Radiation-induced Histopathologic Changes of the Breast

Does Prior Breast Irradiation Increase Complications of Subsequent Reduction Surgery in Breast Cancer Patients? A systematic Review and Meta-Analysis

BACKGROUND

Reduction mammoplasty and mastopexy are potentially complicated by prior breast irradiation as part of breast conserving therapy. Associated tissue changes with therapeutic irradiation have led to surgeons deciding the risks may outweigh potential benefit for those patients. A systematic review of the existing literature was performed to explore surgical outcomes of patients undergoing delayed bilateral reduction mammoplasty or mastopexy following unilateral breast irradiation as part of breast conserving therapy.

METHODS

Medline, PubMed and EMBASE were searched from 1990 to 2023 according to PRISMA guidelines. Studies were combined by the generic inverse variance method on the natural logarithms of rate ratios (RR) using a random effect model in Review manager 5.4.1.

RESULTS

Fifteen studies reported outcomes in 188 patients who underwent breast reduction (BR) following unilateral breast conserving surgery and radiotherapy. The median age at BR was 51.5 years (range 39-60), and median time since radiotherapy was 48 months (range 11.7-86). We compared outcomes for irradiated breast (IB) versus non-irradiated breast (NIB). Pooled results showed higher rate of major complications in the IB (RR 2.52, 95%CI 0.96-6.63, p=0.06), but not statistically significant. However, rate of minor complications was significantly higher in the IB (RR 3.97 95%CI 1.86-8.50, p<0.0004). Incidence of fat necrosis as a discrete complication was 2× higher in IB (RR 2.14 95%CI 0.85-5.35, p-value 0.10) compared to the NIB, but not significant.

CONCLUSION

We found breast reduction to be safe with acceptable risk of major complications. However, the overall complication rate remains higher in IB compared to NIB.

LEVEL OF EVIDENCE III

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 .

Spectrum of atypical ductal hyperplasia (ADH) and ductal carcinoma in-situ (DCIS): Diagnostic challenges

Breast specimens are some of the more common specimens sent to the pathology laboratory for diagnosis. From a clinical perspective, the diagnoses fall into three broad categories: benign, atypical and malignant with patients then being managed according to established guidelines. However, the pathologic diagnosis can sometimes be challenging, and the distinction between these categories is sometimes far more subtle and subjective than non-pathologist may understand. One recurring diagnostic challenge in breast pathology is the diagnosis of atypical ductal hyperplasia (ADH) versus ductal carcinoma in situ (DCIS). While many cases are straightforward, others are quite borderline and challenging to classify consistently with significant interobserver variation amongst pathologists. The distinction between ADH and DCIS is critical from a clinical management perspective because one is treated as a risk factor, and the other as a malignancy that will be completely surgically excised and may require radiation therapy. This review will address the spectrum of ADH and DCIS with the associated diagnostic challenges in the real-world setting from presentation at core needle biopsy to surgery.

Biological effects of intraoperative radiation therapy: histopathological changes and immunomodulation in breast cancer patients

Introduction

Intraoperative radiation therapy (IORT) delivers a single accelerated radiation dose to the breast tumor bed during breast-conserving surgery (BCS). The synergistic biologic effects of simultaneous surgery and radiation remain unclear. This study explores the cellular and molecular changes induced by IORT in the tumor microenvironment and its impact on the immune response modulation.

Methods

Patients with hormone receptor (HR)-positive/HER2-negative, ductal carcinoma in situ (DCIS), or early-stage invasive breast carcinoma undergoing BCS with margin re-excision were included. Histopathological evaluation and RNA-sequencing in the re-excision tissue were compared between patients with IORT (n=11) vs. non-IORT (n=11).

Results

Squamous metaplasia with atypia was exclusively identified in IORT specimens (63.6%, p=0.004), mimicking DCIS. We then identified 1,662 differentially expressed genes (875 upregulated and 787 downregulated) between IORT and non-IORT samples. Gene ontology analyses showed that IORT was associated with the enrichment of several immune response pathways, such as inflammatory response, granulocyte activation, and T-cell activation (p<0.001). When only considering normal tissue from both cohorts, IORT was associated with intrinsic apoptotic signaling, response to gamma radiation, and positive regulation of programmed cell death (p<0.001). Using the xCell algorithm, we inferred a higher abundance of γδ T-cells, dendritic cells, and monocytes in the IORT samples.

Conclusion

IORT induces histological changes, including squamous metaplasia with atypia, and elicits molecular alterations associated with immune response and intrinsic apoptotic pathways. The increased abundance of immune-related components in breast tissue exposed to IORT suggests a potential shift towards active immunogenicity, particularly immune-desert tumors like HR-positive/HER2-negative breast cancer.

Quantitative evaluation of radiation-induced metabolic changes in the ipsilateral breast by FDG-PET/CT

Background and aim

There are no reports of quantitative evaluation of metabolic changes in the mammary gland after radiation therapy. The purpose of this study was to investigate metabolic changes in the ipsilateral mammary gland after radiation therapy and to evaluate the late radiation effects.

Patients and methods

Metabolic changes of the ipsilateral and contralateral mammary glands were retrospectively evaluated by F-18 fluorodeoxyglucose (FDG) PET/CT after whole breast irradiation following lumpectomy in five breast cancer patients. The maximum standardized uptake values (SUVmax) of the ipsilateral mammary gland (S1) and the contralateral mammary gland (S0) were measured. The relative SUVmax (= S1/S0) was measured immediately before, one year after, three years after, and five years after radiation therapy.

Results

The SUVmax of the ipsilateral mammary gland decreased gradually, but there was no decrease in the SUVmax of the contralateral mammary gland. Relative SUVmax values before, 1, 3, and 5 years after radiation therapy were 1.33 ± 0.20, 1.13 ± 0.35, 0.99 ± 0.26 and 0.62 ± 0.10, respectively. Relative SUVmax value at 5 years was significantly lower than before radiation therapy (P < 0.01).

Conclusions

18F-FDG PET/CT may be useful in assessing mammary gland function and predict lactation disorders in advance.

Long-Term Effects of Breast Cancer Therapy and Care: Calm after the Storm?

Breast cancer is still a lethal disease and the leading cause of death in women, undermining patients' survival and quality of life. Modern techniques of surgery and radiotherapy allow for the obtaining of good results in terms of survival, however they cause long-term side effects that persist over time, such as lymphedema and neuropathy. Similarly, the advent of new therapies such as endocrine therapy revolutionized breast cancer outcomes, but side effects are still present even in years of follow-up after cure. Besides the side effects of medical and surgical therapy, breast cancer is a real disruption in patients' lives considering quality of life-related aspects such as the distortion of body image, the psychological consequences of the diagnosis, and the impact on family dynamics. Therefore, the doctor-patient relationship is central to providing the best support both during treatment and afterwards. The aim of this review is to summarize the consequences of medical and surgical treatment on breast cancer patients and to emphasize the importance of early prevention of side effects to improve patients' quality of life.

Atypia in breast pathology: what pathologists need to know

Despite the importance of atypia in diagnosing and classifying breast lesions, the definition of atypia varies depending on the context, with a lack of consistent and objective criteria for assessment. Atypia in breast pathology may be cytonuclear and/or architectural with different applications and implications. Cytonuclear atypia is used to assist the distinction of various intraductal epithelial proliferative lesions including usual ductal hyperplasia (UDH) versus atypical ductal hyperplasia (ADH) or ductal carcinoma in situ (DCIS), and to grade DCIS. In invasive carcinoma, nuclear atypia (i.e., nuclear pleomorphism) is a component of the histological grading system. Stromal cell cytonuclear atypia is one of the key features used to distinguish fibroadenoma from phyllodes tumour (PT) and to classify PT as benign, borderline or malignant. Similarly, cytonuclear atypia is used in the evaluation of myoepithelial cell alterations in the breast. Architectural atypia is used to differentiate flat epithelial atypia (FEA) from ADH or DCIS. In addition to the inherent subjectivity in the interpretation of atypia, which presents as a morphological continuum reflecting a biological spectrum, the lack of standardisation in defining atypia augments diagnostic discordance in breast pathology, with potential implications for patient management. Evidence to date suggests that the traditional criteria used to assess atypia may require modification in the era of digital pathology primary diagnosis. This review aims to provide a comprehensive review of atypia in breast pathology with reference to inconsistencies, challenges and limitations.

Fertility and breast cancer: A literature review of counseling, preservation options and outcomes

Fertility preservation is an important issue in breast cancer patients undergoing oncological treatment. Fertility counseling is a crucial need given the physical and psychological stress experienced by patients. Cryopreservation of mature oocytes is currently the standard fertility-preserving procedure. Other options such as ovarian tissue preservation or gonadal protection during chemotherapy are still experimental, but have proven effectiveness. Prompt referral to a fertility unit is highly recommended in order to ensure quality of care. In this article, we focus on the different strategies to preserve fertility in breast cancer patients, assessing also the safety of pregnancy and breastfeeding after cancer. A systemic literature review was performed for research articles published in English in PubMed, or as abstracts from the European Society for Medical Oncology (ESMO), San Antonio Breast Cancer Symposium (SABCS) and American Society of Clinical Oncology (ASCO) annual meetings, using the search terms "breast cancer" and "fertility".

Regenerative tissue filler for breast conserving surgery and other soft tissue restoration and reconstruction needs

Complete removal of cancerous tissue and preservation of breast cosmesis with a single breast conserving surgery (BCS) is essential for surgeons. New and better options would allow them to more consistently achieve this goal and expand the number of women that receive this preferred therapy, while minimizing the need for re-excision and revision procedures or more aggressive surgical approaches (i.e., mastectomy). We have developed and evaluated a regenerative tissue filler that is applied as a liquid to defects during BCS prior to transitioning to a fibrillar collagen scaffold with soft tissue consistency. Using a porcine simulated BCS model, the collagen filler was shown to induce a regenerative healing response, characterized by rapid cellularization, vascularization, and progressive breast tissue neogenesis, including adipose tissue and mammary glands and ducts. Unlike conventional biomaterials, no foreign body response or inflammatory-mediated "active" biodegradation was observed. The collagen filler also did not compromise simulated surgical re-excision, radiography, or ultrasonography procedures, features that are important for clinical translation. When post-BCS radiation was applied, the collagen filler and its associated tissue response were largely similar to non-irradiated conditions; however, as expected, healing was modestly slower. This in situ scaffold-forming collagen is easy to apply, conforms to patient-specific defects, and regenerates complex soft tissues in the absence of inflammation. It has significant translational potential as the first regenerative tissue filler for BCS as well as other soft tissue restoration and reconstruction needs.

ABM Clinical Protocol #34: Breast Cancer and Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

3D Printing Breast Tissue Models: A Review of Past Work and Directions for Future Work

Breast cancer often results in the removal of the breast, creating a need for replacement tissue. Tissue engineering offers the promise of generating such replacements by combining cells with biomaterial scaffolds and serves as an attractive potential alternative to current surgical repair methods. Such engineered tissues can also serve as important tools for drug screening and provide in vitro models for analysis. 3D bioprinting serves as an exciting technology with significant implications and applications in the field of tissue engineering. Here we review the work that has been undertaken in hopes of generating the recognized in-demand replacement breast tissue using different types of bioprinting. We then offer suggestions for future work needed to advance this field for both in vitro and in vivo applications.

Breastfeeding and Breast Cancer: Managing Lactation in Survivors and Women with a New Diagnosis

BACKGROUND

Supporting breastfeeding is a global health priority, yet few clinical guidelines exist to guide surgical oncologists in managing lactation during or after breast cancer treatment.

METHODS

The literature was reviewed to identify evidence-based strategies for managing lactation during multidisciplinary breast cancer treatment or among breast cancer survivors.

RESULTS

The majority of the evidence is from observational studies, with some higher levels of evidence, including systematic reviews and meta-analyses. Several significant gaps in knowledge remain.

CONCLUSIONS

This review serves as a comprehensive resource of evidence-based recommendations for managing lactation in breast cancer survivors and breastfeeding women with a new breast cancer diagnosis.

Exuberant Squamous Metaplasia with Calcification Following Intraoperative Radiotherapy for Breast Carcinoma: Report of an Unusual Case and Retrospective Review of Cases from a Single Institution

Intraoperative radiotherapy (IORT) is a novel and increasingly utilized radiation technique in the treatment of breast carcinoma. There are few reports on the histologic changes seen in breast tissue from patients who have undergone IORT. We sought to evaluate the histologic changes observed in specimens received following IORT, as well as report an unusual case which prompted our study. A retrospective review of patients who received IORT and subsequently had breast tissue histologically evaluated at our institution was performed. Fifteen post-IORT specimens from 12 patients, including the patient from the reported case, were studied. We report a case of a 77-year-old woman found to have mammographic microcalcifications at the lumpectomy site 6 months following lumpectomy and IORT for ductal carcinoma in situ (DCIS). A stereotactic biopsy showed abundant desquamated anucleate squamous cells with calcification and keratin material associated with squamous metaplasia of ducts. Carcinoma was not present. The predominant findings in the post-IORT specimens were fat necrosis and scar (n = 5), recurrent invasive carcinoma (n = 5), surgical site changes (n = 3), abscess (n = 1), and exuberant squamous metaplasia with calcification (n = 1). Five of fifteen (33%) post-IORT specimens showed squamous metaplasia, all of which were collected within 6 months of IORT delivery. The morphologic changes observed after IORT are similar to those seen after external beam radiotherapy. Exuberant squamous metaplasia is an uncommon consequence of IORT; however, pathologists should be aware of this phenomenon and review a history of prior intraoperative radiation before raising concern for malignancy.

Utility of immunohistochemical markers in irradiated breast tissue: an analysis of the role of myoepithelial markers, p53, and Ki-67

Radiation therapy is an important adjunct to breast-conserving surgery, but the diagnosis of recurrent/de novo carcinoma in a background of radiation atypia can be difficult, especially on small biopsies. Immunostaining for myoepithelial cell proteins is often used to assess invasion in nonirradiated breast tissue, yet these stains have not been investigated specifically in irradiated breast. We studied 29 irradiated breast resection specimens, some with carcinoma in situ (CIS, n=13) and/or invasive carcinoma (n=13). Representative blocks were stained for the myoepithelial proteins p63, smooth muscle myosin heavy chain (SMM), calponin, CK5/6, the proliferative marker Ki-67, and the tumor-suppressor p53. Nonirradiated control tissue was also stained with Ki-67 and p53 (CIS, normal, contralateral). Areas of radiation atypia/atrophy and nearly all CIS in irradiated breast tissue had abundant myoepithelial cells as evidenced by SMM, calponin, and p63 stains, with focal staining attenuation or gaps with SMM and calponin and frequently absent CK5/6 staining. As predicted, myoepithelial cell staining was absent in invasive carcinoma. p63 staining revealed postradiation myoepithelial nuclear morphologic changes. p53 staining was increased, although weak, in irradiated non-neoplastic breast (12% irradiated; 4% nonirradiated); however, irradiated CIS had less p53 staining when compared with control CIS (3% irradiated; 38% nonirradiated). As expected, Ki-67 was increased in carcinoma as compared with non-neoplastic irradiated tissue. Thus, myoepithelial immunostaining is a useful diagnostic adjunct in irradiated breast, with caveats similar to nonirradiated breast. Ki-67 may be helpful in some postradiation specimens; however, p53 staining is not reliable in this setting.

Breast irradiation and lactation: a review

The incidence of breast cancer in premenopausal women is increasing and many of them still remain fertile after treatment. Allied to the current tendency to postpone pregnancy, it is expected that an increasing number of patients undergoing conservative treatment for breast cancer will get pregnant. Anatomical and histopathological aspects and the probability of lactation and breast feeding after breast irradiation are reviewed in this article. Lactation is possible after radiotherapy, present in at least 50% of the patients, but in reduced volume. This perspective is more correlated to the type of surgery and radiation dose used. Biochemical changes were observed in irradiated breast milk. Breastfeeding in the contralateral breast is not affected.

Monomorphic epithelial proliferations of the breast: a possible precursor lesion associated with ipsilateral breast failure after breast conserving therapy in patients with negative lumpectomy margins

BACKGROUND

It is generally believed that ipsilateral breast failures (IBFs) after breast-conserving therapy (BCT) develop from incompletely eradicated carcinoma. We previously suggested that monomorphic epithelial proliferations (MEPs) in the breast may be a pool of partially transformed clones from which breast carcinomas can arise and that radiation therapy (RT) may also reduce the risk of IBF by eradicating MEPs. We examined salvage mastectomy specimens in patients experiencing an IBF to define the relationship between MEPs and IBFs and an additional potential mechanism for IBF risk reduction by RT.

METHODS AND MATERIALS

The location, number, and distribution of radiation changes and MEPs relative to 51 IBFs were mapped in salvage mastectomy specimens from BCT patients with adequately excised, initial carcinomas (negative lumpectomy margins).

RESULTS

All 51 salvage mastectomies had diffuse, late radiation changes. None had active fibrocystic lesions. MEPs were predominantly located in the immediate vicinity of the IBFs. A mean of 39% of MEP cases were located within the IBF, 46% were located within 2 cm of the IBF, and 14% were 2-3 cm from the IBF.

CONCLUSIONS

MEPs appear to be a pool of partially transformed precursor lesions that can give rise to ductal carcinoma in situ and invasive carcinomas (CAs). Many IBFs may arise from MEPs that reemerge after RT. Radiation may also reduce IBF risk after BCT (including in patients with negative margins) by primarily eradicating MEPs.

Breast core needle biopsy: issues and controversies

Core needle biopsy (CNB) is increasingly being used in the investigation of breast disease whether this is asymptomatic and suspected after screening mammography, or presents symptomatically in the patient. In most cases, the result of the procedure provides a definitive diagnosis or at least provides information that is used to plan the further management of the patient. There are, however, a number of unresolved issues with the use of CNB; for example, with regard to the amount of information that can be reliably derived from CNB or with regard to the management of the patient after some CNB diagnoses. Oestrogen and progesterone receptors and HER2 are reported on both core biopsies and excision specimens, but there continues to be debate over which represents the more appropriate specimen type on which to perform these tests. There are a number of possible diagnoses after CNB for which the management is not straightforward and around which there may be controversy, or just a lack of sufficient evidence to support a definite management plan. These 'lesions of uncertain malignant potential' include papillary lesions, fibroepithelial lesions with cellular stroma, mucocoele-like lesions and radial scars. Currently, these are removed surgically but there may be an argument for more conservative management including vacuum-assisted core excision in some cases.

Nonneoplastic alterations of the mammary epithelium can mimic atypia

CONTEXT

The pathologist evaluating breast biopsy specimens sometimes encounters nonneoplastic alterations of the mammary epithelium that raise the differential diagnosis of atypia. Because the identification of atypical ductal hyperplasia of the breast has significant clinical implications, it is important to correctly recognize its nonneoplastic morphologic mimics.

OBJECTIVE

To highlight a spectrum of physiologic and treatment-related changes that can occur in the mammary epithelium and to discuss the differential diagnosis with true atypia.

DATA SOURCES

A comprehensive review of the published English literature on physiologic and treatment-related changes of the breast epithelium was performed.

CONCLUSIONS

Among physiologic alterations of the ductal epithelium, luteal-phase changes and secretory changes can sometimes be overinterpreted as atypical. Treatment-related changes, secondary to chemotherapy and radiation, can pose a major diagnostic challenge and their misinterpretation as neoplastic carries major clinical consequences. Familiarity with the morphology of both physiologic and treatment-related alterations of the mammary epithelium is essential to avoid misdiagnosis.

High mammographic breast density is independent predictor of local but not distant recurrence after lumpectomy and radiotherapy for invasive breast cancer

PURPOSE

Biologically meaningful predictors for locoregional recurrence (LRR) in patients undergoing breast-conserving surgery (BCS) and radiotherapy (RT) are lacking. Tissue components, including extracellular matrix, could confer resistance to ionizing radiation. Fibroglandular and extracellular matrix components of breast tissue relative to adipose tissue can be quantified by the mammographic breast density (MBD), the proportion of dense area relative to the total breast area on mammography. We hypothesized that the MBD might be a predictor of LRR after BCS and RT for invasive breast cancer.

METHODS AND MATERIALS

We conducted a nested case-control study of 136 women with invasive breast cancer who had undergone BCS and RT and had had the MBD ascertained before, or at, diagnosis. Women with known recurrence were matched to women without recurrence by year of diagnosis. The median follow-up was 7.7 years. The percentage of MBD was measured using a computer-based threshold method.

RESULTS

Patients with a high MBD (>/=75% density) vs. low (</=25%) were at increased risk of LRR (hazard ratio, 4.30; 95% confidence interval, 0.88-021.0; p = 0.071) but not distant recurrence. In addition, we found a complete inverse correlation between high MBD and obesity (body mass index, >/=30 kg/m(2)). In a multivariate Cox proportional hazards model, patients with MBD in the greatest quartile were at significantly greater risk of LRR (hazard ratio, 6.6; 95% confidence interval, 1.6-27.7; p = 0.01). Obesity without a high MBD also independently predicted for LRR (hazard ratio, 19.3; 95% confidence interval, 4.5-81.7; p < 0.001).

CONCLUSION

The results of our study have shown that a high MBD and obesity are significant independent predictors of LRR after BCS and RT for invasive breast cancer. Additional studies are warranted to validate these findings.

Radiotherapy and wound healing

Radiotherapy is an invaluable weapon when treating cancer. However, the deleterious effects of radiation, both immediate and long-term, may have a significant effect on local tissues. Problematic wound healing in radiation-damaged tissue constitutes a major problem that is frequently overlooked during the management of patients who require radiotherapy, or have had radiotherapy in the past. Poor wound healing may lead to chronic ulceration, pain, secondary infection and psychological distress and compromise the outcome of general or reconstructive surgery. We discuss the pathophysiology of poor wound healing following radiotherapy, specific problems for radiation-damaged tissue and potential treatments to improve wound healing of irradiated tissues.

Radiation and the microenvironment - tumorigenesis and therapy

Radiation rapidly and persistently alters the soluble and insoluble components of the tissue microenvironment. This affects the cell phenotype, tissue composition and the physical interactions and signalling between cells. These alterations in the microenvironment can contribute to carcinogenesis and alter the tissue response to anticancer therapy. Examples of these responses and their implications are discussed with a view to therapeutic intervention.

How do we measure a residual tumor size in histopathology (the gold standard) after neoadjuvant chemotherapy?

Accurate reporting of the residual tumor size by pathologists after neoadjuvant chemotherapy is an important component of a breast cancer. Recent literature reported comparisons regarding the accuracy of clinical and radiological residual tumor size findings using the histopathology as a "gold standard". However, the histopathological methods of measuring the residual tumor size are not standardized. Most pathologists use the tumor size measured by the gross examination. We collected 32 patient samples and compared the residual tumor size by gross and microscopic pathologic examinations. Using microscopic tumor size as the gold standard, our study showed gross tumor size is overestimated in 25%, underestimated in 56% and correlated to the final microscopic tumor size in 19% of the cases after neoadjuvant chemotherapy. Determining accurate residual tumor size to estimate pathologic response to chemotherapy is essential. We attempted to provide guidelines for pathology reporting post-neoadjuvant chemotherapy on breast cancers.

The radiation-induced fibroatrophic process: therapeutic perspective via the antioxidant pathway

The radiation-induced fibroatrophic process (RIF) constitutes a late, local and unavoidable sequela to high-dose radiotherapy, traditionally considered irreversible. Today, this process is partly reversible, thanks to recent progress in understanding the physiopathology of the lesions it causes and the results of recent clinical trials using antioxidant therapy. This review includes a synthetic description of the static and dynamic features of the RIF process, as reflected by its clinical, instrumental and histopathological characteristics, and by its cellular and molecular regulation. Schematically, three successive clinical and histopathological phases can be distinguished: a pre-fibrotic aspecific inflammatory phase, a constitutive fibrotic cellular phase, and a matrix densification and remodelling phase, possibly ending in terminal tissular necrosis. The respective roles of the chief actors in the RIF process are defined, as well as their development with time. A fibroblastic stromal hypothesis is suggested revolving around a 'gravitational effect' exerted by the couple ROS (reactive oxygen species)--fibroblasts, and partly mediated by TGF-beta1. A variety of strategies have been tested for the management of RIF. In the light of the mechanisms described, a curative procedure has been proposed via the antioxidant pathway. In particular, it was showed that superoxide dismutase and combined pentoxifylline-tocopherol treatment enables the process of established radiation-induced fibroatrophy to be greatly reduced or even reversed, both in clinical practice and animal experiments. The efficacy of combined pentoxifylline-tocopherol treatment in superficial RIF was confirmed in a randomised clinical trial, and then in successful phase II trials especially in uterine fibroatrophy and osteoradionecrosis. It is of critical importance to evaluate these new management approaches in larger clinical trials and to improve the recording of results for better outcome analysis. Mechanistic studies are always necessary to improve understanding of the RIF process and the antifibrotic drug action.

[Morphological response to therapy of breast carcinoma]

Neoadjuvant chemotherapy has been extended to earlier stages of breast carcinoma in order to increase the rate of breast conservation by downstaging. Tumour regression can be observed in up to 80% of the cases and the chemosensitivity of the individual tumour can be studied in vivo. Moreover therapy induced regression has been established as an independent prognostic parameter. Characteristic effects of chemotherapy include reduction in cell number, fibrosis, vacuolization of cytoplasm and increased nuclear pleomorphism. Grading, typing and immunohistochemical properties of the carcinomas remain unchanged in the majority of cases. Predictive for the chemosensitivity of tumours are a high nuclear grade, overexpression of Her-2-neu, lack of estrogen receptor expression and lymph node metastases.

Histopathological changes of cervical tissue in women with systemic sclerosis

Systemic sclerosis is a connective tissue disease that can affect almost any organ of the body. The clinical aspects of systemic sclerosis on the reproductive system have been studied in large series, and an increased rate of cesarean section has been reported. For this reason, in the present study the histopathological features of cervical specimens of hysterectomyzed women with systemic sclerosis were evaluated. An increased frequency of vascular and stromal abnormalities in cervical specimens of women with systemic sclerosis were observed. Vascular medial hypertrophy, intimal thickening, and fibrosis were more often encountered in the cervical specimens of the patients with systemic sclerosis. Some of the histopathological features also showed correlation with the clinical profile of the disease. The patients with vascular medial hypertrophy in their cervical specimens were older, had a higher Rodnan score, and had longer duration of the disease. In contrast to vascular medial hypertrophy, periadventitial edema was found in the cervical specimens of the patients who were younger, had a lower Rodnan score, and had shorter duration of the disease. It was concluded that the problems that are seen in common obstetric and gynecological practices in patients with systemic sclerosis may be explained by these tissue abnormalities.