Low neutrophil-to-lymphocyte ratio and pan-immune-inflammation-value predict nodal pathologic complete response in 1274 breast cancer patients treated with neoadjuvant chemotherapy: a multicenter analysis

Background

Systemic inflammatory markers draw great interest as potential blood-based prognostic factors in several oncological settings.

Objectives

The aim of this study is to evaluate whether neutrophil-to-lymphocyte ratio (NLR) and pan-immune-inflammation value (PIV) predict nodal pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) in node-positive (cN+) breast cancer (BC) patients.

Design

Clinically, cN+ BC patients undergoing NAC followed by breast and axillary surgery were enrolled in a multicentric study from 11 Breast Units.

Methods

Pretreatment blood counts were collected for the analysis and used to calculate NLR and PIV. Logistic regression analyses were performed to evaluate independent predictors of nodal pCR.

Results

A total of 1274 cN+ BC patients were included. Nodal pCR was achieved in 586 (46%) patients. At multivariate analysis, low NLR [odds ratio (OR) = 0.71; 95% CI, 0.51-0.98; p = 0.04] and low PIV (OR = 0.63; 95% CI, 0.44-0.90; p = 0.01) were independently predictive of increased likelihood of nodal pCR. A sub-analysis on cN1 patients (n = 1075) confirmed the statistical significance of these variables. PIV was significantly associated with axillary pCR in estrogen receptor (ER)-/human epidermal growth factor receptor 2 (HER2)+ (OR = 0.31; 95% CI, 0.12-0.83; p = 0.02) and ER-/HER2- (OR = 0.41; 95% CI, 0.17-0.97; p = 0.04) BC patients.

Conclusion

This study found that low NLR and PIV levels predict axillary pCR in patients with BC undergoing NAC.

Registration

Eudract number NCT05798806.

Management of PALB2-associated breast cancer: A literature review and case report

Germline pathogenic variants (PV) of the PALB2 tumor suppressor gene are associated with an increased risk of breast, pancreatic, and ovarian cancer. In previous research, PALB2-associated breast cancer showed aggressive clinicopathological phenotypes, particularly triple-negative subtype, and higher mortality regardless of tumor stage, type of chemotherapy nor hormone receptor status. The identification of this germline alteration may have an impact on clinical management of breast cancer (BC) from the surgical approach to the systemic treatment choice. We herein report the case of a patient with a germline PV of PALB2, diagnosed with locally advanced PD-L1 positive triple-negative BC, who progressed after an immune checkpoint inhibitor (ICI)-containing regimen and then experienced a pathologic complete response after platinum-based chemotherapy. This case report hints a major role of the germline PALB2 alteration compared to the PD-L1 expression as cancer driver and gives us the opportunity to extensively review and discuss the available literature on the optimal management of PALB2-associated BC. Overall, our case report and review of the literature provide additional evidence that the germline analysis of PALB2 gene should be included in routine genetic testing for predictive purposes and to refine treatment algorithms.

Telehealth in oncofertility and breast cancer patients during COVID-19: preliminary results of insenoallasalute.it project

OBJECTIVE

Breast cancer (BC) is the leading diagnosis in premenopausal patients. Lockdown measures during COVID-19 pandemic reduced facilities for premenopausal patients, impairing oncological and reproductive health. To reduce its effect, a telehealth program called insenoallasalute.it was designed in Italy.

PATIENTS AND METHODS

A national-based multicentric observational study was undertaken by insenoallasalute.it study group (Italian Ministry of Health, Modena Hospital and Tor Vergata University Hospital) to raise awareness among women on a) BC and its negative role on reproductive health; b) increase adherence to screening programs and self-examination; c) present oncofertility strategies. A web-based platform with two sections was designed: an informative section and a telehealth application activated with a mobile one-time password. After a self-evaluation test to select premenopausal women with maternal desire and family or personal history for BC or ovarian cancer, and premenopausal women with maternity desires with prior medically assisted procreation, a dedicated agenda for telehealth evaluation was displayed and planned. In case the patients fulfilled the criteria for further evaluation, they were invited to perform an outpatient evaluation in one of the pilot centers.

RESULTS

From July 2021 to December 2021, 2,830 single accounts were activated, and 2,450 (86.57%) completed the tests. 53 patients were selected to undergo telehealth consultation and 40 (80.0%) scheduled the telehealth visit. 6 patients underwent surgery in the study centers.

CONCLUSIONS

In our experience insenoallasalute.it embodied an innovative solution to spread BC awareness, BC screening program, and oncofertility opportunities in the oncological population.

Management of nipple adenomas during pregnancy: a case report

BACKGROUND

Nipple adenoma is a very uncommon, benign neoplasm that involves the nipple. A palpable mass of the nipple associated with nipple discharge and erosion or ulceration is the common clinical presentation. Generally, complete surgical excision of the nipple is the main treatment, alternative therapeutic methods such as Mohs micrographic surgery, nipple splitting enucleation, and cryotherapy can be considered. Disorders of the breast in young women are generally benign. Even if the management during pregnancy is usually conservative and surgical excision is reserved for very strong malignancy suspicion, benign lesions can cause the impossibility to breastfeed after giving birth when involving the nipple.

CASE PRESENTATION

We present the case of a 28-year-old female, who was referred to the Breast Unit of the University Hospital of Modena (Italy) in May 2020 with a 12-months history of enlargement of the left nipple with associated erythema, serohemorrhagic discharge, and pain in the left nipple region. The diagnostic assessment came out in favor of a nipple adenoma. After surgical treatment was recommended, the patient got pregnant. Taking into account the major risks of surgery during pregnancy, a multidisciplinary discussion was conducted, to consider whether to proceed with surgery or postpone it after pregnancy. Because of the volume and the position of the adenoma, the indication for surgical excision was confirmed, to allow regular lactation and breastfeeding immediately after giving birth and to avoid potential obstructive complications. Surgical excision of nipple adenoma without complete resection of the nipple was performed after her first trimester of pregnancy under local anesthesia. A histopathological examination confirmed the diagnosis. No recurrence occurred after 12 months. The patient gave birth, had no deficit in lactation, and successfully breastfed.

CONCLUSIONS

Therefore, we consider that nipple adenoma enucleation might be a safe treatment even during pregnancy. Moreover, conservative local treatment of nipple adenomas can preserve the nipple aesthetically and functionally, thus allowing regular lactation and breastfeeding in young women.

Predictive factors for relapse in triple-negative breast cancer patients without pathological complete response after neoadjuvant chemotherapy

Introduction

Triple-negative breast cancer (TNBC) patients who do not obtain pathological complete response (pCR) after neoadjuvant chemotherapy (NACT) present higher rate of relapse and worse overall survival. Risk factors for relapse in this subset of patients are poorly characterized. This study aimed to identify the predictive factors for relapse in TNBC patients without pCR after NACT.

Methods

Women with TNBC treated with NACT from January 2008 to May 2020 at the Modena Cancer Center were included in the analysis. In patients without pCR, univariate and multivariable Cox analyses were used to determine factors predictive of relapse.

Results

We identified 142 patients with a median follow-up of 55 months. After NACT, 62 patients obtained pCR (43.9%). Young age at diagnosis (<50 years) and high Ki-67 (20%) were signi!cantly associated with pCR. Lack of pCR after NACT resulted in worse 5-year event-free survival (EFS) and overall survival (OS). Factors independently predicting EFS in patients without pCR were the presence of multifocal disease [hazard ratio (HR), 3.77; 95% CI, 1.45–9.61; p=0.005] and residual cancer burden (RCB) III (HR, 3.04; 95% CI, 1.09–9.9; p=0.04). Neither germline BRCA status nor HER2-low expression were associated with relapse.

Discussion

These data can be used to stratify patients and potentially guide treatment decision-making, identifying appropriate candidates for treatment intensi!cation especially in neo-/adjuvant setting.

Ewing’s Sarcoma of the Breast in a Young Woman: A Case Report and Review of the Literature

Ewing’s Sarcoma Family Tumors (ESFT) include classic Ewing’s sarcoma of bone, extra-skeletal Ewing’s sarcoma (EES), malignant small cell tumor of the chest wall (Askin tumor), and soft tissue-based Peripheral Primitive Neuroectodermal tumors (pPNET). The t(11;22)(q24;q12) translocation is associated with 85% of tumors and leads to EWS-FLI-1 (Ewing’s Sarcoma–Friend Leukemia Integration-1) formation. This is a potent transforming gene that encodes a chimeric protein that plays a role in the genesis of Ewing’s Sarcoma and Primitive Neuroectodermal Tumors. The breast location of ESFT remains exceptional. The prognosis is among the poorest of all subtypes of breast cancer and even poorer than other extraosseous Ewing’s sarcomas. We describe the case report of a 23-year-old patient with a growing breast lump, who required an accurate and challenging diagnostic estimation and who ultimately resulted in a peripheral primary neuroectodermal tumor (pPNET). Through this case description and a brief narrative review of the literature, we aim to highlight the rarity of ESFT located in the breast. Histopathological confirmation is mandatory for all growing masses of the breast to reach a conclusive diagnosis and plan the correct treatment. Patients with rare diagnoses should always be centralized in breast units, conducting multidisciplinary meetings and, when necessary, the diagnosis should be shared through wider national or international registries.

Development of a novel nomogram-based online tool to predict axillary status after neoadjuvant chemotherapy in cN+ breast cancer: A multicentre study on 1,950 patients

BACKGROUND

Type of axillary surgery in breast cancer (BC) patients who convert from cN + to ycN0 after neoadjuvant chemotherapy (NAC) is still debated. The aim of the present study was to develop and validate a preoperative predictive nomogram to select those patients with a low risk of residual axillary disease after NAC, in whom axillary surgery could be minimized.

PATIENTS AND METHODS

1950 clinically node-positive BC patients from 11 Breast Units, treated by NAC and subsequent surgery, were included from 2005 to 2020. Patients were divided in two groups: those who achieved nodal pCR vs. those with residual nodal disease after NAC. The cohort was divided into training and validation set with a geographic separation criterion. The outcome was to identify independent predictors of axillary pathologic complete response (pCR).

RESULTS

Independent predictive factors associated to nodal pCR were axillary clinical complete response (cCR) after NAC (OR 3.11, p < 0.0001), ER-/HER2+ (OR 3.26, p < 0.0001) or ER+/HER2+ (OR 2.26, p = 0.0002) or ER-/HER2- (OR 1.89, p = 0.009) BC, breast cCR (OR 2.48, p < 0.0001), Ki67 > 14% (OR 0.52, p = 0.0005), and tumor grading G2 (OR 0.35, p = 0.002) or G3 (OR 0.29, p = 0.0003). The nomogram showed a sensitivity of 71% and a specificity of 73% (AUC 0.77, 95%CI 0.75-0.80). After external validation the accuracy of the nomogram was confirmed.

CONCLUSION

The accuracy makes this freely-available, nomogram-based online tool useful to predict nodal pCR after NAC, translating the concept of tailored axillary surgery also in this setting of patients.

Hymovis MO.RE. in the treatment of knee and ankle chondropathy in elite athletes: preliminary results of the CHAMPS (Cohort study about HYADD4-G Administration for Pain relief on Soccer players) prospective clinical study

OBJECTIVE

This study evaluated single intra-articular injections of Hymovis MO.RE., a hyaluronic acid hexadecyl derivative (HYADD4-G), to manage post-traumatic or degenerative knee or ankle chondropathy in professional soccer players.

PATIENTS AND METHODS

Twenty-five players affected by knee (n = 12) or ankle (n = 13) chondropathy were prospectively enrolled and treated by two single Hymovis MO.RE. (32 mg/4 ml) injections at the beginning of the football season (V0, baseline) and at mid-season (V1, 19-20 weeks thereafter), and were followed-up until the end of the season (V2, after further 19-20 weeks). Knee cases were evaluated using the 2000 IKDC knee subjective examination form and the modified Lysholm scoring system. Ankle cases were evaluated using the American Orthopaedic Foot Ankle Society (AOFAS) ankle-hindfoot score. Patients were also evaluated using a VAS Likert scale and a four-category scale recording both the patient's and the doctor's assessment on joint mobility in degrees and overall treatment efficacy. Adverse events, patient withdrawals and local reaction to injections were also assessed.

RESULTS

In knee patients, the 2000 IKDC subjective score improved from 46.8 ± 11.4 at V0 to 83.1 ± 12.5 at V2. Their modified Lysholm score improved from 58.8 ± 8.9 at V0 to 90.6 ± 8.3 at V2. In the ankle patients, the AOFAS score improved from 52.2 ± 5.6 at V0 to 96.4 ± 4.5 at V2. VAS Likert values and subjective evaluations improved at V1 and were maintained at V2. No side effects were recorded.

CONCLUSIONS

A single Hymovis MO.RE. (32 mg/4 ml) intra-articular injection, repeated after 19-20 weeks, may be a viable option to improve symptoms and function in professional soccer players suffering from knee and ankle chondropathy.

Impact of COVID-19 Pandemic on Surgical Breast Cancer Patients Undergoing Neoadjuvant Therapy: A Multicentric Study

BACKGROUND/AIM

Due to the SARS-CoV-2 pandemic, many scientific committees proposed neoadjuvant therapy (NACT) bridging treatment as a novel strategy and indication. The aim of the study was to evaluate the impact of COVID-19 pandemic on breast cancer patients undergoing NACT.

PATIENTS AND METHODS

All breast cancer patients referred to two Breast Units during COVID-19-pandemic were enrolled.

RESULTS

Out of 814 patients, 43(5.3%) were enrolled in the COVID-19-group and compared with 94 (7.9%) similar Pre-COVID-19 patients. We observed a reduction in the number of patients undergoing NACT, p=0.0019. No difference was reported in terms of clinical presentation, indications, and tumor response. In contrast, a higher number of vascular adverse events was reported (6.9% vs. 0% p=0.029). Immediate breast cancer reconstructions following invasive surgery suffered a significant slowdown (5.9% vs. 47.7%, p=0.019).

CONCLUSION

COVID-19 caused a reduction in the number of patients undergoing NACT, with no changes in terms of indications, clinical presentation, and tumor response. Furthermore, there was an increased incidence of vascular events.

Uncommon differential diagnosis of a breast ulcer: a case study

INTRODUCTION

Spider bites are common worldwide. Frequently symptoms resolve without any adverse outcome, but in rare cases the bite can cause severe morbidity. The most typical presentation of Mediterranean recluse spider (Loxosceles Rufescens) bite is a dermatonecrotic lesion of the skin (skin loxoscelism). When the only manifestation of a spider bite is an ulcerated skin lesion, clinical suspicion and differential diagnosis strongly depend on its site. We present the case of an ulcerated wound of the breast, diagnosed as a Mediterranean recluse spider bite.

CASE PRESENTATION

A 79-year-old woman presented a 10cm-wide soft tissue ulceration of her left breast. At first, the diagnostic hypothesis of an ulcerated cancer was ruled out. Two family members revealed a recent history of Mediterranean recluse spider bite and the same clinical diagnosis was made for our patient. A wide excision was performed, with complete resolution of symptoms.

DISCUSSION

No specific diagnostic criteria for spider bites are available. Diagnosis is usually clinical. Skin loxoscelism could be easily mistaken for cellulitis, various types of skin infections, cutaneous anthrax, vasculitis, scorpion sting, pyoderma gangrenosum, erythema migrans of Lyme disease or prurigo nodularis. A thorough anamnestic interview is fundamental to raise the diagnostic hypothesis. When possible, a biopsy is recommended and it is extremely important when the ulcer can mimic a cancer, as is the case in breast tissue.

CONCLUSION

We recommend a wide excision of the wound after failure of conservative treatment, in order to obtain local control and to perform histological examination on a more representative specimen.

Application of OSNA Nomogram in Patients With Macrometastatic Sentinel Lymph Node: A Retrospective Assessment of Accuracy

Introduction:

Almost 50% to 70% of patients who undergo axillary lymph node dissection (ALND) because of a single metastatic sentinel lymph node (SLN) have no further metastatic nodes at the axillary histology. On these grounds, the one-step nucleic acid amplification (OSNA) nomogram was designed and validated. As a mathematical model, calculated through tumor size (expressed in millimeters) and CK19 mRNA copy number, it is thought to predict nonsentinel lymph node (NSLN) status. The aim of the study is to verify the diagnostic accuracy of the OSNA nomogram in a group of patients with macrometastatic SLN, with a retrospective analysis.

Methods:

The OSNA nomogram was retrospectively applied to a group of 66 patients with macrometastatic SLN who underwent ALND. The result of the final histology of the axillary cavity was compared to the nomogram prediction. We calculated the prevalence of NSLN metastasis in patients who underwent ALND, sensitivity and specificity, negative and positive predictive value of the nomogram.

Results:

In patients with macrometastasis in SLN, the prevalence of patients with metastatic NSLN was 45%. The sensitivity of the nomogram was excellent (90%). The specificity was low (36%). Positive predictive value amounted to 54%, while negative predictive value was good (81%).

Conclusions:

These results suggest that the OSNA nomogram is a valid instrument that can help choose the best surgical strategy for the treatment of axillary cavity. The mathematical model is useful to avoid surgery in a selected group of patients because it accurately predicts NSLN status.

Delay in Breast Cancer Treatments During the First COVID-19 Lockdown. A Multicentric Analysis of 432 Patients

BACKGROUND/AIM

Extraordinary restrictions aimed to limit Sars-CoV-2 spreading; they imposed a total reorganization of the health-system. Oncological treatments experienced a significant slowdown. The aim of our multicentric retrospective study was to evaluate screening suspension and surgical treatment delay during COVID-19 and the impact on breast cancer presentation.

PATIENTS AND METHODS

All patients who underwent breast surgery from March 11, 2020 to May 30, 2020 were evaluated and considered as the Lockdown group. These patients were compared with similar patients of the previous year, the Pre-Lockdown group.

RESULTS

A total of 432 patients were evaluated; n=223 and n=209 in the Lockdown and Pre-lockdown-groups, respectively. At univariate analysis, waiting times, lymph-nodes involvement and cancer grading, showed a statistically significant difference (p<0.05). Multivariate analysis identified waiting-time on list (OR=1.07) as a statistically significant predictive factor of lymph node involvement.

CONCLUSION

Although we did not observe a clinically evident difference in breast cancer presentation, we reported an increase in lymph node involvement.

Breast tuberculosis: A case report of primary type mammary tuberculosis

Mammary tuberculosis is exceptional in developed countries. It can mimic an abscess or a granulomatous mastitis. In subjects coming from endemic areas, it is necessary to suspect a tuberculosis infection in case of recurrent mastitis refractory to antibiotics. Positivity of Quantiferon-TB Gold assay can help to confirm the clinical suspicion.

An electromyographic study of the vastii muscles during open and closed kinetic chain submaximal isometric exercises

BACKGROUND

Rehabilitation programs for patients with patellofemoral dysfunction aim to recruit the vastus medialis obliquus muscle (VMO) in an attempt to reduce pain and to improve patellar tracking.

OBJECTIVES

The aim of the present study was to use surface EMG to assess the effectiveness of two isometric submaximal contractions (10% and 60% of maximal voluntary contraction, MVC) in promoting preferential activation of VMO over vastus medialis longus (VML) and vastus lateralis (VL) in open and closed kinetic chain isometric exercises with the knee joint fixed at 30, 60 and 90 degrees of flexion.

METHODS AND MEASURES

Surface electromyography (EMG) signals were recorded with linear adhesive arrays of four electrodes from fourteen healthy young men (age 23.5±3.2, mean±SD) during isometric knee extension contractions at 10% and 60% of the maximum voluntary contraction (MVC) for 1 min and 20 s respectively at 30, 60 and 90 degrees of knee flexion. Initial values and rate of change (slope) of mean frequency (MNF), average rectified value (ARV) and conduction velocity (CV) of the EMG signal were calculated.

RESULTS

Comparisons between the force levels produced at 10% and 60% MVC revealed that the initial values of ARV and CV for the VL, VML and VMO muscle were greater at 60% MVC compared to 10% MVC (3-way ANOVA; F=536; p<0.001, F=49: p<0.01 for ARV and CV respectively). Comparisons between the different muscles demonstrated lower initial values of CV for VMO compared to VL and VLM at 10% and 60% of MVC (F=15; p<0.05). In addition, initial estimates of ARV were higher for VMO compared to VML at both force levels (F=66; p<0.05). Comparisons between open and closed kinetic chain exercises revealed higher initial estimates of ARV for open kinetic chain knee extension at both force levels (F=62; p<0.01). In addition, the absolute value of MNF slope appeared to increase at higher angles for closed kinetic chain at 60% MVC while it was minimum at 60° degrees for open kinetic chain. No significant differences were observed in the rate of change of CV and MNF among the three muscles.

CONCLUSIONS

Based on the results of this study, both open and closed kinetic chain exercise similarly activate the three portions of the quadriceps muscle, suggesting that selective training of the vastii muscle is not achievable in these conditions.

Contrast enhanced ultrasound with second generation contrast agent for the follow-up of lower-extremity muscle-strain-repairing processes in professional athletes

PURPOSE

In literature, ultrasonographic potentials in traumatic muscle lesions have been codified, whereas the data about this method utility in follow-up are dissonant. The purpose of this work is to evaluate a second-generation ultrasound (US) contrast agent rule for the professional athletes' distractive lesions.

MATERIALS AND METHODS

Twenty professional athletes (18 men and two women, aged between 18 and 34 years) affected by different muscle lesions were examined. All the patients were evaluated within 48 h of the trauma by US device Esaote Technos MPX with a high-frequency linear probe. The examinations were carried out with and without contrast agent after 20, 40 and 60 days after the trauma; second-generation contrast agent was used (SonoVue).

RESULTS

In all athletes (nine first-grade lesions, 11 second-grade lesions), by using contrast agent intravenous injection done after 20 days, the appearance of contrast spots affecting part or all the lesioned area were observed. During the follow-up, after 40 days. the contrast spots widened to include the entire scar area, with haemorrhagic residual in three cases. After 60 days, in no case was a liquid haemorrhagic collection still present, and we found an important reduction of extension of vascular spots and US intensity and their total disappearance in seven cases.

CONCLUSIONS

US with a second-generation contrast agent, thanks to the neoangiogenesis identification, allows recognition, individuation and monitoring the repair processes in the muscle lesion and allows estimation of when athletes can return to competitive activity. This fact obviously reduces both relapses and complications.

[Degenerative changes in the coxofemoral articulation due to occupational causes. I. Radiological description of a control population]

With a view to initiating epidemiological studies aimed at demonstrating the causal or concausal role of certain working activities in degenerative diseases of the coxo-femoral articulations, the authors report data from a radiological study of a reference population and the necessary conditions for their correct use. Statistical analysis of the descriptive features leads to some interesting observations on the evolution with age of the radiological picture of the coxo-femoral joints (and on the aging of these joints). There was an increase with advancing age of some of the alterations that are characteristic of degenerative articular processes, such as sclerosis and osteophytosis. Reduction of articular "rima", however, occurs suddenly between the ages of 36 and 45 and does not seem to subsequently undergo any statistically significant evolution.

[Impairment of the osteoarticular and musculoligamentous components in bill posters: an example of the thoracic outlet syndrome]

The authors analysed the risks and associated damage in bill posters on the basis of a case history description. Biomechanical analysis of the job revealed in particular the involvement of the musculoligamentous structure of the cervical spine and shoulder, mostly during the actual posting of bills. The authors propose a clinical-functional definition of the pain and paresthetic symptoms of the upper limbs which are frequently encountered in this category of workers.