Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients

PURPOSE

Roughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement.

METHODS/PATIENTS

Between January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required.

RESULTS

1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%.

CONCLUSION

We may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients.

The appropriate axillary procedure after a positive sentinel node in breast cancer patients: the "Hôpital Tenon" score revisited. A two-institution study

INTRODUCTION

Until recently, completion ALND has been considered the standard of care after a positive SN in breast cancer patients. However, most patients will not display further axillary involvement. The Tenon score is a simple nomogram that can be used intraoperatively to avoid completion ALND in low-risk patients. We aimed at validating the Tenon score on a SN-positive patient sample that had been preoperatively selected using axillary US examination.

PATIENTS AND METHOD

We used a retrospective analysis of our bicentric database that included 246 breast cancer patients with a positive SN. We calculated sensitivity, specificity, as well as positive and negative predictive values for each cut-off point. ROCs were constructed and corresponding AUC values were calculated as a measure of discriminative capacity.

RESULTS

At least one non-SN was positive in 52 patients (21.1 %). 118 patients (48 %) had a score up to 5. Among them, three had at least one positive non-SN. NPV was 97.5 %. Using that threshold, the ROCs analysis showed an AUC of 0.822 (95 % CI 0.764-0.880).

CONCLUSION

Use of preoperative axillary US examination led to a modification of the proposed Tenon cut-off value from 3.5 to 5 to attain good predictive power for non-SN status. Straightforward intraoperative use of the Tenon score may be considered an advantage over other available nomograms.

Mortality and recurrence patterns of breast cancer patients diagnosed under a screening programme versus comparable non-screened breast cancer patients from the same population: analytical survey from 2002 to 2012

Breast cancer screening programmes seem to bring about significant benefits, including decreased mortality, although they may also have some drawbacks such as false-negative and false-positive results. This study aims to compare the clinical outcome of a group of patients undergoing a breast cancer screening programme with that of a synchronous non-screened group of patients matched for age and follow-up period. We studied basic characteristics of epidemiology, immunohistochemistry, loco-regional relapse, distant metastases, disease-free interval and overall and specific mortality. We compared 510 patients in the screened group with 394 non-screened patients, along the period of 2002-2012. Screening was applied on a target population of 49,847 and was based on double-projection, double-read mammograms. Two years were allowed per round. Overall participation for the five rounds considered was 75.2%, with 86.5% coverage, and a total cumulative population of 123,445. The non-participant women amounted 40,794. Tumour detection rate for the screened women was 3.8 per thousand (475/123,445), while the corresponding rate for non-participants was 9.4 per thousand (382/40,797). Incidence of luminal A subtype was 15% higher in screened than that in non-screened patients (95% confidence interval (CI) 8-22%). Conversely, the triple-negative subtype was 6% higher in the non-screened group (95% CI 2-10%). Incidence of breast conservative treatments and sentinel node biopsies was significantly higher in the screened group. Overall mortality was 2.6 times higher in non-screened than that in screened group (95% CI 1.2-5.6) After 10 years of experience with our own screening programme, we believe that included patients receive a benefit versus comparable non-screened breast cancer patients, with acceptable benefit-risk relation.

Analysis of the pathological response to primary chemotherapy in patients with locally advanced breast cancer (LABC) grouped according to ER, PR and HER2 status

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Background: The determination of ER and PR has a considerable importance when evaluating the prognosis and the response to treatment in breast cancer (BC). Assessment of HER2 status is also a standard for the management of BC. Hormone receptors (HR), HER2, and increasingly, genomic profiles distinguish at least four major classes of BC: HER2+; HER2-HR+, which can be divided into two classes, favorable and unfavorable; and basal-like that express neither HER2 nor HR. In the clinical practice is possible to divided BC according to ER, PR and HER2: ER-PR-HER2+, ER-PR-HER2-, ER+PR+HER2-, ER+RP+HER2+; and less frequently ER+PR-HER2-, ER+PR-HER2+, ER-PR+HER2+ and ER-PR+HER2-. In the neoadjuvant setting the pathological complete response (pCR) to primary chemotherapy (PC) is associated to negativity for ER and PR receptors, and in patients (pts) with HER2 + BC, the addition of trastuzumab to PC increasing the rate of pCR. The aims of this study were to determine the pCR of PC with anthracyclines (A) and taxanes (T) in pts with LABC grouped according to ER, PR and HER2 status. Methods: Pts with LABC treated with PC including A and T were grouped according to ER, PR and HER2 status, and the pCR rate were analyzed using the chi-squared test and correlations with a p value of ≤0,05 were considered statistically significant. Results: A total of 103 pts were treated. There were 14.6% of ER-PR-HER2+ BC, 23.3% ER-PR-HER2-, 35.0%ER+PR+HER2-, 8.7% ER+PR+HER2+, 11.7% ER+PR-HER2-, 2.9% ER+PR-HER2+, 1.9% ER-PR+HER2+, and 1.9% ER-PR+HER2-. For the analysis of pCR only 100 pts were included. There were18 pts who achieved a pCR. Of these pts, 9/18 (50.0%) were RE-RP-HER2-, 5/18 (27.8%) ER-PR-HER2+, 3/18 (16.7%) ER+PR+HER2+, and 1/18 (5.6%) ER+PR+HER2- (p≤0.01). The table 1 show the pCR rate for each subgroup of BC. Conclusions: In patients with LABC to group BC according to ER, PR and HER2 status can help to predict pCR to PC.

[Table: see text]

No significant financial relationships to disclose.

Pulmonary endometriosis: conservative treatment with GnRH agonists

The lung is an infrequent location of extragenital endometriosis, an exceptional cause of hemoptysis or pneumothorax. Adequate management has not yet been well established. We present two cases of pulmonary endometriosis, parenchymal and pleural. The presenting symptoms were catamenial hemoptysis and pneumothorax, respectively, which were treated with GnRH analogues. The first patient received Buserelin (900 micrograms/day intranasally) for 6 months. After 15 months of normal menstrual activity, the symptoms reappeared. The patient was then treated with Triptorelin (3.75 mg/month intramuscularly) for 6 months and remains asymptomatic and menstruating 14 months after discontinuing treatment. The patient presenting with pneumothorax was treated with leuprolide (1 mg/day subcutaneously) for 6 months and is asymptomatic 1 year after stopping treatment. These results suggest that GnRH analogues may be an acceptable alternative to danazol in the medical management of pulmonary endometriosis.