSION

CEM is a useful tool for the local staging of lobular carcinomas and could be an alternative to breast MRI.

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Breast surgery after neoadjuvant chemotherapy in patients with lobular carcinoma: surgical and oncologic outcome

INTRODUCTION

Breast cancer patients with invasive lobular carcinoma (ILC) have an increased risk of positive margins after surgery and often show little response to neoadjuvant chemotherapy (NAC). We aimed to investigate surgical outcomes in patients with ILC treated with NAC.

METHODS

In this retrospective cohort study, all breast cancer patients with ILC treated with NAC who underwent surgery at the Netherlands Cancer Institute from 2010 to 2019 were selected. Patients with mixed type ILC in pre-NAC biopsies were excluded if the lobular component was not confirmed in the surgical specimen. Main outcomes were tumor-positive margins and re-excision rate. Associations between baseline characteristics and tumor-positive margins were assessed, as were complications, locoregional recurrence rate (LRR), recurrence-free survival (RFS), and overall survival (OS).

RESULTS

We included 191 patients. After NAC, 107 (56%) patients had breast conserving surgery (BCS) and 84 (44%) patients underwent mastectomy. Tumor-positive margins were observed in 67 (35%) patients. Fifty five (51%) had BCS and 12 (14%) underwent mastectomy (p value < 0.001). Re-excision was performed in 35 (33%) patients with BCS and in 4 (5%) patients with mastectomy. Definitive surgery was mastectomy in 107 (56%) patients and BCS in 84 (44%) patients. Tumor-positive margins were associated with cT ≥ 3 status (OR 4.62, 95% CI 1.26-16.98, p value 0.021) in the BCS group. Five-year LRR (4.7%), RFS (81%), and OS (93%) were not affected by type of surgery after NAC.

CONCLUSION

Although 33% of ILC breast cancer patients undergoing BCS after NAC required re-excision for positive resection margins, it is considered safe given that five-year RFS remained excellent and LRR and OS did not differ by extent of surgery.

Breast Magnetic Resonance Imaging for Preoperative Evaluation of Breast Cancer: A Systematic Review and Meta-Analysis

Purpose: Preoperative breast magnetic resonance imaging (MRI) is known to detect additional cancers that are occult on mammography and ultrasound. There is debate as to whether these additional lesions affect clinical outcomes. The objective of this systematic review was to summarize the evidence on whether additional information on disease extent obtained with preoperative breast MRI in patients with newly diagnosed breast cancer affects surgical management, rates of recurrence, survival, re-excision, and early detection of bilateral cancer. Methods: Embase, MEDLINE, and Cochrane Central Register of Controlled Trials were searched until January 2021 (partial update July 2022) for studies comparing outcomes with versus without pre-operative MRI. Included were both randomized controlled trials and other comparative studies provided MRI and control groups had equivalent disease and patient characteristics or methods such as multivariable analysis or propensity score matching were used to control potential confounders. Results: The search resulted in 26,399 citations, of which 8 randomized control trials, 1 prospective cohort study, and 42 retrospective studies met the inclusion criteria. Use of MRI resulted in decreased rates of reoperations (OR = 0.73, 95% CI = 0.63 to 0.85), re-excisions (OR = 0.63, 95% CI = 0.45 to 0.89), and recurrence (HR = 0.77, 95% CI = 0.65 to 0.90). Increased detection of synchronous contralateral breast cancers led to a reduction in metachronous contralateral breast cancer (HR = 0.71, 95% CI = 0.59 to 0.85). Hazard ratios for recurrence-free and overall survival were 0.77 (95% CI = 0.53 to 1.12) and 0.89 (95% CI = 0.74 to 1.07). Conclusion: This systematic review indicates substantial benefits of pre-operative breast MRI in decreasing reoperations and recurrence.

Preoperative Breast Magnetic Resonance Imaging: An Ontario Health (Cancer Care Ontario) Clinical Practice Guideline

BACKGROUND

The use of preoperative breast magnetic resonance imaging (MRI) after the diagnosis of breast cancer by mammography and/or ultrasound is inconsistent.

METHODS

After conducting a systematic review and meta-analysis comparing preoperative breast MRI versus no MRI, we reconvened to prepare a clinical practice guideline on this topic.

RESULTS

Based on the evidence that MRI improved recurrence, decreased the rates of reoperations (re-excisions or conversion mastectomy), and increased detection of synchronous contralateral breast cancer, we recommend that preoperative breast MRI should be considered on a case-by-case basis in patients diagnosed with breast cancer for whom additional information about disease extent could influence treatment. Based on stronger evidence, preoperative breast MRI is recommended in patients diagnosed with invasive lobular carcinoma for whom additional information about disease extent could influence treatment. For both recommendations, the decision to proceed with MRI would be conditional on shared decision-making between care providers and the patient, taking into account the benefits and risks of MRI as well as patient preferences. Based on the opinion of the Working Group, preoperative breast MRI is also recommended in the following more specific situations: (a) to aid in surgical planning of breast conserving surgery in patients with suspected or known multicentric or multifocal disease; (b) to identify additional lesions in patients with dense breasts; (c) to determine the presence of pectoralis major muscle/chest wall invasion in patients with posteriorly located tumours or when invasion of the pectoralis major muscle or chest wall is suspected; (d) to aid in surgical planning for skin/nipple-sparing mastectomies, autologous reconstruction, oncoplastic surgery, and breast conserving surgery with suspected nipple/areolar involvement; and (e) in patients with familial/hereditary breast cancer but who have not had recent breast MRI as part of screening or diagnosis.

Special Histologic Type and Rare Breast Tumors - Diagnostic Review and Clinico-Pathological Implications

Breast cancer is the most common malignant tumor in females. While most carcinomas are categorized as invasive carcinoma, no special type (NST), a diverse group of tumors with distinct pathologic and clinical features is also recognized, ranging in incidence from relatively more common to rare. So-called "special histologic type" tumors display more than 90% of a specific, distinctive histologic pattern, while a spectrum of tumors more often encountered in the salivary gland may also arise in the breast. Metaplastic carcinomas can present diagnostic challenges. Some uncommon tumors harbor pathognomonic genetic alterations. This article provides an overview of the key diagnostic points and differential diagnoses for this group of disparate lesions, as well as the salient clinical characteristics of each entity.

Accuracy of Preoperative Breast MRI Versus Conventional Imaging in Measuring Pathologic Extent of Invasive Lobular Carcinoma

OBJECTIVE

To determine whether invasive lobular carcinoma (ILC) extent is more accurately depicted with preoperative MRI (pMRI) than conventional imaging (mammography and/or ultrasound).

METHODS

After IRB approval, we retrospectively identified women with pMRIs (February 2005 to January 2014) to evaluate pure ILC excluding those with ipsilateral pMRI BI-RADS 4 or 5 findings or who had neoadjuvant chemotherapy. Agreement between imaging and pathology sizes was summarized using Bland-Altman plots, absolute and percent differences, and the intraclass correlation coefficient (ICC). Rates of underestimation and overestimation were evaluated and their associations with clinical features were explored.

RESULTS

Among the 56 women included, pMRI demonstrated better agreement with pathology than conventional imaging by mean absolute difference (1.6 mm versus -7.8 mm, P < 0.001), percent difference (10.3% versus -16.4%, P < 0.001), and ICC (0.88 versus 0.61, P = 0.019). Conventional imaging more frequently underestimated ILC span than pMRI using a 5 mm difference threshold (24/56 (43%) versus 10/56 (18%), P < 0.001), a 25% threshold (19/53 (36%) versus 10/53 (19%), P = 0.035), and T category change (17/56 (30%) versus 7/56 (13%), P = 0.006). Imaging-pathology size concordance was greater for MRI-described solitary masses than other lesions for both MRI and conventional imaging (P < 0.05). Variability of conventional imaging was lower for patients ≥ the median age of 62 years than for younger patients (SD: 12 mm versus 22 mm, P = 0.012).

CONCLUSION

MRI depicts pure ILC more accurately than conventional imaging and may have particular value for younger women.

Imaging of Breast Cancers With Predilection for Nonmass Pattern of Growth: Invasive Lobular Carcinoma and DCIS-Does Imaging Capture It All?

OBJECTIVE. Invasive lobular carcinoma (ILC) and ductal carcinoma in situ (DCIS) are distinct histopathologic entities with several commonalities: both have subtle clinical and imaging presentation, have been linked with controversy regarding optimal imaging techniques and management, and exemplify the codependence of adequate imaging evaluation and optimal treatment strategies in breast care. CONCLUSION. We review molecular mechanisms and histopathologic patterns that define the biologic behavior of both ILC and DCIS and discuss how these mechanisms translate into distinct clinical and imaging presentations that affect the staging workup and patient management algorithm.

The Impact of Preoperative Breast Magnetic Resonance Imaging on Surgical Management in Symptomatic Patients With Invasive Lobular Carcinoma

Objective

Due to an insidious proliferative pattern, invasive lobular breast cancer (ILC) often fails to form a defined radiological or palpable lesion and accurate diagnosis remains challenging. This study aimed to determine the value of preoperative magnetic resonance imaging (MRI) for ILC and its impact on surgical outcomes.

Methods

Consecutive symptomatic patients diagnosed with ILC in a tertiary centre over a 9-year period were reviewed. The time from diagnosis until surgery, initial type of surgery/index operation (breast-conserving surgery [BCS]/mastectomy) and the rates of reoperation (re-excision/completion mastectomy) were recorded. Patients were grouped into those who received conventional imaging and preoperative MRI (MR+) and those who received conventional imaging alone (MR-).

Results

There were 218 cases of ILC, and 32.1% (n = 70) had preoperative MRI. Time from diagnosis to surgery was longer in the MR+ than the MR- group (32.5 vs 21.1 days, P < .001) even when adjusting for age and breast density. Initial BCS was performed on 71.4% (n = 50) of MR+ patients and 72.3% (n = 107) of the MR- group. While the rate of completion mastectomy following initial BCS was higher in the MR+ group (30.0%, n = 15 vs 14.0%, n = 15; χ² = 5.63; P = .018), this association was not maintained in multivariable analysis. No difference was recorded in overall (initial and completion) mastectomy rate between the MR+ and MR- group (50.0%, n = 35 vs 37.8%, n = 56; χ² = 2.89; P = .089). Margin re-excision following BCS was comparable between groups (8.0%, n =4, vs 9.3%, n = 10; χ² = 0.076, P = .783) despite the selection bias for borderline conservable cases in the MR+ group. The rate of usage of MRI for ILC cases declined over the study period.

Conclusion

While MRI was associated with minor delays in treatment and did not reduce overall rates of margin re-excision or completion mastectomy, it altered the choice of surgical procedure in almost a quarter of MR+ cases. The benefit of preoperative breast MRI appears to be confined to select (younger, dense breast, borderline conservable) cases in symptomatic ILC.

Adequacy of diagnostic tests and surgical management of symptomatic invasive lobular carcinoma of the breast

INTRODUCTION

Invasive lobular carcinoma (ILC) presents diagnostic and therapeutic challenges as it produces subtle radiological changes. It has been suggested that it is not suitable for breast conserving surgery (BCS). The aim of this study was to ascertain the diagnostic adequacy of modern mammography and ultrasonography in the context of a fast track symptomatic diagnostic clinic in the UK. It also sought to compare the mastectomy, re-excision and BCS rates for ILC with those for invasive ductal carcinoma (IDC).

METHODS

A retrospective analysis of prospectively collected data was carried out on all new symptomatic cancers presenting to the one-stop diagnostic clinic of a single breast unit between 1998 and 2007.

RESULTS

Compared with IDC, ILC was significantly larger at presentation (46mm vs 25mm), needed re-excision after BCS more often (38.8% vs 22.3%) and required mastectomy more frequently (58.8% vs 40.8%). Although mammography performs poorly in diagnosing ILC compared with IDC, when combined with ultrasonography, sensitivity of the combined imaging was not significantly different between these two histological types.

CONCLUSIONS

Provided ultrasonography is performed, standard radiological imaging is adequate for initial diagnosis of symptomatically presenting ILC but some additional preoperative workup should clearly be employed to reduce the higher number of reoperations for this histological type.

Breast magnetic resonance imaging indications in current practice

Although mammography is the primary imaging modality for the breast, it has its limitations especially with dense breast parenchyma. Breast magnetic resonance imaging (MRI) has evolved into an important adjunctive tool as it is currently the most sensitive technique for breast cancer detection. Despite this high sensitivity, overlap in the appearances of some benign and malignant breast lesions results in additional unnecessary intervention with negative results. These false positives, in addition to high cost and limited availability, necessitate establishing proper indications for breast MRI. The literature was here reviewed for recent clinical trials, meta-analyses and review papers which have studied this important subject. PubMed; the US national library of medicine, was utilized to review the literature in the last twenty years. Using the obtained information, current uses of breast MRI are discussed in this paper to determine the indications which are relevant to clinical practice.

Current clinical indications for magnetic resonance imaging of the breast

MRI is increasingly used in breast cancer patients. MRI has a high sensitivity compared to mammography and ultrasound. The specificity is moderate leading to an increased risk of false positive findings. Currently, a beneficial effect of breast MRI has been established in some patient groups and is debated in the general breast cancer population. The diagnostic ability of MRI and its role in various groups of breast cancer patients are discussed in this review.

The potential of hypoxia markers as target for breast molecular imaging--a systematic review and meta-analysis of human marker expression

Background

Molecular imaging of breast cancer is a promising emerging technology, potentially able to improve clinical care. Valid imaging targets for molecular imaging tracer development are membrane-bound hypoxia-related proteins, expressed when tumor growth outpaces neo-angiogenesis. We performed a systematic literature review and meta-analysis of such hypoxia marker expression rates in human breast cancer to evaluate their potential as clinically relevant molecular imaging targets.

Methods

We searched MEDLINE and EMBASE for articles describing membrane-bound proteins that are related to hypoxia inducible factor 1α (HIF-1α), the key regulator of the hypoxia response. We extracted expression rates of carbonic anhydrase-IX (CAIX), glucose transporter-1 (GLUT1), C-X-C chemokine receptor type-4 (CXCR4), or insulin-like growth factor-1 receptor (IGF1R) in human breast disease, evaluated by immunohistochemistry. We pooled study results using random-effects models and applied meta-regression to identify associations with clinicopathological variables.

Results

Of 1,705 identified articles, 117 matched our selection criteria, totaling 30,216 immunohistochemistry results. We found substantial between-study variability in expression rates. Invasive cancer showed pooled expression rates of 35% for CAIX (95% confidence interval (CI): 26-46%), 51% for GLUT1 (CI: 40-61%), 46% for CXCR4 (CI: 33-59%), and 46% for IGF1R (CI: 35-70%). Expression rates increased with tumor grade for GLUT1, CAIX, and CXCR4 (all p < 0.001), but decreased for IGF1R (p < 0.001). GLUT1 showed the highest expression rate in grade III cancers with 58% (45-69%). CXCR4 showed the highest expression rate in small T1 tumors with 48% (CI: 28-69%), but associations with size were only significant for CAIX (p < 0.001; positive association) and IGF1R (p = 0.047; negative association). Although based on few studies, CAIX, GLUT1, and CXCR4 showed profound lower expression rates in normal breast tissue and benign breast disease (p < 0.001), and high rates in carcinoma in situ. Invasive lobular carcinoma consistently showed lower expression rates (p < 0.001).

Conclusions

Our results support the potential of hypoxia-related markers as breast cancer molecular imaging targets. Although specificity is promising, combining targets would be necessary for optimal sensitivity. These data could help guide the choice of imaging targets for tracer development depending on the envisioned clinical application.

Factors affecting surgical margin positivity in invasive ductal breast cancer patients who underwent breast-conserving surgery after preoperative core biopsy diagnosis

Purpose

The aim of our study is to evaluate the factors affecting surgical margin positivity among patients with invasive ductal breast cancer who underwent breast-conserving surgery (BCS) after preoperative diagnostic core biopsy.

Methods

Two hundred sixteen patients with stage I, II invasive ductal breast carcinoma who had histological diagnosis with preoperative tru-cut biopsy and underwent BCS were included in the present study. Potential factors that affect the positive surgical margin were analyzed. In univariate analysis, the comparisons of the factors affecting the surgical margin positivity were made by chi-square test. Logistic regression test was used to detect the independent factors affecting the surgical margin positivity.

Results

Positive axillary lymph node (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.01 to 22.12), lymphovascular invasion (LVI; OR, 3.9; 95% CI, 1.62 to 9.24), extensive intraductal component (EIC; OR, 6.1; 95% CI, 2.30 to 16.00), presence of spiculation (OR, 5.1; 95% CI, 2.00 to 13.10) or presence of microcalcification in the mammography (OR, 13.7; 95% CI, 4.04 to 46.71) have been found to be the independent and adverse factors affecting surgical margin positivity.

Conclusion

Considering decision making for the extent of the excision and for achieving negative surgical margin before BCS, positive axillary lymph node, LVI, EIC, spiculation or microcalcification in mammography are related as predictor factors for positive surgical margin.

Indications for breast MRI: self-assessment module

The educational objectives for this self-assessment module are for the participant to exercise, self-assess, and improve his or her understanding of breast MRI.

A two-millimetre free margin from invasive tumour minimises residual disease in breast-conserving surgery

AIMS

In breast-conserving surgery, the width of free margin around a tumour to ensure adequate excision is controversial. The aim of this study was first to evaluate the frequency of residual disease in wider excision specimens in patients who undergo further surgery because of close margins of < 5 mm. Secondly, the ability of demographic and tumour-related factors to predict the close margins was appraised.

PATIENTS AND METHODS

Three-hundred-and-three patients were included in the study. Patients undergoing wider excision were assessed for the presence of residual disease, and this was tested for association with the width of the initial free margin. Various factors were studied for association with close or involved margins by univariate analysis.

RESULTS

Fifty-three per cent of patients were eligible for re-excision based on the need for a 5-mm clearance. With a free margin of 2 mm or more from invasive tumour, the probability of finding residual disease was 2.4%. The probability of residual disease was higher for ductal carcinoma in situ (DCIS) and did not decline with increasing the free margin width. Tumour size, lobular cancer type, vascular invasion and nodal involvement were associated with close margins.

CONCLUSIONS

We suggest that a free margin of 2 mm from invasive tumour is adequate to minimise residual disease, whereas the equivalent free margin for DCIS remains unclear. Patients with large tumours and lobular cancer type should be counselled at the time of first surgery concerning the higher risk of further excision and mastectomy.

Magnetic resonance mammography of invasive lobular versus ductal carcinoma: systematic comparison of 811 patients reveals high diagnostic accuracy irrespective of typing

OBJECTIVE

Invasive lobular (ILC) and ductal carcinomas (IDC) are the most frequent subtypes of breast cancer. Diagnosis of ILC is often challenging. This study was conducted to (1) evaluate dynamic and morphologic profiles and to (2) compare the diagnostic accuracy of IDC and ILC in magnetic resonance mammography (MRM).

METHODS

Our database consisted of all consecutive MRMs over a 12-year period (standardized protocol: T1-weighted fast low-angle shot; 0.1-mmol gadolinium-diethylenetriaminepentaacetate per kilogram of body weight; T2-weighted turbo spin-echo, 1.5 T; histological verification after MRM), which were evaluated by experienced (>500 MRMs) radiologists in consensus, applying 17 predefined descriptors. All the patients gave written consent; this study was approved by the local institutional review board. Extracting all the ILCs (n = 108), IDCs (n = 347), and benign lesions (n = 436) from the database, the data set of the study was created.In ILC and IDC diagnostic accuracy of single descriptors was calculated and compared separately (chi test). Using all the descriptors, a combined binary logistic regression analysis was applied to calculate the overall diagnostic accuracy for ILC and IDC. The corresponding areas under the curve were compared.

RESULTS

ILC and IDC, showed wash-in and an irregular shape without difference (P = 1.0 and P = 0.4). Wash-out was more typical of IDC (72.6%; ILC, 57.4%; P = 0.007). Perifocal edema was diagnosed more frequently in IDC (45.5%; P = 0.05). For overall accuracy, the areas under the curve were 0.929 for ILC and 0.939 for IDC (P = 0.5).

CONCLUSIONS

The dynamic and morphologic profiles of ILC and IDC were overlapping, and minor differences between both subgroups could be identified. Accordingly, the overall diagnostic accuracy of MRM was high and without difference between both subtypes of breast cancer.

The impact of preoperative breast MRI on the re-excision rate in invasive lobular carcinoma of the breast

Re-excision rates after breast conserving surgery(BCS) of invasive lobular carcinoma (ILC) are high.Preoperative breast MRI has the potential to reduce re-excision rates, but may lead to an increased rate of mastectomies. Hence, we assessed the influence of preoperative breast MRI on the re-excision rate and the rate of mastectomies. We performed a retrospective cohort study of a consecutive series of patients with ILC who presented in one of two dedicated tertiary cancer centers between 1993 and 2005. We assessed the initial type of surgery(BCS or mastectomy), the re-excision rate and the final type of surgery. Patients were stratified into two groups:those who received preoperative MRI (MR? group) and those who did not (MR- group). In the MR- group, 27%of the patients underwent a re-excision after initial BCS. In the MR? group, this rate was significantly lower at 9%.The odds ratio was 3.64 (95% CI: 1.30-10.20, P = 0.010).There was a trend towards a lower final mastectomy rate in the MR? group compared to the MR- group (48 vs. 59%,P = 0.098). In conclusion, preoperative MRI in patients with ILC can reduce re-excision rates without increasing the rate of mastectomies.

Clinicopathologic factors associated with involved margins after breast-conserving surgery for invasive lobular carcinoma

INTRODUCTION

Obtaining negative margins for patients undergoing breast-conserving surgery (BCS) for invasive lobular carcinoma (ILC) can be difficult because of the unique histologic pattern of ILC. Our goal was to determine whether any specific patient- or disease-related factors influenced margin status.

PATIENTS AND METHODS

We retrospectively reviewed 211 patients with ILC treated from 1994 through 2004 to determine if specific clinical and pathologic factors influenced the ability to obtain negative margins.

RESULTS

We identified 110 patients (52%) who underwent total mastectomy and 101 (48%) who underwent BCS. Among patients who underwent BCS, 50 (50%) had close or positive margins. Patients with close or positive margins were more likely to have architectural distortion on ultrasonography (vs. mass or calcifications; P = .049), to have undergone excisional biopsy (vs. core or fine-needle aspiration; P = .008), and to have associated ductal carcinoma in situ (P = .021). On multivariate analysis, only biopsy method retained significance (P = .006).

CONCLUSION

Core needle biopsy is the preferred method of diagnostic biopsy before surgical intervention. With appropriate patient selection, most patients with early-stage ILC can undergo successful BCS.

Margin assessment after neoadjuvant chemotherapy in invasive lobular cancer

BACKGROUND

Optimal surgical management of patients with invasive lobular carcinoma (ILC) who undergo neoadjuvant chemotherapy (NAC) is unknown. We evaluated optimal margin distance and local recurrence (LR) rates for these patients.

METHODS

Ninety-three (30%) of 311 patients with ILC received NAC. We examined margin status, residual disease after re-excision, and clinical outcomes.

RESULTS

Margin positivity rates after the final operative procedure were similar between the NAC and surgery-first group (P > .05). The proportion of patients, stratified by margin status, who were taken back for re-excision was not different between the 2 groups, and, similarly, there were no differences in frequency of residual disease (all P > .05). At a median follow-up of 3.1 years, 1 patient in the NAC group and 2 in the surgery-first group developed LR (P = 1.0).

CONCLUSIONS

Patients with ILC who have undergone NAC and have margins >1 mm have a low probability of residual disease and LR.

Automated microscopy to evaluate surgical specimens via touch prep in breast cancer

BACKGROUND

Breast conservation therapy is the standard treatment for breast cancer; however, 20-50% of operations have a positive margin leading to secondary procedures. The standard of care to evaluate surgical margins is based on permanent section. Imprint cytology (touch prep) has been used to evaluate surgical samples, but conventional techniques require an experienced cytopathologist for correct interpretation. An automated image screening process has been developed to discern cancer cells from normal epithelial cells. This technique is based on cellularity of the imprint specimen and does not require expertise in cytopathology.

METHODS

A rapid immunofluorescent staining technique coupled with automated microscopy was used to classify specimens as cancer vs. noncancer based on the density of epithelial cells captured on touch prep of tumor cross-sections. The results of the automated analysis vs. a manual screen of ten 20x fields were compared to the pathology interpretation on permanent section.

RESULTS

A total of 34 consecutive cases were analyzed: 10 normal cases, and 24 cancer cases. The cross-section specimens for invasive cancer were correctly classified in at least 65% of the cases by using manual microscopy and at least 83% by using automated microscopy. The manual and automated microscopy correlated well for measurements of epithelial cell density (R(2)=0.64); however, the automated microscopy was more accurate.

CONCLUSIONS

This preliminary study using an automated system for intraoperative interpretation does not require a cytopathologist and shows that rapid, low-resolution imaging can correctly identify cancer cells for invasive carcinoma in surgical specimens. Therefore, automated determination of cellularity in touch prep is a promising technique for future margin interpretation of breast conservation therapy.

The value of MRI compared to mammography in the assessment of tumour extent in invasive lobular carcinoma of the breast

AIMS

Invasive lobular carcinoma of the breast (ILC) is known to be substantially underestimated by mammography, which makes correct planning of treatment difficult. MRI has been proposed as a valuable adjunct to mammography. The purpose of the current study is to evaluate its value, compare it to mammography and assess the possible causes of over- and underestimation of lesion size on MRI.

METHOD

The mammograms and MRI scans of 67 consecutive patients with ILC were retrieved and re-evaluated. Size measurements were correlated to the sizes extracted from the pathology report.

RESULTS

MRI measurements correlated better to pathologic size (r=0.85) than mammographic measurements (r=0.27). Underestimation of tumour size was more common on mammography (p<0.001); overestimation occurred with equal frequency (p=0.69). Overestimation on MRI, caused by non-malignant findings, was attributed to enhancing lobular carcinoma in situ.

CONCLUSION

MRI is a more accurate modality for determining tumour size in patients with ILC than mammography. The typical underestimation of lesion size by mammography can be prevented with the aid of MRI, without increasing the risk of lesion overestimation.

Relationship between Initial Margin Status for Invasive Breast Cancer and Residual Carcinoma after Re-Excision

Little data exists addressing the relationship between initial margin status in a specimen from an excisional biopsy and the presence of residual carcinoma in a subsequent specimen from lumpectomy or mastectomy. We sought to determine the relationship between initial margin status and the presence of residual invasive cancer, and to identify any relationship to other variables. This study was a retrospective review of pathology reports of 582 early-stage invasive duct carcinomas with open excisional biopsies. The initial specimen was classified into one of six margin categories: multiply focally positive (n = 174), focally positive (n = 132), margins <1 mm (n = 98), margins 1 to 2 mm (n = 20), margins >2 mm (n = 46), and margins undetermined (n = 90). All patients had a subsequent definitive second procedure. Pathology reports from the second procedure revealed the presence of residual invasive cancer by initial margin status as follows: in 30 per cent of the initial procedures with multiply focally positive margins, in 22 per cent with focally positive margins, in 8 per cent, 15 per cent, and 4 per cent with margins of <1 mm, 1 to 2 mm, and >2 mm, respectively, and in 28 per cent with undetermined margins. Women with palpable tumors, larger tumor size, and positive axillary nodes were more likely to have multiply focal and focally positive margins. Multiply focally positive and focally positive margins had similar residual invasive carcinoma rates and should be re-excised. All clear margins were equivalent; thus, re-excision was not necessary.

MRI compared to conventional diagnostic work-up in the detection and evaluation of invasive lobular carcinoma of the breast: a review of existing literature

Purpose

The clinical diagnosis and management of invasive lobular carcinoma (ILC) of the breast presents difficulties. Magnetic resonance imaging (MRI) has been proposed as the imaging modality of choice for the evaluation of ILC. Small studies addressing different aspects of MRI in ILC have been presented but no large series to date. To address the usefulness of MRI in the work-up of ILC, we performed a review of the currently published literature.

Materials and methods

We performed a literature search using the query “lobular AND (MRI OR MR OR MRT OR magnetic)” in the Cochrane library, PubMed and scholar.google.com, to retrieve all articles that dealt with the use of MRI in patients with ILC. We addressed sensitivity, morphologic appearance, correlation with pathology, detection of additional lesions, and impact of MRI on surgery as different endpoints. Whenever possible we performed meta-analysis of the pooled data.

Results

Sensitivity is 93.3% and equal to overall sensitivity of MRI for malignancy in the breast. Morphologic appearance is highly heterogeneous and probably heavily influenced by interreader variability. Correlation with pathology ranges from 0.81 to 0.97; overestimation of lesion size occurs but is rare. In 32% of patients, additional ipsilateral lesions are detected and in 7% contralateral lesions are only detected by MRI. Consequently, MRI induces change in surgical management in 28.3% of cases.

Conclusion

This analysis indicates MRI to be valuable in the work-up of ILC. It provides additional knowledge that cannot be obtained by conventional imaging modalities which can be helpful in patient treatment.

Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer

PURPOSE

To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins.

MATERIALS AND METHODS

Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45), grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative).

RESULTS

Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus 61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional biopsy (79 and 78%, respectively).

CONCLUSIONS

Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation. Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of negative margins at initial excision.