The follow-up of breast cancer

Second-Look Ultrasound Using Shear-Wave Elastography in MRI-Suspected Locoregional Recurrence of Breast Carcinoma

PURPOSE

To investigate if second-look US using shear-wave elastography (SWE) can help to differentiate between benign and malignant changes in the postoperative breast after surgical treatment of breast carcinoma.

MATERIALS AND METHODS

SWE and related sonographic features were reviewed in 90 female patients with a history of surgical treatment of breast carcinoma and a suspicious lesion detected on a follow-up MRI scan. A single experienced radiologist performed all second-look US exams with SWE measurements placing a circular region of interest measuring 2 mm in diameter over the stiffest part of the lesion. Tissue samples for histopathological analysis were obtained during the same US examination via core-needle biopsy.

RESULTS

Out of 90 lesions, 39 were proven malignant on histopathological analysis. 50 % of malignant lesions had El_max values ranging from 128 to 199 kPa, and 50 % of benign lesions had El_max values ranging from 65 to 169 kPa. The cut-off value of 171.2 kPa for El_max shows a sensitivity of 59 % and specificity of 78.4 % for carcinoma recurrence, area under the curve 0.706 (CI95 % 0.6-0.81), P = 0.001. In univariate logistic models, restricted diffusion and stiffness on SWE, El_max > 171.2 kPa, were shown as significant recurrence predictors. In the multivariate model, restricted diffusion remains significant independent recurrence predictor. With a recurrence prevalence of 43 %, the test sensitivity is 95 % (CI95 % 81-99 %) and the specificity is 75 % (CI95 % 60-85 %).

CONCLUSION

Stiffer lesions should be considered suspicious on second-look US in the postoperative breast and SWE can be a helpful tool in identifying malignant lesions, especially if this is related to restricted diffusion on MRI exam. Lesion stiffness, however, should not be considered as an independent predictor of lesion malignancy in the postoperative breast, because of benign changes that can appear stiff on SWE, as well as carcinoma recurrences that may appear soft.

Appropriateness and Economic Analysis of Conventional Circulating Biomarkers Assessment in Early Breast Cancer: A Real-World Experience from the E.Pic.A Study

The risk of relapse for early breast cancer (BC) patients persists even after decades and to date, no specific and sensitive effective circulating biomarker for recurrence prediction has been identified yet. The international guidelines do not recommend the assessment of the serum tumor markers CEA and CA15-3 in the follow-up of asymptomatic early BC patients. In our institute, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, as part of the E.Pic.A study, which was designed to assess the economic appropriateness of integrated care pathways in early BC, the use of CEA and CA15-3 as circulating tumor biomarkers in early BC patients was evaluated in 1502 patients one year after surgery, from 2015 to 2018, with an overall expense of EUR 51,764. A total of EUR 47,780 (92%) was used for execution of circulating tumor markers in early BC patients with stage 0, I and II tumors, neglecting the current guidelines and considered inappropriate by our professional board. We found that no patients with stage I BC experienced relapse in the 365 days after surgery, and in any case examination of the circulating markers CEA and CA15-3 was considered crucial for diagnosis of relapse. Our findings suggest that this inadequacy is a low-value area, supporting the reallocation of economic resources for interventions of a higher value for patients.

Clinical impact of follow-up imaging on mortality in Korean breast cancer patients: A national cohort study

Background

As the incidence of breast cancer has increased and the survival rate has improved, supporting the optimal follow‐up strategy has become an important issue. This study aimed to evaluate follow‐up imaging usage after breast cancer surgery and the implications on mortality in Korea.

Methods

This study included 96,575 breast cancer patients diagnosed during 2002–2010 and registered in the Korea Central Cancer Registry, Statistics Korea, and Korean National Health Insurance Service. We evaluated the frequency of breast imaging (mammography and breast MRI) and systemic imaging for evaluating the presence of distant metastasis (chest CT, bone scan, and PET‐CT), and performed analyses to determine if they had an effect on mortality.

Results

The median follow‐up period was 72.9 months (range: 12.0–133.3) and 7.5% of the patients died. Among all patients, 54.7%, 16.2%, 45.6%, and 8.5% received 3 or more mammograms, chest CTs, bone scans, and PET‐CTs within 3 years after surgery, respectively. Among patients who developed recurrence after 3 or more years, a comparison of overall mortality and breast‐cancer specific mortality according to the frequency of imaging by modality (<3 vs. ≥3) showed that only mammography had significantly reduced mortality (hazard ratio [HR]: 0.72, 95% CI: 0.61–0.84, p < 0.0001; HR: 0.72, 95% CI: 0.61–0.84; p < 0.0001).

Conclusions

This study showed that only frequent mammography reduced mortality and frequent imaging follow‐up with other modalities did not when compared to less frequent imaging. This finding provides supportive evidence that clinicians need to adhere to the current guidelines for surveillance after breast cancer surgery.

PET/CT Variants and Pitfalls in Breast Cancers

There are a number of normal variants and pitfalls which are important to consider when evaluating F-18 Fluorodeoxyglucose (FDG) with Positron Emission Tomography (PET) in breast cancer patients. Although FDG-PET is not indicated for the initial diagnosis of breast cancer, focally increased glucose metabolism within breast tissue represents a high likelihood for a neoplastic process and requires further evaluation. Focally increased glucose metabolism is not unique to breast cancer. Other malignancies such as lymphoma, metastases from solid tumors as well as inflammatory changes also may demonstrate increased glucose metabolism either within the breast or at other sites throughout the body. Importantly, benign breast disease may also exhibit increased glucose metabolism, limiting the specificity of FDG-PET. Breast cancer has a wide range of metabolic activity attributed to tumor heterogeneity and breast cancer subtype. Intracellular signaling pathways regulating tumor glucose utilization contribute to these pitfalls of PET/CT in breast cancer. The evaluation of axillary lymph nodes by FDG-PET is less accurate than sentinel lymph node procedure, however is very accurate in identifying level II and III axillary lymph node metastases or retropectoral metastases. It is important to note that non-malignant inflammation in lymph nodes are often detected by modern PET/CT technology. Therefore, particular consideration should be given to recent vaccinations, particularly to COVID-19, which can commonly result in increased metabolic activity of axillary nodes. Whole body FDG-PET for staging of breast cancer requires specific attention to physiologic variants of FDG distribution and a careful comparison with co-registered anatomical imaging. The most important pitfalls are related to inflammatory changes including sarcoidosis, sarcoid like reactions, and other granulomatous diseases as well as secondary neoplastic processes.

The feasibility of circulating tumor DNA analysis as a marker of recurrence in triple-negative breast cancer

Triple-negative breast cancer (TNBC) has a poorer prognosis than other breast cancer subtypes; therefore, identifying markers of early recurrence is important. The present study aimed to establish a liquid biopsy protocol for droplet digital PCR-based detection of frequently mutated genes in patients with TNBC. Tumor DNA from 36 patients with TNBC who relapsed within 2 years after surgical resection was retrospectively analyzed. Somatic mutational profiles were evaluated using targeted sequencing to identify frequently mutated genes and genes associated with molecularly targeted therapies. The association between genetic alterations and associated protein phosphorylation was investigated using immunohistochemical analysis. Recurrent hot spot mutations in the plasma were monitored over time. Mutation-specific probes were used to successfully detect mutations in the blood samples of patients who were positive for PIK3CA H1047R and AKT1 E17K mutations. Somatic mutations in AKT1 (14.9%) and PIK3CA (25.5%) were frequently identified in the data. Robust phosphorylation of AKT and S6RP was more common in tumors with PIK3CA H1047R and AKT1 E17K mutational background than in tumors with wild-type PIK3CA and AKT1. In conclusion, the present study evaluated a high-sensitivity detection system for frequently mutated genes that was also applicable for cell-free DNA. The PI3K/AKT pathway was revealed to be activated in patients harboring PIK3CA H1047R and AKT1 E17K mutations; therefore, the PI3K/AKT pathway may be a promising candidate for targeted therapy in these patients.

Correlation between salivary and serum CA15-3 concentrations in patients with breast cancer

The early detection of breast cancer enables the use of less aggressive treatment and increases patient survival. The transmembrane glycoprotein mucin 1, which is also known as cancer antigen 15-3 (CA15-3), is aberrantly glycosylated and overexpressed in a variety of epithelial cancers, and serves a crucial role in the progression of the disease. CA15-3 is currently used as a marker of breast cancer. In the present study, CA15-3 concentrations in saliva and blood of patients with breast cancer were evaluated to test new assays to detect salivary CA15-3 in addition to ELISA and its diagnostic value. To the best of our knowledge, there are no previous reports of the use of chemiluminescence assay (CLIA) and electrochemiluminescence assay (ECLIA) in saliva. Saliva and blood were collected on the same day from patients with breast cancer (n=26) and healthy controls (n=28). For each subject, the level of serum CA15-3 was measured using ECLIA, and the level of salivary CA15-3 was measured using ECLIA, CLIA and enzyme-linked immunosorbent assay (ELISA). ELISA and CLIA were able to detect CA15-3 in saliva; however, ECLIA could not detect salivary CA15-3. There was no significant difference between the mean serum and salivary CA15-3 levels in patients with breast cancer or healthy controls. The levels of CA15-3 were highest for luminal breast cancer subtypes and stage IV cases. A moderate correlation was observed between salivary and serum CA15-3 levels as measured by ELISA in breast cancer patients (r=0.56; P=0.0047). The results demonstrated that ECLIA was not a good method to detect salivary CA15-3, although it is the gold standard for detecting serum CA15-3. The presence of CA15-3 in saliva was confirmed, and this will be useful in future research. Further investigations are necessary to confirm the ability to detect salivary CA15-3 and its correlation with serum CA15-3.

Granular cell tumor of the breast: a multidisciplinary challenge

Granular cell tumors are rare soft tissue tumors; they are almost never malignant, but can mimic a carcinoma clinically, radiologically and microscopically. The finding of a suspicious lump often entails subsequent diagnostic procedures that can pose significant anxiety on patients before reaching a challenging differential diagnosis. The physical and psychological burden is even more significant when such findings occur during the follow up of a previous oncologic condition. Sometimes the fear for a potential local or distant recurrence can be responsible for a misdiagnosis and lead to patient overtreatment.

Overview of Breast Cancer Therapy

Breast cancer treatment is multidisciplinary. Most women with early stage breast cancer are candidates for breast-conserving surgery with radiotherapy or mastectomy. The risk of local recurrence and the chance of survival does not differ with these approaches. Sentinel node biopsy is used for axillary staging, and individualized approaches are minimizing the need for axillary dissection in women with positive sentinel nodes. Adjuvant systemic therapy is used in most women based on proven survival benefit, and molecular profiling to individualize treatment based on risk is now a clinical reality for patients with hormone receptor-positive cancers.

Analysis of patient-detected breast cancer recurrence

BACKGROUND

After primary surgical resection, breast cancer survivors regularly undergo surveillance using multiple modalities to detect recurrences.

OBJECTIVE

The goal of this study was to determine how breast cancer recurrences were detected in our sample population of breast cancer survivors. We hypothesize that the majority of recurrences are patient-detected.

METHODS

This was a retrospective observational study evaluating patients with a detected breast cancer recurrence between 2010 and 2015. Patients were analyzed by initial detection modality (patient versus clinician versus imaging). Other variables of interest included insurance status, ambulation capability, living situation, age at diagnosis and recurrence, and time to recurrence. Statistical methods included chi-square tests, log-rank tests, and analysis of variance.

RESULTS

115 patients were identified with a recurrence (mean age 61 years). 88 (77%) recurrences were patient-detected, 14 (12%) were detected by imaging, and 13 (11%) were clinician-detected (chi-square goodness of fit test p < 0.001). Median time to recurrence was 4 years in the patient-detection group compared to 3 for the clinician group and 2 for imaging detection (log-rank test p = 0.01).

CONCLUSION

While the majority of recurrences were patient-detected, these were detected later and at a more advanced clinical stage. This could represent an opportunity to enhance outcomes by empowering patient detection strategies.

Does a less intensive surveillance protocol affect the survival of patients after treatment of a sarcoma of the limb?

Aims

A single-centre prospective randomized trial was conducted to investigate whether a less intensive follow-up protocol would not be inferior to a conventional follow-up protocol, in terms of overall survival, in patients who have undergone surgery for sarcoma of the limb. Initial short-term results were published in 2014.

Patients and Methods

The primary objective was to show non-inferiority of a chest radiograph (CXR) group compared with a CT scan group, and of a less frequent (six-monthly) group than a more frequent (three-monthly) group, in two-by-two comparison. The primary outcome was overall survival and the secondary outcome was a recurrence-free survival. Five-year survival was compared between the CXR and CT scan groups and between the three-monthly and six-monthly groups. Of 500 patients who were enrolled, 476 were available for follow-up. Survival analyses were performed on a per-protocol basis (n = 412).

Results

The updated results recorded 12 (2.4%) local recurrences, 182 (36.8%) metastases, and 56 (11.3%) combined (local + metastases) recurrence at a median follow-up of 81 months (60 to 118). Of 68 local recurrences, 60 (88%) were identified by the patients themselves. The six-monthly regime (overall survival (OS) 54%, recurrence-free survival (RFS) 46%) did not lead to a worse survival and was not inferior to the three-monthly regime (OS 55%, RFS 47%) in terms of detecting recurrence. Although CT scans (OS 53%, RFS 54%) detected pulmonary metastasis earlier, it did not lead to a better survival compared with CXR (OS 56%, RFS 59%).

Conclusion

The overall survival of patients who are treated for a sarcoma of the limb is not inferior to those followed up with a less intensive regimen than a more intensive protocol, in terms of frequency of visits and mode of imaging. CXR at six-monthly intervals and patient education about examination of the site of the surgery will detect most recurrences without deleterious effects on the eventual outcome. Cite this article: Bone Joint J 2018;100-B:262–8.

Magnetic Resonance Imaging after Breast Oncoplastic Surgery: An Update

Breast-oncoplastic surgery, allowing local tumor control and a better cosmetic outcome, is oncologically safe when applied to early-stage breast cancer. Breast cancer recurrence following conservative therapy may occur during the first 5 years after treatment, with a peak incidence after 2 years. Therefore, during the follow-up period, patients undergo a series of ultrasound (US) and mammographic examinations. However, after surgery and radiation therapy, several modifications occur in the treated breast, causing difficulties in image interpretation, especially when local recurrence is suspected. Although not included in routine follow-up, magnetic resonance imaging (MRI) is often used in clinical practice, being considered more sensitive than the conventional imaging examinations in discriminating between postsurgical tissue modifications and tumor recurrence. In this review article, we analyze expected and pathologic breast MRI findings after conservative oncoplastic surgery compared to US and mammographic findings in order to distinguish local recurrence and avoid potential pitfalls in image interpretation.

Developing an Evidence-based Followup Schedule for Bone Sarcomas Based on Local Recurrence and Metastatic Progression

BACKGROUND

The potential for local recurrence and pulmonary metastasis after treatment of primary bone sarcomas necessitates careful patient followup; however, minimal data exist regarding the incidence and timing of these events, and therefore an evidence-based surveillance protocol has not been developed.

QUESTIONS/PURPOSES

The purposes of this study were to (1) describe the frequency and timing of local recurrence by histologic grade over time; (2) describe the frequency and timing of metastasis by histologic grade and diagnosis over time; and (3) use these data to either justify current surveillance schedules and/or propose modifications that may improve the rate of new pulmonary metastatic events detected per examination.

METHODS

A retrospective review was performed of all patients who underwent resection of a primary, nonmetastatic bone sarcoma (excluding chordoma) at a single tertiary oncology center from 1989 to 2010. Of the 680 patients identified, 15 were excluded for loss of followup in the first 2 years, leaving 665 eligible for study. Of these, 437 patients were alive with no evidence of disease at the conclusion of the study (mean followup, 136 months; range, 25-321 months). Cox regression analysis was performed to evaluate and control for patient age, tumor size, tumor location, and surgical margins. With patients stratified by sarcoma grade, Kaplan-Meier survival curves were constructed for the endpoints of local recurrence and metastasis, and log-rank tests were used to compare the rates of these events between grades and diagnoses. The number of new pulmonary metastatic events per patient-year was calculated for each sarcoma grade over the time intervals used in current surveillance protocols (0-2, 2-5, 5-10, and > 10 years) to facilitate development of a surveillance schedule that would maximize events detected per imaging study performed. In addition, to determine the effect of disease type, subset analysis was performed for osteosarcoma (OSA) and chondrosarcoma because these were the only diagnoses with sufficient numbers to support individual statistical analysis.

RESULTS

With the numbers available for study, the overall local recurrence-free survival did not differ between sarcoma grades at any time points (p = 0.864). Metastasis-free survival curves differed between sarcoma grades (p < 0.001), and the pattern of Grade 2 OSA metastasis was more consistent with other Grade 3 sarcomas, so it was subsequently classified as high grade. No metastases of Grade 1 sarcomas occurred after 3 years, whereas Grade 2 and 3 sarcomas continued to metastasize until 10 years and rarely thereafter. According to the number of new pulmonary metastatic events per patient-year in each group, we propose that chest surveillance be performed according to the following schedule: annually only until 5 years for low-grade sarcomas; every 3 months for 2 years and annually from 2 to 10 years for intermediate-grade sarcomas; and every 3 months for 2 years, every 6 months from 2 to 5 years, and annually from 5 to 10 years for high-grade sarcomas.

CONCLUSIONS

Pulmonary screening beyond 5 years may not be necessary for Grade 1 tumors but should be continued until 10 years for Grade 2 and 3 bone sarcomas. The surveillance frequency listed here, which is based on the number of new pulmonary metastatic events per patient-year in each grade, would increase the number of such events detected per examination performed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Potential Safety Loophole of Fat Grafting in Breast Cancer Patients

Autologous fat grafting (AFG) accounts for 9.1 % of all cosmetic surgical procedures in the world. Its use has been increasing tremendously in breast reconstruction and produces satisfying outcomes. However, the lack of standard guidelines for routine screening protocols in breast cancer patients before and after AFG warrants consideration of the safety of AFG use in post-mastectomy and post-lumpectomy reconstruction. This manuscript examines AFG in breast reconstruction publications and details the complications, the mechanism of AFG, as well as the relationship between adipose stem cells (ASCs) and cancer recurrence. The ASCs transferred in AFG act as multiple potent stem cells, which can impact cancer recurrence in various ways. Both in vitro and in vivo studies show that ASCs can stimulate the recurrence of breast cancer. Based on a review of existing evidence, we provide recommendations and guidelines for AFG use in breast reconstruction to aid in clinical decision-making. Further investigations are needed to evaluate the long-term clinical safety of AFG as well as the proposed guidelines.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Mammographic and Ultrasonographic Findings of Oxidized Regenerated Cellulose in Breast Cancer Surgery: A 5-Year Experience

BACKGROUND

The purpose of this study was to describe the ultrasonographic (US) and mammographic (MX) findings in patients who underwent breast-conserving surgery followed by oxidized regenerated cellulose (ORC) implantation in the surgical cavity and their size variations in follow-up.

MATERIALS AND METHODS

We retrospectively reviewed 417 MX and 743 US images performed between January 2009 and January 2014 for 262 women who underwent breast-conserving surgery. All patients underwent US, only 203 women underwent MX examination.

RESULTS

In 170 of 262 patients, US examinations showed abnormal findings. Three main US patterns were identified: (1) complex masses: well-encapsulated ipoisoechoic lesions with circumscribed margins with internal hyperechoic nodules (56%); (2) hypoanechoic lesions without internal hyperechoic nodules (24%); and (3) completely anechoic collections (20%). Moreover, Doppler ultrasound examination was performed on all of the patients. In 95 of 203 patients, MX examinations showed abnormalities. Four main MX patterns were identified: (1) round or oval opacity with circumscribed margins (58%); (2) round or oval opacity with indistinct or ill-defined margins (17%); (3) irregular opacity with indistinct or spiculated margins (9%); and (4) architectural distortion or focal asymmetry (15%). Most of the lesions showed a decrease in size at US and MX follow-up examination and the decrease was statistically significant (P < .01).

CONCLUSION

When applied to the surgical residual cavity, ORC aids to control local hemorrhage and reduce the risk of postoperative infections, but can lead to alterations in surgical scar. Thus, knowledge of the radiological findings might allow avoidance of misdiagnosis of tumor recurrence or unnecessary diagnostic examinations.

The reality in the follow-up of breast cancer survivors: survey of Korean Breast Cancer Society

Purpose

Follow-up after primary treatment for breast cancer is an important component of survivor care and various international guidelines exist for the surveillance. However, little is known about current actual practice patterns of physicians whether they adhere to or deviate from recommended guidelines. The aim of this study was to determine how physicians follow-up their patients after primary treatment for breast cancer in Korea.

Methods

A questionnaire survey with 34 questions in 4 categories was e-mailed to the members of Korean Breast Cancer Society from November to December 2013. Respondents were asked how they use follow-up modalities after primary treatment of breast cancer and we compared the survey results with present guidelines.

Results

Of the 129 respondents, 123 (95.3%) were breast surgeons. The most important consideration in follow-up was tumor stage. History taking, physical examinations, and mammography were conducted in similar frequency recommended by other guidelines while breast ultrasonography was performed more often. The advanced imaging studies such as CT, MRI, and bone scan, which had been recommended to be conducted only if necessary, were also examined more frequently. Regular screenings for secondary malignancy were performed in 38 respondents (29.5%). Five years later after primary treatment, almost the whole respondents (94.6%) themselves monitored their patients.

Conclusion

A majority of respondents have been performed more intensive follow-up modalities in comparison with present guidelines and less frequently screenings for secondary malignancy. For optimal follow-up of breast cancer survivors, tailored delivery system should be considered.

Serum ANGPTL2 levels reflect clinical features of breast cancer patients: implications for the pathogenesis of breast cancer metastasis

INTRODUCTION

Breast cancer is a leading cause of cancer-related death in women worldwide, and its metastasis is a major cause of disease mortality. Therefore, identification of the mechanisms underlying breast cancer metastasis is crucial for the development of therapeutic and diagnostic strategies. Our recent study of immunodeficient female mice transplanted with MDA-MB231 breast cancer cells demonstrated that tumor cell-derived angiopoietin-like protein 2 (ANGPTL2) accelerates metastasis through both increasing tumor cell migration in an autocrine/paracrine manner, and enhancing tumor angiogenesis. To determine whether ANGPTL2 contributes to its clinical pathogenesis, we asked whether serum ANGPTL2 levels reflect the clinical features of breast cancer progression.

METHODS

We monitored the levels of secreted ANGPTL2 in supernatants of cultured proliferating MDA-MB231 cells. We also determined whether the circulating ANGPTL2 levels were positively correlated with cancer progression in an in vivo breast cancer xenograft model using MDA-MB231 cells. Finally, we investigated whether serum ANGPTL2 levels were associated with clinical features in breast cancer patients.

RESULTS

Both in vitro and in vivo experiments showed that the levels of ANGPTL2 secreted from breast cancer cells increased with cell proliferation and cancer progression. Serum ANGPTL2 levels in patients with metastatic breast cancer were significantly higher than those in healthy subjects or in patients with ductal carcinoma in situ or non-metastatic invasive ductal carcinoma. Serum ANGPTL2 levels in patients negative for estrogen receptors and progesterone receptors, particularly triple-negative cases, reflected histological grades.

CONCLUSIONS

These findings suggest that serum ANGPTL2 levels in breast cancer patients could represent a potential marker of breast cancer metastasis.

Does intensity of surveillance affect survival after surgery for sarcomas? Results of a randomized noninferiority trial

BACKGROUND

Whether current postoperative surveillance regimes result in improved overall survival (OS) of patients with extremity sarcomas is unknown.

QUESTIONS/PURPOSES

We hypothesized that a less intensive followup protocol would not be inferior to the conventional followup protocol in terms of OS. We (1) assessed OS of patients to determine if less intensive followup regimens led to worsened survival and asked (2) whether chest radiograph followup group was inferior to CT scan followup group in detecting pulmonary metastasis; and (3) whether less frequent (6-monthly) followup interval was inferior to more frequent (3-monthly) followup in detecting pulmonary metastasis and local recurrence.

METHODS

A prospective randomized single-center noninferiority trial was conducted between January 2006 and June 2010. On the basis of 3-year survival of 60% with intensive, more frequent followup, 500 nonmetastatic patients were randomized to demonstrate noninferiority by a margin (delta) of 10% (hazard ratio [HR], 1.36). The primary end point was OS at 3 years. The secondary objective was to compare disease-free survival (DFS) (time to recurrence) at 3 years. At minimum followup of 30 months (median, 42 months; range, 30-81 months), 178 deaths were documented.

RESULTS

Three-year OS and DFS for all patients was 67% and 52%, respectively. Three-year OS was 67% and 66% in chest radiography and CT groups, respectively (HR, 0.9; upper 90% confidence interval [CI], 1.13). DFS rate was 54% and 49% in chest radiography and CT groups, respectively (HR, 0.82; upper 90% CI, 0.97). Three-year OS was 64% and 69% in 6-monthly and 3-monthly groups, respectively (HR, 1.2; upper 90% CI, 1.47). DFS was 51% and 52% in 6-monthly and 3-monthly groups, respectively (HR, 1.01; upper 90% CI, 1.2). Almost 90% of local recurrences were identified by patients themselves.

CONCLUSIONS

Inexpensive imaging detects the vast majority of recurrent disease in patients with sarcoma without deleterious effects on eventual outcomes. Patient education regarding self-examination will detect most instances of local recurrence although this was not directly assessed in this study. Although less frequent visits adequately detected metastasis and local recurrence, this trial could not conclusively demonstrate noninferiority in OS for a 6-monthly interval of followup visits against 3-monthly visits.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Serum tumor markers in patients with breast cancer

Several serum tumor markers have been investigated in patients with breast cancer for assessing outcome, predicting recurrence and monitoring the therapeutic response. There is a general consensus concerning their limited application in diagnosing malignancy; however, serum tumor markers can be considered for the early detection of recurrence. The most effective markers for this indication are cancer antigens (CA)15-3 and 27.29, and c-erbB-2, although their efficacy in establishing disease progression has not been determined to date. In terms of evaluating prognosis and predicting response to therapy, only the expression of c-erbB-2 has clinical evidence. To conclude, at present, no serum tumor marker is cost effective, and none can be used with confidence in the decision making regarding breast cancer patients.

Exploring the use of the survivorship consult in providing survivorship care

PURPOSE

Advances in breast cancer treatment have increased survival and contributed to longer periods of survivorship as reported by the Committee CCSsS (Canadian Cancer Statistics) (2011) and Hewitt et al. (2005), increasing the relevance of survivorship care. Survivorship care includes encouraging survivors to acquire the knowledge, skills and confidence to manage their life, as well as engaging survivors through post-diagnosis disease self-management and self-care strategies. The Survivorship Consult (SC) was designed to help survivors reflect on their needs, establish goals and create an action plan.

METHODS

Twenty-six breast cancer survivors who participated in the SC at Princess Margaret Cancer Centre took part in semi-structured interviews to assess the survivor experience and effectiveness of the SC. Data from these interviews were coded, and themes were identified using a modified grounded theory approach.

RESULTS

Themes that emerged regarding the experience and effectiveness of the SC included (1) the supportive experience of collaborative dialogue with supportive care clinicians (i.e. nurses, social workers, occupational therapists, etc.), (2) the development of personalized goals that motivated individuals to implement recommendations, (3) an enhanced understanding of their health condition, team and options, (4) an improved ability to identify needs and (5) an increased sense of confidence to manage issues related to care.

CONCLUSIONS

The assessment of the SC improved the experience of breast cancer patients by providing a supportive environment where they could feel cared about, by increasing understanding of their condition and its treatment, by improving communication with the care team and by motivating patients to manage care issues. Further research is needed on survivors who conduct the SC before the treatment phase of their cancer trajectory.

Clinical utility of serum tumor markers and circulating tumor cell assays in the treatment of breast cancer

OPINION STATEMENT

Though serum tumor markers and circulating tumor cells (CTCs) have been available to the oncologist for many years, their place in the management of breast cancer remains unclear. Due to issues with sensitivity and specificity, tumor markers are unreliable for the detection of metastases in early stage breast cancer. For patients with metastatic breast cancer without measurable disease (e.g., bone-only disease, pleural effusions, or ascites), it is reasonable to obtain baseline values of serum tumor markers and attempt to correlate them with the first set of scans. In patients with elevated markers at baseline whose tumor marker levels decrease in correlation with an improvement in clinical symptoms, it may be reasonable to use them in conjunction with imaging to help determine whether there is progression of disease. CTCs have been found to hold strong prognostic value for breast cancer in both the early stage and metastatic settings. No large prospective studies to date, however, have shown any predictive value for CTCs and their clinical utility is therefore limited. Whether changing treatment in response to an increase in CTCs without radiologic progression results in improvements in quality of life or survival remains to be seen. CTCs hold great promise in the management of breast cancer and future studies will help delineate their role more appropriately.

Monocarboxylate transporter 1 is up-regulated in basal-like breast carcinoma

AIMS

Monocarboxylate transporters (MCTs) have been considered promising targets for cancer therapy, since they facilitate lactate efflux in glycolytic tumours. However, their role in solid tumours is still poorly understood. Thus, the present work aimed to contribute to understanding the involvement of MCT1 and MCT4 in breast cancer progression as well as MCT regulation by CD147.

METHODS AND RESULTS

The expression of the membrane transporters MCT1 and MCT4 was analysed in a series of breast carcinomas (249 cases) and their clinicopathological significance investigated. Additionally, we analysed the significance of CD147 co-expression, as an important regulator of MCT expression and activity. MCT1 was significantly increased in breast carcinomas when compared with normal breast tissue and, importantly, both MCT1 and CD147 were associated with poor prognostic variables such as basal-like subtype and high grade tumours.

CONCLUSIONS

These results provide evidence for a prognostic value of MCT1 in breast carcinoma and support the exploitation of the complex MCT1/CD147 as a promising target for cancer therapy, especially in basal-like breast carcinoma.

The histone deacetylase inhibitor butyroyloxymethyl diethylphosphate (AN-7) protects normal cells against toxicity of anticancer agents while augmenting their anticancer activity

The histone deacetylase inhibitor (HDACI) butyroyloxymethyl diethylphosphate (AN-7) has been shown to synergize doxorubicin (Dox) anticancer activity while attenuating its cardiotoxicity. In this study we further explored the selectivity of AN-7's action in several cancer and normal cells treated with anticancer agents. The cells studied were murine mammary 4T1, human breast T47D and glioblastoma U251 cancer cell lines, neonatal rat cardiomyocytes, cardiofibroblasts and astrocytes, and immortalized cardiomyocyte H9C2 cells. Cell death, ROS production and changes in protein expression were measured and in vivo effects were evaluated in Balb-c mice. AN-7 synergized Dox and anti-HER2 cytotoxicity against mammary carcinoma cells with combination indices of 0.74 and 0.79, respectively, while it protected cardiomyocytes against their toxicity. Additionally AN-7 protected astrocytes from Dox-cytoxicity. Cell-type specific changes in the expression of proteins controlling survival, angiogenesis and inflammation by AN-7 or AN-7+Dox were observed. In mice, the protective effect of AN-7 against Dox cardiotoxicity was associated with a reduction in inflammatory factors. In summary, AN-7 augmented the anticancer activity of Dox and anti-HER2 and attenuated their toxicity against normal cells. AN-7 modulation of c-Myc, thrombospondin-1, lo-FGF-2 and other proteins were cell type specific. The effects of AN-7, Dox and their combination were preserved in vivo indicating the potential benefit of combining AN-7 and Dox for clinical use.

Breast self-examination in long-term breast cancer survivors

INTRODUCTION

For many breast cancer survivors, continued surveillance will be necessary to increase the possibility of finding a new diagnosis in an early stage. One such surveillance approach, breast self-examination, has not been studied specifically in breast cancer survivors. The current study was designed to assess the practice of BSE in a sample of long-term breast cancer survivors, and to examine the personal, emotional, cognitive, and health-care provider factors that may contribute to its performance.

METHODS

Three hundred forty-five breast cancer survivors (34% response rate, 345/1,001) diagnosed with in situ-stage II breast cancer between 1997-2004 at a community hospital provided answers to a mailed, self-report questionnaire.

RESULTS

Seventy-six percent of respondents reported that they had performed a BSE in the last 30-days. Forty percent reported performing BSE once/month, 39% more than once/month, and 21% less than once/month since their diagnosis. Most of the women (90%) reported that a doctor or nurse told them to perform a BSE once/month since their diagnosis, although only 69% had actually been shown how to perform a BSE. Consistently, the perception of increased barriers to BSE performance was associated with performance of BSE less than once/month (OR = 1.4, 95% CI 1.2, 1.6; OR = 0.8, 95% CI 0.8, 0.9). In addition, depending on the model, age (OR = 1.1, 95% CI 1.0, 1.2), perceived effectiveness of cancer treatments (OR = 0.7, 95% CI 0.5, 0.9), and perceived benefits of BSE (OR = 0.8, 95% CI 0.7, 0.9) also was associated with differences in BSE performance.

CONCLUSION

The current study suggests that breast cancer survivors between 4 and 11 years from diagnosis practice BSE, although their perception of the barriers to conducting BSE influences the frequency of this behavior. Further examination is needed to understand why some survivors perceive greater barriers to BSE performance than others. Also needed is a prospective examination of BSE performance using behavioral measures in relation to self-report.

IMPLICATIONS FOR CANCER SURVIVORS

Increased attention should be paid to this particular screening behavior performed by a majority of breast cancer survivors by both researchers and health-care providers alike. Whether survivors perform the behavior correctly and the impact it has on their emotional and cognitive well-being should be further explored.

The reality in the surveillance of breast cancer survivors-results of a patient survey

BACKGROUND

International guidelines for the surveillance of breast cancer patients recommend a minimized clinical follow-up including routine history and physical examination and regularly scheduled mammograms. However, the abandonment of scheduled follow-up examinations in breast cancer survivors remains a contradiction to established follow-up guidelines for other solid tumours.

PATIENTS AND METHODS

We report the patients' view on the basis of a survey performed in two separate geographical areas in Germany. The questionnaires were sent out to 2.658 patients with a history of breast cancer.

RESULTS

A total of 801 patients (30.1%) responded to the questionnaire. The results of the survey can be summarized in two major categories: First, necessity for surveillance was affirmed by a majority (>95%), and 47.8% of the organized patients answered that there was a need for more intensive diagnostic effort during follow-up. The main expectation from an intensified follow-up was the increased feeling of security as expressed by >80% of the women. Second, the present survey indicates that most of the regularly scheduled follow-up visits were expanded using extensive laboratory and imaging procedures exceeding the quantity of examinations recommended in the present follow-up guidelines.

CONCLUSION

Despite the fact that only one third of the patients responded to the questionnaire, the survey indicates that a majority of physicians who treated these patients still do not accept the present follow-up guidelines. To some extent this may be explained by the observation that patients and possibly also their doctors trust that intensified follow-up increases diagnostic security and survival. Since considerable changes in the treatment options of breast cancer have been made during the last decades a new trial of investigations in follow-up is warranted.

Telomere DNA content predicts breast cancer-free survival interval

BACKGROUND

Telomeres are nucleoprotein complexes that protect chromosome ends from degradation and recombination. Critically shortened telomeres generate genomic instability. It has been postulated that the extent of telomere DNA loss is related to the degree of genomic instability within a tumor and therefore may presage clinical outcome. The objective of this investigation was to evaluate the hypothesis that telomere DNA content (TC) in breast tumor tissues predicts breast cancer-free survival interval.

MATERIALS AND METHODS

Slot blot titration assay was used to quantitate TC in 530 archival breast tumor tissues in a population-based cohort. The relationships between TC, 12 risk factors for breast cancer adverse events (i.e., death due to breast cancer, breast cancer recurrence, or development of a new primary breast tumor), and breast cancer-free survival interval were evaluated by Fisher's exact test, log-rank analysis, and univariate and multivariate Cox proportional hazards models.

RESULTS

TC was independent of each of the 12 risk factors. Ethnicity, tumor-node-metastasis stage, estrogen receptor, progesterone receptor, and p53 status, chemotherapy sequence, adjuvant therapy, and TC each conferred significant relative hazards. The best overall multivariate Cox proportional hazards model included TC, p53 status, tumor-node-metastasis stage, and estrogen receptor status as independent predictors of breast cancer-free survival interval (P < 0.00005). Low TC (< or =200% of standard), relative to the high-TC group (>200% of standard), conferred an adjusted relative hazard of 2.88 (95% confidence interval, 1.16-7.15; P = 0.022) for breast cancer-related adverse events.

CONCLUSIONS

TC in breast cancer tissue is an independent predictor in this group of breast cancer-free survival interval.

FDG-PET/CT in restaging of patients with recurrent breast cancer: possible impact on staging and therapy

We aimed to compare the value of combined positron emission tomography (PET)/CT, PET+CT (viewed side by side), CT alone and PET alone concerning the rTNM stage and influence on therapy in patients with recurrent breast cancer. 44 patients with suspicion of recurrent breast cancer underwent whole-body [18F]-2-fluoro-2-deoxy-d-glucose (FDG)-PET/CT. Images of combined PET/CT, PET+CT, PET alone and CT alone were evaluated by four blinded reader teams. Diagnostic accuracies and influence on therapy were compared. Histology and a mean clinical follow up of 456 days served as the standard of reference. Differences between the staging procedures were tested for statistical significance by McNemar's test. Overall TNM tumour stage was correctly determined in 40/44 patients with PET/CT, in 38/44 with PET+CT, in 36/44 with PET alone and in 36/44 patients with CT alone. No statistically significant difference was detected between all tested imaging modalities. PET/CT changed the therapy in two patients compared with PET+CT, in four patients compared with PET alone and in five patients compared with CT alone. Combined PET/CT appeared to be more accurate in assessing the rTNM and showed a moderate impact on therapy over PET and CT. Minor improvements were noted when compared with PET+CT. Experienced readers might therefore be able to provide accurate staging results for further therapy from separately acquired studies.

[Post-treatment surveillance for potentially curable malignancies]

Through an enormous research effort over the past five decades and especially due to early screening, an increasing number of cancers are potentially curable. Patients expand immeasurable energy in adhering to treatment plans and supportive care. Unfortunately, nothing prepares them for the anxiety that often comes with completion of therapy. More importantly, physicians are not properly equipped with data from controlled trials to define appropriate post-treatment surveillance, data with which they could educate patients and allay their fears. The goal of post-treatment surveillance is to enable the early detection of relapses and thus enhance the possibility of subsequent cure. Accordingly special follow-up is appropriate only for patients who can receive a second-line therapy. Clinical trials support conservative, rather than aggressive, surveillance to detect curable local relapse of breast tumors and potentially surgically curable metastases (mainly in the liver) of colon cancer. For germ-cell tumors, second-line treatments are potentially curative in nearly all instances. Follow-up for other cancers depends on patients' anxiety levels and on the costs of surveillance.

Validation of image quality in full-field digital mammography: Is the replacement of wet by dry laser printers justified?

OBJECTIVE

Dry laser printers have replaced wet laser printers to produce hard copies of high-resolution digital images, primarily because of environmental concerns. However, no scientific research data have been published that compare the image quality of dry and wet laser printers in full-field digital mammography (FFDM). This study questions the image quality of these printers.

MATERIALS AND METHODS

Objective image quality parameters of both printers were evaluated using a standardized printer test image, i.e., optical density and detectability of specific image elements (lines, curves, and shapes). Furthermore, mammograms of 129 patients with different breast tissue composition patterns were imaged with both printers. A total of 1806 subjective image quality parameters (brightness, contrast, and detail detection of anatomic structures), the detectability of breast lesions, as well as diagnostic performance according to the BI-RADS classification were evaluated. In addition, the presence of film artifacts was investigated.

RESULTS

Optical density values were equal for the dry and the wet laser printer. Detection of specific image elements on the printer test image was not different. Ratings of subjective image quality parameters were equal, as were the detectability of breast lesions and the diagnostic performance. Dry laser printer images showed more artifacts (164 versus 27). However, these artifacts did not influence image quality.

CONCLUSION

Based on the evidence of objective and subjective parameters, a dry laser printer equals the image quality of a wet laser printer in FFDM. Therefore, not only for reasons of environmental preference, the replacement of wet laser printers by dry laser printers in FFDM is justified.

Comparison of breast cancer mortality rates with those of ovarian and colorectal carcinoma

Background

Traditional survival curves cannot easily be used to predict outcome for an individual patient on a year-to-year basis. This difficulty is partly overcome by yearly mortality analysis. This method was employed to analyse long-term follow-up of three cancers: colorectal, ovarian and breast cancer.

Methods

The study used prospectively collected cancer registry data from geographically defined regions in Scotland. Cohort sizes were 7196 patients with breast cancer, 3200 with colorectal cancer and 1866 with ovarian cancer. Follow-up extended to 23 years.

Results

Two distinct patterns of mortality emerged. Mortality rates for ovarian and colorectal cancer were initially high (41 and 21 per cent) but decreased rapidly; by 10 years patients had either died or were cured. The influence of stage diminished with follow-up. Breast cancer mortality was lower than that of colorectal or ovarian cancer, but remained raised in comparison to the general population throughout follow-up. The influence of breast cancer size reduced with follow-up, whereas that of nodal status persisted.

Conclusion

Patients with breast cancer live at increased risk of death to the end of follow-up, supporting the concept of dormancy in breast cancer biology. This was not observed with colorectal or ovarian cancer.

Mode of interaction between butyroyloxymethyl-diethyl phosphate (AN-7) and doxorubicin in MCF-7 and resistant MCF-7/Dx cell lines

PURPOSE

To investigate the anticancer activity and mode of action of butyroyloxymethyl-diethyl phosphate (AN-7), a prodrug of butyric acid and formaldehyde, as a single agent and in combination with doxorubicin in human carcinoma MCF-7 and the multidrug resistant MCF-7 Dx cell lines.

METHODS

The anti-cancer activity of AN-7 as a single agent or in combination with doxorubicin was measured by the Hoechst cell viability and colony forming assays as well as by FACS analyses of cells stained with propidium iodide and annexin V-FITC. Modulations of protein expression and acetylation were measured by Western blot analyses. The number of doxorubicin-DNA adducts formed was evaluated using (14)C-labeled doxorubicin.

RESULTS

The AN-7 and homologous prodrugs exhibited similar growth inhibition effects against drug resistant and sensitive cells, and elicited their anticancer effect partially by inhibition of HDAC. The AN-7 transiently augmented histone acetylation and increase of p21 expression. Synergy between AN-7 and doxorubicin was demonstrated in the sensitive and the resistant cell lines by viability and colony formation assays and was further confirmed by FACS analysis showing an increase in cell mortality. The number of doxorubicin-DNA adducts in total genomic DNA isolated from cells treated with (14)C-labeled doxorubicin and AN-7 increased substantially compared to treatment with doxorubicin only. Treatment with AN-7 or doxorubicin increased p53 acetylation that was further potentiated by their combination.

CONCLUSION

The AN-7 combined with doxorubicin overcame drug resistance; at least in part by the intracellularly releasable formaldehyde that augmented formation of doxorubicin-DNA adducts and butyric acid that induced histone and p53 acetylation. Since the use of doxorubicin is limited by toxicity, the combination could offer an effective treatment modality with lower toxicity for breast cancer.

Serum tumor markers in breast cancer: are they of clinical value?

BACKGROUND

Although multiple serum-based tumor markers have been described for breast cancer, such as CA 15-3, BR 27.29 (CA27.29), carcinoembryonic antigen (CEA), tissue polypeptide antigen, tissue polypeptide specific antigen, and HER-2 (the extracellular domain), the most widely used are CA 15-3 and CEA.

METHODS

The literature relevant to serum tumor markers in breast cancer was reviewed. Particular attention was given to systematic reviews, prospective randomized trials, and guidelines issued by expert panels.

RESULTS

Because of a lack of sensitivity for early disease and lack of specificity, none of the available markers is of value for the detection of early breast cancer. High preoperative concentrations of CA 15-3 are, however, associated with adverse patient outcome. Although serial determinations of tumor markers after primary treatment for breast cancer can preclinically detect recurrent/metastatic disease with lead times of approximately 2-9 months, the clinical value of this lead time remains to be determined. Serum markers, however, are the only validated approach for monitoring treatment in patients with advanced disease that cannot be evaluated by use of conventional criteria.

CONCLUSIONS

CA 15-3 is one of the first circulating prognostic factors for breast cancer. Preoperative concentrations thus might be combined with existing prognostic factors for predicting outcome in patients with newly diagnosed breast cancer. At present, the most important clinical application of CA 15-3 is in monitoring therapy in patients with advanced breast cancer that is not assessable by existing clinical or radiologic procedures.

Preoperative Profiling of Symptomatic Breast Cancer by Diagnostic Core Biopsy

BACKGROUND

Precise preoperative profiling of breast tumors could facilitate fuller consideration of (neo)adjuvant therapies.

METHODS

Diagnostic core biopsy (DCB) accuracy in profiling the primary tumor was prospectively studied in 95 patients with operable breast cancer. The histological type and grade (hematoxylin and eosin staining) and membrane receptor status (semiquantitative immunohistochemistry for estrogen [ER] and progesterone [PR] receptors, as well as Her-2 antigen expression) were assigned by the DCB before surgery. These measures were then compared with those of the definitive surgical specimen available after operation.

RESULTS

DCB correctly ascribed tumor type and grade and ER, PR, and Her-2 receptor status in most cases (correlating exactly in 97.5%, 77%, 68%, 71%, and 60%, respectively) with at least moderate concordance (weighted kappa, >.41). When miscategorized, DCB consistently tended to upscore the receptor stain intensity compared with the surgical specimen (22%, 19%, and 27% had higher ER, PR, and Her-2 categorical scores, respectively). ER H-scores correlated best in specimens that stained strongly (224.4 +/- 3 vs. 215.5 +/- 5) and were significantly higher on DCB in those that stained either moderately (195.6 +/- 8.2 vs. 156.8 +/- 5.1; P < .0001) or weakly (157.1 +/- 24.8 vs. 81.4 +/- 4; P = .02). DCB accurately identified all tumors with clinically important ER and Her-2 expression. Furthermore, it promoted three patients into the therapeutically significant range of ER (n = 1) or Her-2 (n = 2) expression. ER negativity on DCB (n = 25) indicated a high-grade tumor (88%), although 11 (44%) patients also overexpressed Her-2. Significant Her-2 expression (n = 16) on DCB predicted the tumor as being poorly differentiated (80%) and both ER and PR negative (67%).

CONCLUSIONS

DCB accurately profiles clinically relevant measures of primary tumor cell differentiation. It also reliably categorizes patients with regard to (neo)adjuvant therapy before radical surgery is attempted.

Image Quality of a Wet Laser Printer Versus a Paper Printer for Full-Field Digital Mammograms

OBJECTIVE

The purpose of our study was to compare the image quality of a wet laser printer with that of a paper printer for full-field digital mammography (FFDM).

MATERIALS AND METHODS

For both a wet laser printer and a paper printer connected to an FFDM system, image quality parameters were evaluated using a standardized printer test image (luminance density, dynamic range). The detectability of standardized objects on a phantom was also evaluated. Furthermore, 640 mammograms of 80 patients with different breast tissue composition patterns were imaged with both printers. Subjective image quality parameters (brightness, contrast, and detection of details of anatomic structures-that is, skin, subcutis, musculature, glandular tissue, and fat), the detectability of breast lesions (mass, calcifications), and the diagnostic performance according to the BI-RADS classification were evaluated.

RESULTS

Both the luminance density and the dynamic range were superior for the wet laser printer. More standardized objects were visible on the phantom imaged with the wet laser printer than with the paper printer (13/16 vs 11/16). Each subjective image quality parameter of the mammograms from the wet laser printer was rated superior to those of the paper printer. Significantly more breast lesions were detected on the wet laser printer images than on the paper printer images (masses, 13 vs 10; calcifications, 65 vs 48; p < 0.05). With the paper printer images, BI-RADS 4 and 5 categories were underestimated for 10 (43.5%) of 23 patients.

CONCLUSION

For FFDM, images obtained from a wet laser printer show superior objective and subjective image quality compared with a paper printer. As a consequence, the paper printer should not be used for FFDM.

The clinical use of tumor makers in select cancers: are you confident enough to discuss them with your patients?

PURPOSE/OBJECTIVES

To review the clinical use of tumor markers in select cancers and highlight future directions in tumor marker development.

DATA SOURCES

Guidelines from national and international societies, scientific literature, and Internet resources.

DATA SYNTHESIS

Tumor markers are important tools in the management of cancer. Sequencing of the human genome has led to new tumor marker development in the fields of proteomics and DNA microarray technologies.

CONCLUSIONS

Tumor marker technology is expanding rapidly; almost a dozen tumor markers currently are being used in the oncology arena, with many more in development. The use of tumor markers can be controversial, particularly because guidelines have not been established for all of the markers.

IMPLICATIONS FOR NURSING

Oncology nurses need to be well versed in the use of tumor markers to educate and counsel patients with cancer.

Forequarter amputation for recurrent breast cancer: A case report and review of the literature

Axillary recurrence of breast cancer is an uncommon event that can lead to debilitating pain, lymphedema, and paralysis of the upper extremity. Multimodality therapy including surgery is usually used to control local recurrence. In a subset of patients, the extent of disease is such that local excision of the recurrence is not possible. In the absence of metastatic disease, forequarter amputation may be used as an effective means of surgical salvage and palliation for locally recurrent breast cancer. In this report, we describe management of a patient with advanced axillary recurrence treated with forequarter amputation and review the current literature on the use of this operation in breast cancer patients.

Menopausal status dependence of the timing of breast cancer recurrence after surgical removal of the primary tumour

INTRODUCTION

Information on the metastasis process in breast cancer patients undergoing primary tumour removal may be extracted from an analysis of the timing of clinical recurrence.

METHODS

The hazard rate for local-regional and/or distant recurrence as the first event during the first 4 years after surgery was studied in 1173 patients undergoing mastectomy alone as primary treatment for operable breast cancer. Subset analyses were performed according to tumour size, axillary nodal status and menopausal status.

RESULTS

A sharp two-peaked hazard function was observed for node-positive pre-menopausal patients, whereas results from node-positive post-menopausal women always displayed a single broad peak. The first narrow peak among pre-menopausal women showed a very steep rise to a maximum about 8-10 months after mastectomy. The second peak was considerably broader, reaching its maximum at 28-30 months. Post-menopausal patients displayed a wide, nearly symmetrical peak with maximum risk at about 18-20 months. Peaks displayed increasing height with increasing axillary lymph node involvement. No multi-peaked pattern was evident for either pre-menopausal or post-menopausal node-negative patients; however, this finding should be considered cautiously because of the limited number of events. Tumour size influenced recurrence risk but not its timing. Findings resulting from the different subsets of patients were remarkably coherent and each observed peak maintained the same position on the time axis in all analysed subsets.

CONCLUSIONS

The risk of early recurrence for node positive patients is dependent on menopausal status. The amount of axillary nodal involvement and the tumour size modulate the risk value at any given time. For pre-menopausal node-positive patients, the abrupt increase of the first narrow peak of the recurrence risk suggests a triggering event that synchronises early risk. We suggest that this event is the surgical removal of the primary tumour. The later, broader, more symmetrical risk peaks indicate that some features of the corresponding metastatic development may present stochastic traits. A metastasis development model incorporating tumour dormancy in specific micro-metastatic phases, stochastic transitions between them and sudden acceleration of the metastatic process by surgery can explain these risk dynamics.

The choice of the correct imaging modality in breast cancer management

This brief overview discusses which of the diagnostic options are more reliable and effective for breast cancer imaging with a view to avoiding the unjustified use of techniques that are suboptimal. The technological development of diagnostic imaging has been very impressive, and both radiological (mammography, ultrasonography, computed tomography, magnetic resonance imaging) and nuclear medicine tools (bone scan, planar and SPECT scintigraphy, sentinel node biopsy, positron emission tomography) have helped to overcome past limitations in the detection of small lesions. Furthermore, new approaches have been developed that permit successful differential diagnosis of doubtful lesions and rapid identification of systemic metastases, and allow non-invasive characterisation of the biology of cancer tissue. There is evidence that these advances may have helped in optimising therapeutic strategies. Importantly, the metabolic information provided by nuclear medicine procedures may be combined with the anatomical data supplied by radiological techniques in order to assist in predicting tumour response, planning radiotherapy and monitoring patient outcome. It is difficult to formulate conclusive diagnostic guidelines for application in the work-up of breast cancer, because while the role of some examinations, such as mammography and ultrasonography, is well established, that of others, such as magnetic resonance imaging and positron emission tomography, is still a matter of debate. There is a need for further prospective evaluations with appropriate clinical trials designed to evaluate the impact of these approaches in improving survival and quality of life.