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Khare S, Santosh I, Laroiya I, Singh T, Bal A, Singh G. Assessment of Pathological Complete Response Using Vacuum-Assisted Biopsy in Breast Cancer Patients Who Have Clinical and Radiological Complete Response After Neo-Adjuvant Chemotherapy. Breast Cancer (Auckl) 2023; 17:11782234231205698. [PMID: 38024141 PMCID: PMC10655653 DOI: 10.1177/11782234231205698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 09/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background Any treatment protocol that leads to complete elimination of surgery may lead to a better patient acceptance of breast cancer treatments. Objectives We conducted this study to assess the feasibility of preoperative vacuum-assisted biopsies in identifying pathological complete response (pCR) and its accuracy in correlation to final histopathology report (HPR), in an Indian setting. Methods This was a prospective study conducted between October 1, 2019, and March 31, 2021. Patients with early breast cancer, estrogen and progesterone receptors negative and either Her2 positive or negative, and who were fit to undergo marker placement at the centre of the tumour and to receive third-generation chemotherapy (4 cycles of 3 weekly doxorubicin and cyclophosphamide followed by 4 cycles of 3 weekly docetaxel) were included in the study. Following the enrolment, a tissue marker was placed at the centre of the tumour and appropriate chemotherapy was started. Patients who achieved clinical complete response were subjected to ultrasound-guided vacuum-assisted biopsy (VAB) from the tumour bed before surgery. Pathology results of the VAB and resected specimen were then compared. Descriptive statistics were used in the study. Results Eighteen patients were enrolled in the study, with a mean age of 43.6 ± 9.8 years. However, only 10 were eligible for VAB procedure, and sensitivity and specificity were calculated based on the results of these 10 patients only. Vacuum-assisted biopsy showed sensitivity of 50% and specificity of 100% in identifying pCR. Combination of mammography, ultrasonography, and VAB showed sensitivity of 77.8% and specificity of 66.7% in identifying pCR. Conclusion Vacuum-assisted biopsy of tumour bed may not be sensitive enough to eliminate surgery even in patients who have had exceptional response to neo-adjuvant chemotherapy.
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Affiliation(s)
- Siddhant Khare
- Department of General Surgery, PGIMER, Chandigarh, India
| | | | - Ishita Laroiya
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, PGIMER, Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, PGIMER, Chandigarh, India
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Tralongo P, Bordonaro R, Ferrau F, Trombatore G. Are the Number of Operations Appropriate to Define a High-Quality Breast Cancer Center? World J Oncol 2023; 14:443-445. [PMID: 37869247 PMCID: PMC10588504 DOI: 10.14740/wjon1629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Paolo Tralongo
- Department of Oncology, Medical Oncology Unit, Umberto I Hospital, and Breast Unit, ASP Siracusa, Italy
| | - Roberto Bordonaro
- Department of Oncology, Medical Oncology Unit ARNAS Garibaldi, Catania, Italy
| | - Francesco Ferrau
- Medical Oncology Unit, S. Vincenzo Hospital, Taormina (Messina), Italy
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Sekine C, Uchiyama N, Watase C, Murata T, Shiino S, Jimbo K, Iwamoto E, Takayama S, Kurihara H, Satomi K, Yoshida M, Kinoshita T, Suto A. Preliminary experiences of PET/MRI in predicting complete response in patients with breast cancer treated with neoadjuvant chemotherapy. Mol Clin Oncol 2021; 16:50. [PMID: 35070299 PMCID: PMC8764658 DOI: 10.3892/mco.2021.2483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 12/07/2021] [Indexed: 11/14/2022] Open
Abstract
Clinical response predictions through image examinations after neoadjuvant chemotherapy (NAC) for breast cancer is important. The present study aimed to evaluate the utility of a novel imaging modality, positron-emission tomography/magnetic resonance imaging (PET/MRI), in predicting the pathological complete response (pCR) to NAC in patients with early breast cancer. A total of 74 patients underwent PET/MRI, mammography (MG), including tomosynthesis, and ultrasound (US) after NAC. The complete response was predicted using each modality and these outcomes were compared accordingly. In terms of PET/MRI, complete response (CR) was defined as the disappearance of 18F-fluorodeoxyglucose uptake and the absence of enhanced lesions with contrast enhanced MRI. In MG and US, undetectable lesions were considered as CR. The background and tumor characteristics of patients were also analyzed between the pCR and non-pCR cases. Overall, 18 (24.3%) of the 74 patients achieved pCR. The overall sensitivity and specificity of PET/MRI were 72.2 and 78.6%, respectively. Both the sensitivity in hormone receptor (HR)-positive cases and the specificity in HR-negative cases were 100%. HR-negative and human epidermal growth factor receptor 2 (HER2)-positive cases demonstrated a significant association with pCR compared with HR-positive cases and triple negative cases (P=0.017). Furthermore, patients with ‘mass’ type lesions evaluated by MRI before NAC experienced pCR with a higher frequency than those with ‘non-mass’ type lesions. There was a statistically significant difference between the two groups (P=0.018). In conclusion, PET/MRI is a different diagnostic approach that utilizes a multi-modality system. It demonstrates reasonable diagnostic accuracies of the responses of NAC with reference to hormonal subtypes in breast cancer.
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Affiliation(s)
- Chikako Sekine
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Nachiko Uchiyama
- Department of Radiology, National Cancer Center, Tokyo 104‑0045, Japan
| | - Chikashi Watase
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Takeshi Murata
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Sho Shiino
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Kenjiro Jimbo
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Eriko Iwamoto
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Shin Takayama
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
| | - Hiroaki Kurihara
- Department of Radiology, National Cancer Center, Tokyo 104‑0045, Japan
| | - Kaishi Satomi
- Department of Diagnostic Pathology, National Cancer Center, Tokyo 104‑0045, Japan
| | - Masayuki Yoshida
- Department of Diagnostic Pathology, National Cancer Center, Tokyo 104‑0045, Japan
| | - Takayuki Kinoshita
- Department of Breast Surgery, National Hospital Organization Tokyo Medical Center, Tokyo 152‑8902, Japan
| | - Akihiko Suto
- Department of Breast Surgery, National Cancer Center, Tokyo 104‑0045, Japan
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Apte A, Marsh S, Chandrasekharan S, Chakravorty A. Avoiding breast cancer surgery in a select cohort of complete responders to neoadjuvant chemotherapy: The long-term outcomes. Ann Med Surg (Lond) 2021; 66:102380. [PMID: 34026113 PMCID: PMC8134025 DOI: 10.1016/j.amsu.2021.102380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/03/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Lately, there has been a resurgence of interest in de-escalation of breast surgery in complete responders to neoadjuvant chemotherapy (NAC). Advanced cytotoxic & targeted therapies have improved tumour response.This study evaluates long-term outcomes of post-NAC breast cancer patients, in relation to their surgical management dictated by the NAC response. MATERIALS AND METHODS Post-NAC breast cancer patients from January 2000 to December 2010 were divided into "No surgery", "WLE" and "Mastectomy" groups. ANOVA and Kaplan-Meier statistical analyses were used to compare overall survival (OS) and disease-free-survival (DFS) in these groups. RESULTS This retrospective study included 121 patients with a long median follow-up of 11.5 years. At 10 years the OS was 66.10% and DFS was 59.82%. Complete NAC-responders did not undergo breast surgery but received radiotherapy. Patients were divided into No surgery (n = 28), WLE (n = 44), Mastectomy (n = 49) groups.Comparisons of OS and DFS between groups showed statistically significant differences (p = 0.0003, p = 0.0007 respectively). The no surgery group showed low local recurrence (7.14%). CONCLUSION The observed slightly better long-term outcomes with low local recurrences in complete NAC-responders who did not undergo breast surgery but received radiotherapy could be linked to cautious response assessment and meticulous patient selection with early, biologically favourable breast cancer.Importance of PCR assessment cannot be underestimated if breast surgery were to be de-escalated or even omitted in complete NAC-responders.Considering the study limitations, avoiding surgery in all complete NAC-responders may still not be the preferred option. Future appropriate clinical trials with well-defined protocols may pave the way forward.
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Affiliation(s)
- Anuradha Apte
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Simon Marsh
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Sankaran Chandrasekharan
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
| | - Arunmoy Chakravorty
- Colchester General Hospital, East Suffolk and North Essex NHS Foundation Trust, Turner Road, Colchester, CO4 5JL, UK
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Shi Z, Wang X, Qiu P, Liu Y, Zhao T, Sun X, Chen P, Wang C, Zhang Z, Cong B, Wang Y. Predictive factors of pathologically node-negative disease for HER2 positive and triple-negative breast cancer after neoadjuvant therapy. Gland Surg 2021; 10:166-174. [PMID: 33633973 DOI: 10.21037/gs-20-573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background With the improvement of the efficacy of neoadjuvant therapy (NAT) that is guided by molecular subtypes, the rate of pathologically node-negative disease after NAT (ypN0) is increasing for HER2 positive (HER2+) and triple-negative (TN) breast cancer patients. The necessity of axillary surgery for patients with high ypN0 has been questioned. This study aimed to identify patients among HER2+ and TN breast cancer with low risk for axillary metastases after NAT, and, perhaps, they are suitable for selective elimination of axillary surgery staging. Methods From January 2010 to August 2018, 865 breast cancer patients who underwent NAT were included in this retrospective clinical study, and 184 patients (21.3%,184/865) suffered from TN and HER2+ breast cancer and received full-course NAT. The correlation among clinicopathological characteristics of HER2+ and TN breast cancer and ypN0 were analyzed. Results Among the 184 HER2+ and TN breast cancer patients, tumor staging, lymph node staging and Ki-67 before NAT, clinically node-negative disease after NAT (ycN0), and breast radiologic and pathologic complete response (bpCR) were correlated with ypN0 (P<0.05). Lymph node staging before NAT (OR =0.363, P<0.001), ycN0 (OR =4.995, P<0.001) and bpCR (OR =11.285, P<0.001) were the independent effects of ypN0. The ypN0 rate after NAT in cN0/1 patients with bpCR and ycN0 (97.6%, 40/41) was significantly higher than that in cN2/3 patients (62.5%, 10/16) (P<0.001). Among the 37 patients with initial nodal ultrasonography showing cN0 disease, 17 of 17 (100.0%) with and 18 of 20 (90.0%) without bpCR had no evidence of residual nodal disease (P=0.178). Among the 42 patients with cN1 to ycN0, 23 of 24 (95.8%) with and 10 of 18 (55.6%) without bpCR had no evidence of residual nodal disease (P<0.001). Patients without bpCR had a relative risk for nodal residual metastases of 10.560 (95% CI: 2.720-41.003; P<0.001) compared with those with bpCR in cN1 group. Conclusions In terms of HER2+ and TN breast cancer patients, clinical lymph node staging before NAT, ycN0 and bpCR were the independent predictors of ypN0. bpCR was highly correlated with nodal status after NAT. The risk of axillary lymph nodes residual metastases after NAT in the patients of bpCR with cN0 and cN1 to ycN0 was less than 5%, thus making it possible to selectively avoid axillary surgery.
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Affiliation(s)
- Zhiqiang Shi
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Xueer Wang
- Department of Radiotherapy, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Pengfei Qiu
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Yanbing Liu
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Tong Zhao
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Xiao Sun
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Peng Chen
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Chunjian Wang
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Zhaopeng Zhang
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Binbin Cong
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
| | - Yongsheng Wang
- Breast Cancer Center, Shandong Cancer Hospital and Institute, Shandong First Medical University and Shandong Academy of Medical Science, Jinan, China
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Miyoshi T, Yamaguchi S, Fujimoto H, Yoshioka S, Shiobara M, Wakatsuki K, Suda K, Miyazawa K, Aida T, Watanabe Y, Otsuka M. A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy. Eur J Surg Oncol 2020; 47:789-795. [PMID: 33051115 DOI: 10.1016/j.ejso.2020.10.003] [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: 08/28/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND We devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure. PATIENTS AND METHODS Twenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device. RESULTS In 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm3 (range, 12.8-62.8 cm3), and percent breast volume excised was 6.8% (range, 2.5-15.7%). CONCLUSIONS This pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.
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Affiliation(s)
| | | | - Hiroshi Fujimoto
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | | | | | - Kazuo Wakatsuki
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Kosuke Suda
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Kotaro Miyazawa
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | - Toshiaki Aida
- Department of Surgery, Kaihin Municipal Hospital, Chiba, Japan
| | | | - Masayuki Otsuka
- Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
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Makanjuola DI, Alkushi A, Al Anazi K. Defining radiologic complete response using a correlation of presurgical ultrasound and mammographic localization findings with pathological complete response following neoadjuvant chemotherapy in breast cancer. Eur J Radiol 2020; 130:109146. [PMID: 32673929 DOI: 10.1016/j.ejrad.2020.109146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 05/25/2020] [Accepted: 06/20/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Breast cancer affects a significant number of patients younger than 40 years in the Gulf and breast conservative treatment is highly preferred. Pathological complete response (pCR) following neoadjuvant chemotherapy is increasingly being observed with the new chemotherapy agents. Although MRI is more accurate in such evaluations, digital mammography and high-resolution ultrasound (US) which are less expensive may accurately predict pCR which is the focus of this study. METHODS A 6-year retrospective study of 93 breast cancer cases who had neoadjuvant chemotherapy and had presurgical radiological localization was carried out. Forty-five had US localization while 48 underwent mammographic localization when US failed to define any residual mass. Radiologic complete response (rCR) was defined as absence of mass with only postbiopsy clip overlying normal breast parenchyma pattern in US and in mammography (clip sign). Mass or abnormal parenchymal pattern was considered as residual tumor. The pathology reports of pCR or not with background changes were recorded. RESULTS Ultrasound localization correctly predicted 42 out of 43 pathologic masses with 98 % accuracy. Mammographic localization correctly predicted 40 out of 43 pCR with 93 % accuracy. The best responders were triple negative and HER2 positive hormone negative breast cancer. CONCLUSION The study defines radiologic complete response (rCR) as absence of a mass with the postbiopsy tissue marker overlying a normal-looking breast parenchyma in both ultrasound and mammographic evaluation. A correlation of 93 % was found with pCR. The few false negative cases were associated with overlying dense breast and possibly post treatment reaction. Allocation of a BI-RADS category for rCR is suggested.
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Affiliation(s)
| | - Abdulmohsen Alkushi
- FRCPC, Department of Pathology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Khalid Al Anazi
- MBBS, Medical Imaging Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Maier AM, Heil J, Harcos A, Sinn HP, Rauch G, Uhlmann L, Gomez C, Stieber A, Funk A, Barr RG, Hennigs A, Riedel F, Schäfgen B, Hug S, Marmé F, Sohn C, Golatta M. Prediction of pathological complete response in breast cancer patients during neoadjuvant chemotherapy: Is shear wave elastography a useful tool in clinical routine? Eur J Radiol 2020; 128:109025. [PMID: 32371182 DOI: 10.1016/j.ejrad.2020.109025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the validity of Shear Wave Elastography (SWE) for the preoperative assessment of pathological complete response (pCR) to standard clinical assessment in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). MATERIALS AND METHODS This prospective, consecutive clinical trial was conducted under routine clinical practice. Analysis included 134 patients. SWE served as index test, final pathology from surgical specimen as reference standard. PCR (ypT0) was defined as primary endpoint. Elasticity changes were compared for the pCR- vs. non-pCR group. To determine the validity of shear wave velocity (Vs), ROC analyses and diagnostic accuracy parameters were calculated and compared to the final standard clinical assessment by physical examination, mammography and B-mode ultrasound (ycT + vs. ycT0). RESULTS Vs was significantly reduced in pCR and non-pCR groups during NACT (pCR: ΔVs(abs) = 3.90 m/s, p < 0.001; non-pCR: ΔVs(abs) = 3.10 m/s, p < 0.001). The pCR-group showed significant lower Vs for all control visits (t1,2,END: p < 0.001). ROC analysis of Vs yielded moderate AUCs for the total population (t0: 0.613, t1: 0.745, t2: 0.685, tEND: 0.718). Compared to standard clinical assessment, Vs(tEND) (cut-off: ≤3.35 m/s) was superior in sensitivity (79.6 % vs. 54.5 %), NPV (86.4 % vs. 77.5 %), FNR (20.4 % vs. 45.5 %), inferior in specificity (58.6 % vs. 77.5 %), PPV (46.3 % vs. 54.5 %), FPR (41.4 % vs. 22.5 %). CONCLUSION SWE measures significant differences in tumour elasticity changes in pCR vs. non-pCR cases. SWE shows improved sensitivity compared to standard clinical assessment, high NPV and low FNR, but failed in specificity in order to predict pCR under routine conditions.
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Affiliation(s)
- Anna Marie Maier
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Jörg Heil
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Aba Harcos
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Hans-Peter Sinn
- Department of Pathology, Heidelberg University, Heidelberg, Germany
| | - Geraldine Rauch
- Charité Universitätsmedizin Berlin, Institute of Biometry and Clinical Epidemiology, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health Berlin, Berlin, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Christina Gomez
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Anne Stieber
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Annika Funk
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Richard G Barr
- Department of Radiology, Northeastern Ohio Medical University, Rootstown, Ohio and Radiology Consultants Inc., Youngstown, Ohio, USA
| | - André Hennigs
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Fabian Riedel
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Benedikt Schäfgen
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Sarah Hug
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Frederik Marmé
- Experimental & Translational Gynecological Oncology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
| | - Christof Sohn
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany
| | - Michael Golatta
- Department of Gynecology, Breast Unit, Heidelberg University, Heidelberg, Germany.
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Multicentre prospective observational study evaluating recommendations for mastectomy by multidisciplinary teams. Br J Surg 2019; 107:227-237. [PMID: 31691270 DOI: 10.1002/bjs.11383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/05/2019] [Accepted: 09/05/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates. METHODS Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected. RESULTS Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent). CONCLUSION Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.
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10
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Özkurt E, Sakai T, Wong SM, Tukenmez M, Golshan M. Survival Outcomes for Patients With Clinical Complete Response After Neoadjuvant Chemotherapy: Is Omitting Surgery an Option? Ann Surg Oncol 2019; 26:3260-3268. [PMID: 31342356 DOI: 10.1245/s10434-019-07534-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgery after neoadjuvant chemotherapy (NCT) is an accepted treatment approach for locally advanced and some early-stage breast cancers, even for patients with a clinical complete response (cCR) after NCT. This study sought to evaluate the survival outcomes for patients with cCR to NCT who did not undergo surgery. METHODS The National Cancer Data Base (NCDB) was used to identify 93,417 women age 18 years or older with a diagnosis of invasive breast cancer who received NCT between 2010 and 2015. The study identified 350 women with cT1-4, N0-3, and M0 tumors who underwent NCT and did not have surgery. A matched surgical cohort was extracted from the NCDB, and overall survival (OS) was compared between the surgical and nonsurgical patients after NCT. RESULTS Of the 350 NCT patients who did not undergo surgery, 45 (12.9%) had cCR, 51 (14.6%) had a partial response, 241 (68.9%) had a response but whether complete or partial was not recorded, and 13 (3.7%) had no response/progression. The 5-year OS was better in the cCR group than in the no-cCR group (96.8% vs 69.8%; p = 0.004). A 5-year OS analysis of the cCR patients without surgery (n = 45; median follow-up period, 37 months) compared with the patients with a pathologic complete response who underwent surgery (n = 3938; median follow-up period, 43 months) showed no statistically significant difference (96.8% vs 92.5%, respectively; p = 0.15). CONCLUSION This retrospective cohort study demonstrated that active surveillance or de-escalation therapy may be an option for patients who achieve cCR. Prospective studies are underway to determine whether a subgroup of patients may forgo surgery in the setting of cCR after NCT.
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Affiliation(s)
- Enver Özkurt
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Breast Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Topkapi, Istanbul, Turkey
| | - Takehiko Sakai
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Stephanie M Wong
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Mustafa Tukenmez
- Breast Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Topkapi, Istanbul, Turkey
| | - Mehra Golshan
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA. .,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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11
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Shi ZQ, Qiu PF, Liu YB, Cong BB, Zhao T, Chen P, Wang CJ, Zhang ZP, Sun X, Wang YS. Neo-adjuvant chemotherapy and axillary de-escalation management for patients with clinically node-negative breast cancer. Breast J 2019; 25:1154-1159. [PMID: 31332886 DOI: 10.1111/tbj.13422] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 01/10/2019] [Accepted: 01/10/2019] [Indexed: 11/29/2022]
Abstract
This study aimed to explore the optimal time of sentinel lymph node biopsy (SLNB) and neo-adjuvant chemotherapy (NAC) and to assess the feasibility of selective elimination of axillary surgery after NAC in clinically node-negative (cN0) patients. From April 2010 to August 2018, 845 patients undergoing surgery after NAC were included in this retrospective study to analyze the correlation between different clinicopathological characteristics of cN0 patients and negative axillary lymph node after NAC (ypN0). Among the 148 cN0 patients, 83.1% (123/148) were ypN0. The rates of ypN0 in patients with hormone receptor positive (HR+)/HER2-, HR+/HER2+, HR-/HER2+, and triple-negative (TN) breast cancer were 75.4% (46/61), 82.6% (19/23), 85.2% (23/27), and 94.6% (35/37), respectively (P < 0.001). The rates of ypN0 in TN and HER2+ patients were 94.6% and 95.5%, which were significantly higher than that in HR+/HER2- patients (P < 0.05). Molecular subtypes, clinical stage, radiologic complete response, and pathologic complete response (bpCR) of the breast tumor correlated with ypN0 after full-course NAC (P < 0.05). Molecular subtypes (OR = 2.374, P = 0.033), clinical stage (OR = 0.320, P = 0.029), and bpCR (OR = 0.454, P = 0.012) were independent predictors for ypN0. The optimal time of SLNB and NAC in cN0 patients might be different among different molecular subtypes: it would be preferable to perform SLNB prior to NAC for HR+/HER2- patients, and SLNB after NAC for TN and HER2+ patients to reduce the risk of axillary lymph node dissection. In view of the high ypN0 rate in cN0 patients, axillary surgical staging might be selectively eliminated, especially for HER2+ and TN patients.
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Affiliation(s)
- Zhi-Qiang Shi
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peng-Fei Qiu
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.,Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yan-Bing Liu
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Bin-Bin Cong
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China.,School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences, Jinan, China
| | - Tong Zhao
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Peng Chen
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Chun-Jian Wang
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Zhao-Peng Zhang
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Xiao Sun
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
| | - Yong-Sheng Wang
- Breast Cancer Center, Shandong Cancer Hospital Affiliated to Shandong University, Jinan, China
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12
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Cordoba O, Carrillo-Guivernau L, Reyero-Fernández C. Surgical Management of Breast Cancer Treated with Neoadjuvant Therapy. Breast Care (Basel) 2018; 13:238-243. [PMID: 30319325 PMCID: PMC6167713 DOI: 10.1159/000491760] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Neoadjuvant therapy (NAT) allows downstaging in some cases of breast cancer. By consequence, it may enable a more conservative surgical approach or make surgery possible in cases ineligible for surgery before NAT. In this article, we review the evidence and management recommendations for optimal surgical treatment in this setting.
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Affiliation(s)
- Octavi Cordoba
- Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
| | - Lourdes Carrillo-Guivernau
- Breast Cancer Unit, Obstetrics and Gynecology Department, Hospital Universitari Son Espases, Palma, Spain
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13
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Ollila DW, Hwang ES, Brenin DR, Kuerer HM, Yao K, Feldman S. The Changing Paradigms for Breast Cancer Surgery: Performing Fewer and Less-Invasive Operations. Ann Surg Oncol 2018; 25:2807-2812. [PMID: 29968033 DOI: 10.1245/s10434-018-6618-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Indexed: 12/14/2022]
Abstract
Historically, through the conduct of prospective clinical trials, breast cancer surgeons have performed less radical breast and axillary surgeries with no survival decrement to our patients. Currently, other opportunities exist for the treating breast surgeon to do less. Possibilities include active surveillance for ductal carcinoma in situ, ablative therapy for small primary breast cancers, selective omission of a sentinel node biopsy, and selective elimination of breast surgery after neoadjuvant systemic therapy. Breast surgeons must be leaders in the development and testing of effective therapy with the least intervention possible.
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Affiliation(s)
- David W Ollila
- Department of Surgery, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - David R Brenin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Sheldon Feldman
- Department of Surgery, Montefiore Medical Center, The University Hospital for the Albert Einstein College of Medicine, New York, NY, USA
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14
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van la Parra RFD, Tadros AB, Checka CM, Rauch GM, Lucci A, Smith BD, Krishnamurthy S, Valero V, Yang WT, Kuerer HM. Baseline factors predicting a response to neoadjuvant chemotherapy with implications for non-surgical management of triple-negative breast cancer. Br J Surg 2018; 105:535-543. [PMID: 29465744 DOI: 10.1002/bjs.10755] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/03/2017] [Accepted: 10/14/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with triple-negative breast cancer (TNBC) and a pathological complete response (pCR) after neoadjuvant chemotherapy may be suitable for non-surgical management. The goal of this study was to identify baseline clinicopathological variables that are associated with residual disease, and to evaluate the effect of neoadjuvant chemotherapy on both the invasive and ductal carcinoma in situ (DCIS) components in TNBC. METHODS Patients with TNBC treated with neoadjuvant chemotherapy followed by surgical resection were identified. Patients with a pCR were compared with those who had residual disease in the breast and/or lymph nodes. Clinicopathological variables were analysed to determine their association with residual disease. RESULTS Of the 328 patients, 36·9 per cent had no residual disease and 9·1 per cent had residual DCIS only. Patients with residual disease were more likely to have malignant microcalcifications (P = 0·023) and DCIS on the initial core needle biopsy (CNB) (P = 0·030). Variables independently associated with residual disease included: DCIS on CNB (odds ratio (OR) 2·46; P = 0·022), T2 disease (OR 2·40; P = 0·029), N1 status (OR 2·03; P = 0·030) and low Ki-67 (OR 2·41; P = 0·083). Imaging after neoadjuvant chemotherapy had an accuracy of 71·7 (95 per cent c.i. 66·3 to 76·6) per cent and a negative predictive value of 76·9 (60·7 to 88·9) per cent for identifying residual disease in the breast and lymph nodes. Neoadjuvant chemotherapy did not eradicate the DCIS component in 55 per cent of patients. CONCLUSION The presence of microcalcifications on imaging and DCIS on initial CNB are associated with residual disease after neoadjuvant chemotherapy in TNBC. These variables can aid in identifying patients with TNBC suitable for inclusion in trials evaluating non-surgical management after neoadjuvant chemotherapy.
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Affiliation(s)
- R F D van la Parra
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A B Tadros
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - C M Checka
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G M Rauch
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - A Lucci
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - B D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - S Krishnamurthy
- Department of Pathology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - V Valero
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - W T Yang
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - H M Kuerer
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Richter H, Hennigs A, Schaefgen B, Hahn M, Blohmer JU, Kümmel S, Kühn T, Thill M, Friedrichs K, Sohn C, Golatta M, Heil J. Is Breast Surgery Necessary for Breast Carcinoma in Complete Remission Following Neoadjuvant Chemotherapy? Geburtshilfe Frauenheilkd 2018; 78:48-53. [PMID: 29375145 PMCID: PMC5778196 DOI: 10.1055/s-0043-124082] [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: 09/22/2017] [Revised: 12/02/2017] [Accepted: 12/03/2017] [Indexed: 11/19/2022] Open
Abstract
The likelihood of pathological complete remission (pCR) of breast cancer following neoadjuvant chemotherapy (NACT) is increasing; most of all in the triple negative and HER2 positive tumour subgroups. The question thus arises whether or not breast surgery is necessary when there is complete remission after NACT, and whether it provides any improvement of the oncological treatment result when tumour is no longer detectable. Avoiding surgery and possibly even radiotherapy would only be conceivable on the basis of a reliable diagnosis of pCR without operating. Current imaging does not achieve the necessary sensitivity and specificity to assure the diagnosis of pathological complete remission. Further studies are therefore required to determine which methods are best able to evaluate tumour response to NACT. Studies on image-guided, minimally invasive biopsies after NACT have delivered first promising results towards diagnosing pCR before surgery and could provide the basis for further studies on the possibility of avoiding surgery in this specific patient collective.
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Affiliation(s)
- Hannah Richter
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - André Hennigs
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Benedikt Schaefgen
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Markus Hahn
- Department für Frauengesundheit, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jens Uwe Blohmer
- Brustzentrum der Klinik für Gynäkologie, Campus Charité Mitte, Berlin, Germany
| | - Sherko Kümmel
- Brustzentrum der Kliniken Essen-Mitte, Evang. Huyssens-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Thorsten Kühn
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Esslingen GmbH, Esslingen, Germany
| | - Marc Thill
- Brustzentrum, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
| | - Kay Friedrichs
- Mammazentrum am Krankenhaus Jerusalem Hamburg, Hamburg, Germany
| | - Christof Sohn
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Michael Golatta
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
| | - Jörg Heil
- Brustzentrum der Universitäts-Frauenklinik Heidelberg, Heidelberg, Germany
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16
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Derks MGM, van de Velde CJH. Neoadjuvant chemotherapy in breast cancer: more than just downsizing. Lancet Oncol 2017; 19:2-3. [PMID: 29242042 DOI: 10.1016/s1470-2045(17)30914-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 10/09/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Marloes G M Derks
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
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17
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Cain H, Macpherson I, Beresford M, Pinder S, Pong J, Dixon J. Neoadjuvant Therapy in Early Breast Cancer: Treatment Considerations and Common Debates in Practice. Clin Oncol (R Coll Radiol) 2017; 29:642-652. [DOI: 10.1016/j.clon.2017.06.003] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/11/2017] [Accepted: 05/17/2017] [Indexed: 01/16/2023]
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18
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Tadros AB, Yang WT, Krishnamurthy S, Rauch GM, Smith BD, Valero V, Black DM, Lucci A, Caudle AS, DeSnyder SM, Teshome M, Barcenas CH, Miggins M, Adrada BE, Moseley T, Hwang RF, Hunt KK, Kuerer HM. Identification of Patients With Documented Pathologic Complete Response in the Breast After Neoadjuvant Chemotherapy for Omission of Axillary Surgery. JAMA Surg 2017; 152:665-670. [PMID: 28423171 DOI: 10.1001/jamasurg.2017.0562] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance A pathologic complete response (pCR; no invasive or in situ cancer) occurs in 40% to 50% of patients with HER2-positive (HER2+) and triple-negative (TN) breast cancer. The need for surgery if percutaneous biopsy of the breast after neoadjuvant chemotherapy (NCT) indicates pCR in the breast (hereinafter referred to as breast pCR) has been questioned, and appropriate management of the axilla in such patients is unknown. Objective To identify patients among exceptional responders to NCT with a low risk for axillary metastases when breast pCR is documented who may be eligible for an omission of surgery clinical trial design. Design, Setting, and Participants This prospective cohort study at a single-institution academic national comprehensive cancer center included 527 consecutive patients with HER2+/TN (T1/T2 and N0/N1) cancer treated with NCT followed by standard breast and nodal surgery from January 1, 2010, through December 31, 2014. Main Outcomes and Measures Patients who achieved a breast pCR were compared with patients who did not based on subtype, initial ultrasonographic findings, and documented pathologic nodal status. Incidence of positive findings for nodal disease on final pathologic review was calculated for patients with and without pCR and compared using relative risk ratios with 95% CIs. Results The analysis included 527 patients (median age, 51 [range, 23-84] years). Among 290 patients with initial nodal ultrasonography showing N0 disease, 116 (40.4%) had a breast pCR and 100% had no evidence of axillary lymph node metastases after NCT. Among 237 patients with initial biopsy-proved N1 disease, 69 of 77 (89.6%) with and 68 of 160 (42.5%) without a breast pCR had no evidence of residual nodal disease (P < .01). Patients without a breast pCR had a relative risk for positive nodal metastases of 7.4 (95% CI, 3.7-14.8; P < .001) compared with those with a breast pCR. Conclusions and Relevance Breast pCR is highly correlated with nodal status after NCT, and the risk for missing nodal metastases without axillary surgery in this cohort is extremely low. These data provide the fundamental basis and rationale for management of the axilla in clinical trials of omission of cancer surgery when image-guided biopsy indicates a breast pCR.
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Affiliation(s)
- Audree B Tadros
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Wei T Yang
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston
| | | | - Gaiane M Rauch
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston
| | - Benjamin D Smith
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Vicente Valero
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Dalliah M Black
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Anthony Lucci
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Abigail S Caudle
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Sarah M DeSnyder
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Mediget Teshome
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Carlos H Barcenas
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Makesha Miggins
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Beatriz E Adrada
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston
| | - Tanya Moseley
- Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston
| | - Rosa F Hwang
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Kelly K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston
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19
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Rauch GM, Adrada BE, Kuerer HM, van la Parra RFD, Leung JWT, Yang WT. Multimodality Imaging for Evaluating Response to Neoadjuvant Chemotherapy in Breast Cancer. AJR Am J Roentgenol 2017; 208:290-299. [DOI: 10.2214/ajr.16.17223] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Gaiane M. Rauch
- Department of Diagnostic Radiology, Unit 1473, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030-4009
| | - Beatriz Elena Adrada
- Department of Diagnostic Radiology, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Henry Mark Kuerer
- Department of Breast Surgical Oncology, Unit 1434, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Raquel F. D. van la Parra
- Department of Breast Surgical Oncology, Unit 1434, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jessica W. T. Leung
- Department of Diagnostic Radiology, Unit 1350, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei Tse Yang
- Department of Diagnostic Radiology, Unit 1459, The University of Texas MD Anderson Cancer Center, Houston, TX
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20
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Schaefgen B, Heil J, Richter H, Harcos A, Gomez C, Stieber A, Sohn C, Golatta M. Detection and Removal of Ceramic Clip Markers from Breast Tissue by Ultrasound-Guided, Vacuum-Assisted Minimally Invasive Biopsy in a Turkey Breast Model. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:341-345. [PMID: 27692873 DOI: 10.1016/j.ultrasmedbio.2016.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 07/14/2016] [Accepted: 08/20/2016] [Indexed: 06/06/2023]
Abstract
This article explores the ability of sonographically guided, vacuum-assisted minimally invasive biopsy (VAB) to detect and remove ceramic clip markers from breast tissue. This is a feasibility pre-study for a clinical study using vacuum-assisted biopsy to predict pathologic complete response of breast cancer. Twenty-six ceramic clip markers were placed in five turkey breasts. Clip markers were then detected sonographically and removed using VAB by experienced physicians. Quality of visibility was graded by the performing doctors. The specimens were examined macroscopically to see if they contained the clip marker. The main outcome measure was the accuracy of VAB to detect and remove the clip marker. The VAB device was inspected for any damage possibly caused by hitting the clip marker. The clip markers were detected in 25 cases (96.2%). Twenty clip markers (76.9%) were removed completely by VAB and five (19.2%) were partially removed. One clip marker (3.8%) was not removed. On average, detection of the clip marker took 67 s and the biopsy took 178 s. Quality of visibility was mostly graded as very good (14 cases/53.8%) or good (nine cases/34.6%), and in all of these cases the clip marker was at least partially removed. The clip marker was visible and removed in the vast majority of the cases. VAB is able to remove the clip marker in integrity without causing damage to the system.
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Affiliation(s)
| | - Jörg Heil
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Hannah Richter
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Aba Harcos
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Christina Gomez
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Anne Stieber
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Christof Sohn
- University Breast Unit, Department of Gynecology, Heidelberg, Germany
| | - Michael Golatta
- University Breast Unit, Department of Gynecology, Heidelberg, Germany.
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21
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van la Parra RFD, Kuerer HM. Selective elimination of breast cancer surgery in exceptional responders: historical perspective and current trials. Breast Cancer Res 2016; 18:28. [PMID: 26951131 PMCID: PMC4782355 DOI: 10.1186/s13058-016-0684-6] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/07/2016] [Indexed: 12/20/2022] Open
Abstract
With improvements in chemotherapy regimens, targeted therapies, and our fundamental understanding of the relationship of tumor subtype and pathologic complete response (pCR), there has been dramatic improvement in pCR rates in the past decade, especially among triple-negative and human epidermal growth factor receptor 2-positive breast cancers. Rates of pCR in these groups of patients can be in the 60 % range and thus question the paradigm for the necessity of breast and nodal surgery in all cases, particularly when the patient will be receiving adjuvant local therapy with radiotherapy. Current practice for patients who respond well to neoadjuvant chemotherapy (NCT) is often to proceed with the same breast and axillary procedures as would have been offered women who had not received NCT, regardless of the apparent clinical response. Given these high response rates in defined subgroups among exceptional responders it is appropriate to question whether surgery is now a redundant procedure in their overall management. Further, definitive radiation without surgical resection with or without systemic therapy has been proven effective for several other malignant disease sites including some stages of esophageal, anal, laryngeal, prostate, cervical, and lung carcinoma. The main impediments for potential elimination of surgery have been the fact that prior and current standard and functional breast imaging methods are incapable of accurate prediction of residual disease and that integrating percutaneous biopsy of the breast primary and nodes following NCT may circumvent this issue. This article highlights historical attempts at omission of surgery following NCT in an earlier era, the current status of breast and nodal imaging to predict residual carcinoma, and ongoing and planned trials designed to identify appropriate patients who might be selected for clinical trials designed to test the safety of selected elimination of breast cancer surgery in percutaneous image-guided biopsy-proven exceptional responders to NCT.
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Affiliation(s)
- Raquel F D van la Parra
- Department of Surgical Oncology, Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, 1066 CX, The Netherlands. .,Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1434, Houston, TX, 77030, USA.
| | - Henry M Kuerer
- Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Unit 1434, Houston, TX, 77030, USA.
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22
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Schaefgen B, Mati M, Sinn HP, Golatta M, Stieber A, Rauch G, Hennigs A, Richter H, Domschke C, Schuetz F, Sohn C, Schneeweiss A, Heil J. Can Routine Imaging After Neoadjuvant Chemotherapy in Breast Cancer Predict Pathologic Complete Response? Ann Surg Oncol 2015; 23:789-95. [PMID: 26467456 DOI: 10.1245/s10434-015-4918-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study evaluated breast imaging procedures for predicting pathologic complete response (pCR = ypT0) after neoadjuvant chemotherapy (NACT) for breast cancer to challenge surgery as a diagnostic procedure after NACT. METHODS This retrospective, exploratory, monocenter study included 150 invasive breast cancers treated by NACT. The patients received magnetic resonance imaging (MRI), mammography (MGR), and ultrasound (US). The results were classified in three response subgroups according to response evaluation criteria in solid tumors. To incorporate specific features of MRI and MGR, an additional category [clinical near complete response (near-cCR)] was defined. Residual cancer in imaging and pathology was defined as a positive result. Negative predictive values (NPVs), false-negative rates (FNRs), and false-positive rates (FPRs) of all imaging procedures were analyzed for the whole cohort and for triple-negative (TN), HER2-positive (HER2+), and HER2-negative/hormone-receptor-positive (HER2-/HR+) cancers, respectively. RESULTS In 46 cases (31%), pCR (ypT0) was achieved. Clinical complete response (cCR) and near-cCR showed nearly the same NPVs and FNRs. The NPV was highest with 61% for near-cCR in MRI and lowest with 44% for near-cCR in MGR for the whole cohort. The FNRs ranged from 4 to 25% according to different imaging methods. The MRI performance seemed to be superior, especially in TN cancers (NPV 94%; FNR 5%). The lowest FPR was 10 % in MRI, and the highest FPR was 44% in US. CONCLUSION Neither MRI nor MGR or US can diagnose a pCR (ypT0) with sufficient accuracy to replace pathologic diagnosis of the surgical excision specimen.
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Affiliation(s)
- B Schaefgen
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - M Mati
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - H P Sinn
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - M Golatta
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - A Stieber
- Department of Diagnostic and Interventional Radiology, University Breast Unit, Heidelberg, Germany
| | - G Rauch
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - A Hennigs
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - H Richter
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - C Domschke
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - F Schuetz
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - C Sohn
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
| | - A Schneeweiss
- Department of Gynecology, University Breast Unit, Heidelberg, Germany.,National Center for Tumor Diseases, University of Heidelberg, Heidelberg, Germany
| | - Joerg Heil
- Department of Gynecology, University Breast Unit, Heidelberg, Germany.
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23
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Lee MC, Gonzalez SJ, Lin H, Zhao X, Kiluk JV, Laronga C, Mooney B. Prospective Trial of Breast MRI Versus 2D and 3D Ultrasound for Evaluation of Response to Neoadjuvant Chemotherapy. Ann Surg Oncol 2015; 22:2888-2894. [DOI: 10.1245/s10434-014-4357-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Evaluation of Sentinel Lymph Node Dose Distribution in 3D Conformal Radiotherapy Techniques in 67 pN0 Breast Cancer Patients. Int J Breast Cancer 2015. [PMID: 26221542 PMCID: PMC4499384 DOI: 10.1155/2015/539842] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Introduction. The anatomic position of the sentinel lymph node is variable. The purpose of the following study was to assess the dose distribution delivered to the surgically marked sentinel lymph node site by 3D conformal radio therapy technique. Material and Method. We retrospectively analysed 70 radiotherapy (RT) treatment plans of consecutive primary breast cancer patients with a successful, disease-free, sentinel lymph node resection. Results. In our case series the SN clip volume received a mean dose of 40.7 Gy (min 28.8 Gy/max 47.6 Gy). Conclusion. By using surgical clip markers in combination with 3D CT images our data supports the pathway of tumouricidal doses in the SN bed. The target volume should be defined by surgical clip markers and 3D CT images to give accurate dose estimations.
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Inflammatory breast cancer: time to standardise diagnosis assessment and management, and for the joining of forces to facilitate effective research. Br J Cancer 2015; 112:1613-5. [PMID: 25867266 PMCID: PMC4453671 DOI: 10.1038/bjc.2015.115] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Babyshkina N, Malinovskaya E, Patalyak S, Bragina O, Tarabanovskaya N, Doroshenko A, Slonimskaya E, Perelmuter V, Cherdyntseva N. Neoadjuvant chemotherapy for different molecular breast cancer subtypes: a retrospective study in Russian population. Med Oncol 2014; 31:165. [PMID: 25139196 DOI: 10.1007/s12032-014-0165-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 08/07/2014] [Indexed: 12/23/2022]
Abstract
The aim of this retrospective study was to evaluate the objective clinical response (cOR), pathological complete response (pCR), and progression-free survival (PFS) in 231 Russian patients with four subtypes of breast cancer treated with neoadjuvant chemotherapy. About 130 (56.3 %) patients received anthracycline-based, 56 (24.2 %) capecitabine-containing (CAX), 28 (12.1 %) taxotere and 17 (7.4 %) non-anthracycline-containing chemotherapy regimens at the Tomsk Cancer Research Institute between 2000 and 2010. Tumors were subtyped according to the hormone receptor (HR) and human epidermal growth factor receptor 2 (HER2) immunohistochemical data. The majority of tumors (48.9 %) were ER+/PR+ and HER2-negative (HR+/HER2-), 10.4 % were ER+ PR+ and HER2-positive (HR+/HER2+), 9.1 % were ER-/PR- and HER2-overexpressed (HER2-enriched) and 31.6 % were ER-/PR- and HER2-negative (triple negative). Both cOR and pCR were significantly higher in the triple-negative tumors compared to the other subtypes (P = 0.021 and P = 0.033, respectively). Among the four chemotherapy regimens, only CAX regimen had a predictive value for cOR (HR 2.30, 95 % CI 1.16-4.58, P = 0.009). Multivariate regression analysis showed that the triple-negative subtype (HR 2.54, 95 % CI 1.06-1.42, P = 0.011) and CAX regimen (HR 3.01, 95 % CI 1.01-1.46, P = 0.002) were significantly associated with cOR. No association between patient's PFS and a tumor subtype was observed. However, there was a trend for a prolonged PFS among patients with cOR (P = 0.056). Our data indicate a potentially better prognosis for triple-negative breast cancer patients if treated with the CAX neoadjuvant regimen.
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Affiliation(s)
- Nataliya Babyshkina
- Department of Molecular Oncology and Immunology, Cancer Research Institute of Siberian Branch, Russian Academy of Medical Sciences, 5 Kooperativny Street, Tomsk, 634050, Russian,
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Kümmel S, Holtschmidt J, Loibl S. Surgical treatment of primary breast cancer in the neoadjuvant setting. Br J Surg 2014; 101:912-24. [DOI: 10.1002/bjs.9545] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Neoadjuvant chemotherapy (NACT) is a standard treatment option for primary operable breast cancer when adjuvant chemotherapy is indicated.
Methods
This article reviews the use of NACT in breast cancer treatment.
Results
Pathological complete response (pCR) rates of up to 60 per cent have been reached for certain breast cancer subgroups. Patients achieving a pCR have a lower locoregional recurrence rate. Nevertheless, the rate of breast-conserving surgery seems to be stable at around 65–70 per cent, although more than 80 per cent of patients respond to NACT. The risk of local relapse does not appear to be higher after NACT, which supports the recommendation to operate within the new margins, as long as there is no tumour in the inked area of the surgical specimen. However, tumours do not shrink concentrically and the re-excision rate is higher after NACT. Mastectomy rates for lobular carcinomas remain high irrespective of tumour response. The role of sentinel lymph node biopsy (SLNB) in the context of NACT has been studied in recent years, and it is not yet completely clear which type of axillary staging is the most suitable. SLNB before NACT in clinically node-negative patients has been the preferred option. However, this practice is currently changing, and it seems advisable to have the SLNB after NACT to reduce the risk of a false-negative SLNB.
Conclusion
Overall, patients do benefit from NACT, especially those with human epidermal growth factor receptor 2-positive and triple-negative breast cancer, but surgical/local procedures need to be adapted.
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Affiliation(s)
- S Kümmel
- Kliniken Essen Mitte, Klinik für Senologie, Essen, Germany
| | - J Holtschmidt
- Kliniken Essen Mitte, Klinik für Senologie, Essen, Germany
| | - S Loibl
- German Breast Group, Neu-Isenburg, Germany
- Sana Klinikum Offenbach, Offenbach, Germany
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Hebbar N, Shrestha-Bhattarai T, Rangnekar VM. Par-4 prevents breast cancer recurrence. Breast Cancer Res 2013; 15:314. [PMID: 24164776 PMCID: PMC3978615 DOI: 10.1186/bcr3562] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Therapy resistance and disease recurrence are two of the most challenging aspects in breast cancer treatment. A recent article in Cancer Cell makes a significant contribution toward a better understanding of this therapeutic problem by establishing downregulation of the tumor suppressor Par-4 as the primary determinant of breast cancer recurrence. This viewpoint brings forth the importance of their findings and its implications on future research and therapy.
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