Omitting Axillary Dissection in Breast Cancer with Sentinel-Node Metastases

BACKGROUND

Trials evaluating the omission of completion axillary-lymph-node dissection in patients with clinically node-negative breast cancer and sentinel-lymph-node metastases have been compromised by limited statistical power, uncertain nodal radiotherapy target volumes, and a scarcity of data on relevant clinical subgroups.

METHODS

We conducted a noninferiority trial in which patients with clinically node-negative primary T1 to T3 breast cancer (tumor size, T1, ≤20 mm; T2, 21 to 50 mm; and T3, >50 mm in the largest dimension) with one or two sentinel-node macrometastases (metastasis size, >2 mm in the largest dimension) were randomly assigned in a 1:1 ratio to completion axillary-lymph-node dissection or its omission (sentinel-node biopsy only). Adjuvant treatment and radiation therapy were used in accordance with national guidelines. The primary end point was overall survival. We report here the per-protocol and modified intention-to-treat analyses of the prespecified secondary end point of recurrence-free survival. To show noninferiority of sentinel-node biopsy only, the upper boundary of the confidence interval for the hazard ratio for recurrence or death had to be below 1.44.

RESULTS

Between January 2015 and December 2021, a total of 2766 patients were enrolled across five countries. The per-protocol population included 2540 patients, of whom 1335 were assigned to undergo sentinel-node biopsy only and 1205 to undergo completion axillary-lymph-node dissection (dissection group). Radiation therapy including nodal target volumes was administered to 1192 of 1326 patients (89.9%) in the sentinel-node biopsy-only group and to 1058 of 1197 (88.4%) in the dissection group. The median follow-up was 46.8 months (range, 1.5 to 94.5). Overall, 191 patients had recurrence or died. The estimated 5-year recurrence-free survival was 89.7% (95% confidence interval [CI], 87.5 to 91.9) in the sentinel-node biopsy-only group and 88.7% (95% CI, 86.3 to 91.1) in the dissection group, with a country-adjusted hazard ratio for recurrence or death of 0.89 (95% CI, 0.66 to 1.19), which was significantly (P<0.001) below the prespecified noninferiority margin.

CONCLUSIONS

The omission of completion axillary-lymph-node dissection was noninferior to the more extensive surgery in patients with clinically node-negative breast cancer who had sentinel-node macrometastases, most of whom received nodal radiation therapy. (Funded by the Swedish Research Council and others; SENOMAC ClinicalTrials.gov number, NCT02240472.).

Targeted axillary dissection: worldwide variations in clinical practice

PURPOSE

Targeted axillary dissection (TAD) for the axillary staging of clinically node-positive (cN +) breast cancer patients converting to clinically node negative post neoadjuvant chemotherapy (NAC), has gained popularity due to its minimal false negative rate and low arm morbidity. The aim of this study is to shed more light on the variation in the clinical practice globally in terms of indications and perceived limitations of TAD.

METHODS

A panel of expert breast surgeons constructed a structured questionnaire comprising of 18 questions and asked surgeons worldwide for their opinions and routine practice on TAD. The questionnaire was electronically distributed and answers were collected between May 1st and August 1st 2022.

RESULTS

Responses included 137 entries from 36 countries. Of them, 73.7% consider TAD for cN + patients planned to receive NAC. Among them, the greatest number of respondents (45%) perform the procedure for tumours up to T3, whereas 27% regardless of T-stage. The majority (42%) perform TAD on patients with 1-3 positive nodes and only 30% consider TAD when matted nodes are present. HER2 positive and Triple Negative subtypes are more likely to undergo TAD than Luminal A and B (86%, 79.1%, 39.5%, and 62.8%, respectively). Maximum acceptable lymph node burden is median 3 nodes for any subtype with a tendency to accept more positive nodes for Triple Negative.

CONCLUSION

This study demonstrates the differences in current practice regarding TAD as well as the fact that the biology of the tumour heavily affects the method of axillary staging.

Applicability of magnetic seeds for target lymph node biopsy after neoadjuvant chemotherapy in initially node-positive breast cancer patients: data from the AXSANA study

PURPOSE

Currently, various techniques are available to mark and selectively remove initially suspicious axillary lymph nodes (target lymph nodes, TLNs) in breast cancer patients receiving neoadjuvant chemotherapy (NACT). To date, limited data are available on whether the use of magnetic seeds (MS) is suitable for localizing TLNs. This study aimed to investigate the feasibility of MS in patients undergoing target lymph node biopsy (TLNB) or targeted axillary dissection (TAD) after NACT.

METHODS

Prospective data from the ongoing multicentric AXSANA study were extracted from selected patients in whom the TLN had been marked with an MS before NACT and who were enrolled from June 2020 to June 2023. The endpoints of the analysis were the detection rate, the rate of lost markers, and the potential impairment on magnetic resonance imaging (MRI) assessment.

RESULTS

In 187 patients from 27 study sites in seven countries, MS were placed into the TLN before NACT. In 151 of these, post-NACT surgery had been completed at the time of analysis. In 146 patients (96.0%), a TLN could successfully be detected. In three patients, the seed was removed but no lymphoid tissue was detected on histopathology. The rate of lost markers was 1.2% (2 out of 164 MS). In 15 out of 151 patients (9.9%), MRI assessment was reported to be compromised by MS placement.

CONCLUSION

MS show excellent applicability for TLNB/TAD when inserted before NACT with a high DR and a low rate of lost markers. Axillary MS can impair MRI assessment of the breast.

TRIAL REGISTRATION NUMBER

NCT04373655 (date of registration May 4, 2020).

Designing clinical trials based on modern imaging and metastasis-directed treatments in patients with oligometastatic breast cancer: a consensus recommendation from the EORTC Imaging and Breast Cancer Groups

Breast cancer remains the most common cause of cancer death among women. Despite its considerable histological and molecular heterogeneity, those characteristics are not distinguished in most definitions of oligometastatic disease and clinical trials of oligometastatic breast cancer. After an exhaustive review of the literature covering all aspects of oligometastatic breast cancer, 35 experts from the European Organisation for Research and Treatment of Cancer Imaging and Breast Cancer Groups elaborated a Delphi questionnaire aimed at offering consensus recommendations, including oligometastatic breast cancer definition, optimal diagnostic pathways, and clinical trials required to evaluate the effect of diagnostic imaging strategies and metastasis-directed therapies. The main recommendations are the introduction of modern imaging methods in metastatic screening for an earlier diagnosis of oligometastatic breast cancer and the development of prospective trials also considering the histological and molecular complexity of breast cancer. Strategies for the randomisation of imaging methods and therapeutic approaches in different subsets of patients are also addressed.

Current clinical practice in the management of phyllodes tumors of the breast: an international cross-sectional study among surgeons and oncologists

PURPOSE

Phyllodes tumors of the breast are rare fibroepithelial lesions that are classified as benign, borderline or malignant. There is little consensus on best practice for the work-up, management, and follow-up of patients with phyllodes tumors of the breast, and evidence-based guidelines are lacking.

METHODS

We conducted a cross-sectional survey of surgeons and oncologists with the aim to describe current clinical practice in the management of phyllodes tumors. The survey was constructed in REDCap and distributed between July 2021 and February 2022 through international collaborators in sixteen countries across four continents.

RESULTS

A total of 419 responses were collected and analyzed. The majority of respondents were experienced and worked in a university hospital. Most agreed to recommend a tumor-free excision margin for benign tumors, increasing margins for borderline and malignant tumors. The multidisciplinary team meeting plays a major role in the treatment plan and follow-up. The vast majority did not consider axillary surgery. There were mixed opinions on adjuvant treatment, with a trend towards more liberal regiments in patients with locally advanced tumors. Most respondents preferred a five-year follow-up period for all phyllodes tumor types.

CONCLUSIONS

This study shows considerable variation in clinical practice managing phyllodes tumors. This suggests the potential for overtreatment of many patients and the need for education and further research targeting appropriate surgical margins, follow-up time and a multidisciplinary approach. There is a need to develop guidelines that recognize the heterogeneity of phyllodes tumors.

Axillary surgery after neoadjuvant therapy in initially node-positive breast cancer: international EUBREAST survey

BACKGROUND

There is no consensus on axillary management after neoadjuvant therapy (NAT) in patients with clinically node-positive (cN+) breast cancer. To investigate current clinical practice, an international survey was conducted among breast surgeons and radiation oncologists. The aim of the first part of the survey was to provide a snapshot of international discrepancies regarding axillary surgery in this context.

METHODS

The European Breast Cancer Research Association of Surgical Trialists (EUBREAST) developed a web-based survey containing 39 questions describing clinical scenarios in the setting of axillary management in patients with cN1 disease converting to ycN0 after NAT. The survey was then distributed to breast surgeons and radiation oncologists via 14 breast cancer societies between April and October 2021.

RESULTS

Responses from 349 physicians in 45 countries were recorded. The most common post-NAT axillary surgery in patients with cN1 disease converting to ycN0 was targeted axillary dissection (54.2 per cent), followed by sentinel lymph node biopsy (SLNB) alone (20.9 per cent), level 1-2 axillary lymph node dissection (ALND) (18.4 per cent), level 1-3 ALND (4 per cent), and targeted lymph node biopsy (2.5 per cent). For SLNB alone, dual tracers were most commonly used (62.3 per cent). Management varied widely in patients with ambiguous axillary status before initiation of treatment or a residual metastatic burden in the axilla after NAT. In patients with ycN+ tumours, ALND was the preferred surgical approach for 66.8 per cent of respondents.

CONCLUSION

These results highlight the wide heterogeneity in surgical approaches to the axilla after NAT. To standardize the guidelines, further data from clinical research are urgently needed, which underlines the importance of the ongoing AXSANA (EUBREAST-3) study.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy

Aim

Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario.

Methods

A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology.

Results

The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR.

Conclusions

The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR

•

Autologous breast reconstruction is increasingly preferred over implants in the setting of radiation therapy.

•

Use of patient-reported outcomes is endorsed.

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Shape and size of reconstructed breasts can hinder radiotherapy planning.

•

There is a need for randomised phase III trials.

False Negativity of Targeted Axillary Dissection in Breast Cancer

Introduction

Targeted axillary dissection (TAD) has been proposed as an alternative method for the staging of patients with node-positive breast cancer who undergo neoadjuvant chemotherapy. However, not much is known yet about the false-negative rate (FNR) of the method and the subsequent risk of underestimation of residual axillary disease.

Methods

This study reviews published articles with calculations of false negativity of TAD and potential factors that may influence it.

Results

The FNR of TAD is usually reported as being <10%, but this calculation is usually based on small study populations. Lower FNR is a common finding along with lower N status, while not enough data are available yet for greater axillary involvement. When a marked node is revealed to be a sentinel lymph node (SLN) at surgery after neoadjuvant chemotherapy (NAC), this seems to be another factor that contributes to reliable TAD. With regard to the methods used to mark the positive node before chemotherapy and retrieval at surgery, there is no clear advantage of one over the other. The availability of relevant resources, the costs, and local legislation must all be taken into account for the selection of the optimal strategy.

Conclusion

Although still in its early days, the FNR of TAD can be low, at least in patients with relatively little axillary involvement and when the marked node is the SLN. All reported methods of lymph node marking seem reliable.

Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study

In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

BACKGROUND

80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality.

METHODS

This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494.

FINDINGS

Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70-8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39-8·80) and upper-middle-income countries (2·06, 1·11-3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26-11·59) and upper-middle-income countries (3·89, 2·08-7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications.

INTERPRETATION

Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications.

FUNDING

National Institute for Health Research Global Health Research Unit.

The value of the intraoperative assessment of the SLN via frozen section in the post Z0011 era

INTRODUCTION

Sentinel node (SN) assessment via frozen section (FS) has declined since the publication of Z0011 which modified the management of a specific group of patients with positive SN. The risk of misleading the surgeons to a preventable ALND and the cost are among the main factors for that. The aim of our study is to assess the value of FS in the post Z0011.

MATERIAL AND METHODS

244 patients out of 434 were eligible for an upfront SLNB. Based on the final histology and the clinical data we selected the eligible for breast conserving surgery patients (55.4%). 78 patients had positive SN and 26 of them fulfilled the criteria of Z0011. We assessed the false negative findings, the impact on the management and the indications and value of FS in the post Z0011 era.

RESULTS

Overall, there were 12 FN cases out of which 7 were macrometastases (8.97%). Only in one case there were > 2 positive LN and 3 patients needed mastectomy. The remaining cases fulfilled the criteria of Z0011 and needed no further surgery hence in 96.1% of the cases the axillary status was correctly assessed via FS and the reoperation rate was 1.2%. On the contrary, if FS was not used, at least 21.3% of the patents would have needed reoperation based on the today's guidelines.

DISCUSSION

We believe FS is still valuable and may spare a significant percentage of patients from a second operation (SNB) without leading to axillary overtreatment if used wisely.

How breast cancer treatments affect the quality of life of women with non-metastatic breast cancer one year after surgical treatment: a cross-sectional study in Greece

Background

The continuously increasing survivorship of female breast cancer makes the monitoring and improvement of patients’ quality of life ever so important. While globally there is a growing body of research on health-related quality of life 1 year after surgical treatment for non-metastatic breast cancer, up-to-date information regarding Greek patients is scarce.

Objective

To measure the level of QoL of non-metastatic BC survivors in Greece 1 year after surgery.

Methods

A sample of 200 female breast cancer survivors aged 18 to 75, who followed up as outpatients in five public hospitals were included in this cross-sectional study. All recruited patients agreed to participate in the study (100% response rate). Quality of life data were collected through the EORTC QLQ-C30 as well as BR23 questionnaires.

Results

Cronbach’s alpha for all scales of the two questionnaires was from 0.551 to 0.936 indicating very good reliability. According to the Multiple Linear Regression, older patients showed a lower future perspective (p = .031), with those living in rural areas, which was associated with more financial difficulties (p = .001). Women with tertiary education and those who had been hospitalized in a university hospital recorded better on global health status (p = .003 and .000 respectively). Patients who underwent chemotherapy reported better scores in the emotional function sub-scale (p = .025). Women with reconstruction and at least one complication appeared to have significantly better scores in future perspective and social function (p = .005, .002 respectively).

Conclusions

Breast cancer survivors were found to have an overall good quality of life, functioning/symptoms scores and were satisfied with the provided care.

Multifocal and multicentric breast cancer, is it time to think again?

Multifocal multicentric breast cancer has traditionally been considered a contraindication to breast conserving surgery because of concerns regarding locoregional control and risk of disease recurrence. However, the evidence supporting this practice is limited. Increasingly, many breast surgeons are advocating breast conservation in selected cases. This short narrative review summarises current evidence on the role of surgery in multifocal multicentric breast cancer and shows that when technically feasible the option of breast conservation is oncologically safe.

Nipple-sparing skin-reducing mastectomy with reconstruction for large ptotic breasts

BACKGROUND

Breast reconstruction is routinely used to alleviate the psychological adverse effects of mastectomy. Nipple preservation further improves the cosmetic result, and causes less trauma on the body surface. Nipple-sparing mastectomy, however, comes with challenges, especially in the case of large, ptotic breasts to the degree that large-sized breasts have conventionally been a contraindication for nipple preservation. In this report, we describe a novel technique for nipple preservation in immediate reconstruction of large, ptotic breasts.

METHODS

From 2013 to 2018, 24 patients (30 breasts) with large, ptotic breasts were treated with mastectomy and immediate reconstruction with nipple preservation. Median BMI was 28 and 8 patients were smokers. The technique involves the de-epithelialisation of a large area of the breast skin, the mastectomy through a lateral full-thickness incision within the de-epithelialised area, imbrication of the de-epithelialised skin, lifting of the nipple to a higher position and finally closure of wound.

RESULTS

There were no full, 4 partial nipple necroses and 3 re-operations were done under local anaesthetic to correct partial peripheral necrosis of the areola. Six patients needed seroma aspiration and 4 presented with cellulitis. No implants were lost and there were no delays to adjuvant treatment.

CONCLUSIONS

The proposed technique has significant advantages and may be ideal when large skin reductions are necessary in immediate breast reconstruction with nipple preservation. The low complication rate makes the method ideal when adjuvant treatment is to follow and/or patients are of high risk for surgical complications.

The role of digital breast tomosynthesis in breast cancer screening: a manufacturer- and metrics-specific analysis

Aim

Digital Breast Tomosynthesis (DBT), with or without Digital Mammography (DM) or Synthetic Mammography (SM), has been introduced or is under consideration for its introduction in breast cancer screening in several countries, as it has been shown that it has advantages over DM. Despite this there is no agreement on how to implement DBT in screening, and in many cases there is a lack of official guidance on the optimum usage of each commercially available system. The aim of this review is to carry out a manufacturer-specific summary of studies on the implementation of DBT in breast cancer screening.

Methods

An exhaustive literature review was undertaken to identify clinical observer studies that evaluated at least one of five common metrics: sensitivity, specificity, area under the curve (AUC) of the receiver-operating characteristics (ROC) analysis, recall rate and cancer detection rate. Four common DBT implementation methods were discussed in this review: (1) DBT, (2) DM with DBT, (3) 1-view DBT with or without 1-view DM or 2-view DM and (4) DBT with SM.

Results

A summary of 89 studies, selected from a database of 677 studies, on the assessment of the implementation of DBT in breast cancer screening is presented in tables and discussed in a manufacturer- and metric-specific approach. Much more studies were carried out using some DBT systems than others. For one implementation method of DBT by one manufacturer there is a shortage of studies, for another implementation there are conflicting results. In some cases, there is a strong agreement between studies, making the advantages and disadvantages of each system clear.

Conclusion

The optimum implementation method of DBT in breast screening, in terms of diagnostic benefit and patient radiation dose, for one manufacturer does not necessarily apply to other manufacturers.

Estrogen receptor beta increases sensitivity to enzalutamide in androgen receptor-positive triple-negative breast cancer

PURPOSE

Androgen receptor (AR) is playing an important role in the progression of a subset of TNBC. We evaluated the impact of ERβ expression along with anti-AR drugs in AR-positive TNBC.

METHODS

ERβ expression was examined in AR-positive TNBC cell line using MTT assay, scratch and Annexin V-FITC assay in the presence or absence of anti-androgens. Protein levels of involved molecules were assessed using Western blot. Receptors' localization was detected by immunofluorescence and their physical association was examined using proximity ligation assay (PLA), which enables the visualization of interacting proteins in fixed cells and tissues.

RESULTS

Transient transfection of ERβ in MDA-MB 453 AR-positive TNBC cell line significantly inhibited cell proliferation, metastatic potential and induced apoptosis. ERβ expression reversed the aggravating role of AR in both indirect and direct ways. Indirectly, ERβ decreased AR activation through the inhibition of PI3K/AKT signaling pathway. Directly, ERβ formed heterodimers with AR in MDA-MB 453 cells and in human tissue samples impeding AR from forming homodimers. Enzalutamide is a more potent anti-androgen in AR + TNBC compared to bicalutamide. ERβ expression increased the sensitivity of MDA-MB 453 cells to anti-androgens and especially to enzalutamide. The administration of enzalutamide enhanced AR:ERβ heterodimers formation increasing the anti-tumor capacity of ERβ.

CONCLUSIONS

Collectively, our results provide evidence for a novel mechanism by which ERβ exerts oncosuppressive effect in AR-positive TBNC through direct and indirect interactions with AR. Moreover, ERβ expression may identify a new subset of TNBC that would respond more favorable to anti-androgens.

Delayed Breast Cellulitis following Surgery for Breast Cancer: A Literature Review

Background

Delayed breast cellulitis (DBC) is a relatively rare complication following breast-conserving surgery. It is often challenging to distinguish DBC from other clinical conditions such as postoperative infection, inflammatory reaction following radiation, and recurrent inflammatory carcinoma. The definition of DBC, diagnostic approach, and treatment are not well established in the literature.

Methods

We performed a literature search with the keywords 'Delayed breast cellulitis' and 'Breast conservation therapy cellulitis', without limitations to the dates or the article types, in the PubMed database. Information about the number of cases with DBC, the age of the patients, the interval between the onset of symptoms and the time of surgery or radiotherapy, and the type and outcome of DBC treatment were reviewed and tabulated.

Results

We identified only 5 papers that were absolutely related to our subject, reflecting the fact that 'delayed breast cellulitis' is a fairly unknown term and the condition is rather underreported. Although most agree that DBC is primarily an aseptic inflammatory process, bacterial growth may contribute to its development or recurrence. Obesity, breast size, location of the breast tumor, removal of the axillary lymph nodes, and connective tissue disorders are considered as risk factors. There is no clear evidence on how DBC should be best managed. Antibiotic treatment is controversial, and many authors suggest anti-inflammatory agents or sole observation. Prevention of lymph stasis and its consequences with massage and skin care may be helpful. Despite the fact that malignancy is rare, in cases where the condition persists for more than 4 months, a core biopsy should be performed to rule out recurrent or second primary carcinoma.

Conclusion

The correct diagnostic approach is essential as it provides patients with reassurance, minimizes anxiety, and prevents unnecessary medical investigations, treatments, and costs.

Health-related quality of life of young women with breast cancer. Review of the literature

PURPOSE

The purpose of the present article was to investigate the health related quality of life (QoL) of young women with breast cancer.

METHODS

For the purposes of this article, we reviewed the literature via the electronic databases Pubmed, Scopus and Google Scholar. Key words used were breast cancer, young women, health related quality of life, and quality of life.

RESULTS

Young women reported fatigue, pain in the breast and hand problems with lymphedema as the most frequent physical effects of treatment. Other physical problems were the not periodic and painful menses, vaginal dryness and loss of libido. Many young women had depressive symptoms such as depressed mood, helplessness, hopelessness, sleep loss, psychomotor retardation and disorders of appetite. There were often concerns about the health monitoring and self-image, while they were anxious if they will have a baby in the future or if they can nurture the existing ones. Many problems arose in the career of young women. They faced discrimination in the labor supply and/or layoff because they were considered unable to do their job effectively. In addition, they reported isolation problems and feeling different from other women of similar age.

CONCLUSIONS

Young women consider that their healthrelated QoL is worse compared with older women. Young women worry about their future, with particular reference to their role as mothers and especially to children-bearing. The free screening and non-exclusion of young women is particularly important for breast cancer prevention and women's well-being.

Nestin and CD146 expression in metaplastic breast cancer: stem-cell therapy in need? Lessons reported from a male patient

OBJECTIVE

Metaplastic breast carcinomas represent a rare subtype of breast cancer exhibiting aggressive clinical features. They appear as highly chemoresistant tumors, therefore showing poor outcome and high rates of local recurrence or distant metastasis.

CASE REPORT

A 37-year-old greek man was referred to our hospital for evaluation of a locally advanced, ulcerated, fixed, irregular and hard in consistency mass covering his left breast and chest wall. Further work out with CT and biopsy of the tumor revealed a triple negative metaplastic breast cancer classified as cT4cN3cM1. The patient received first line chemotherapy and afterward a palliative resection of the tumor. The histology revealed the presence of a combined triple negative adenocarcinoma with a predominant metaplastic squamous carcinoma and a spindle cell (sarcomatoid) carcinoma of the breast. In the tissue sample stem cell markers, nestin and CD146 (MCAM) were expressed, enhancing the theory that cancer cells of this tumor could possibly harbor stem cell properties. The patient received several chemotherapy regimens but died 6 months after the initiation of treatment.

CONCLUSIONS

Metaplastic breast cancer consists of cells with stem cell properties. New targeted therapies are warranted in the view of the tumor's high resistance to conventional chemotherapy. Targeting nestin and CD146 might be a promising therapy as they seem to be implicated in the EMT pathway.

The Role of NSAIDs in Breast Cancer Prevention and Relapse: Current Evidence and Future Perspectives

Aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) have received considerable interest as potential chemopreventive agents. The aim of this review is to summarize the accumulated knowledge on the effect of NSAIDs on breast cancer incidence and natural history, and the underlying pathophysiology. NSAIDs mainly block inflammation by inhibiting cyclooxygenase enzymes, leading to lower prostaglandin synthesis. The latter has been reported to affect breast cancer risk through hormonal and inflammation-related pathways. Intensity, dose, frequency, duration, and timing of administration may also be significant. There is currently enough evidence to support a role of NSAIDs in breast cancer prevention and relapse, which deserves further large-scale experimental and clinical investigation.

Microwave versus saline-linked radiofrequency (Aquamantys) assisted liver resection in a porcine liver resection model. A safety and feasibility pilot study

PURPOSE

The aim of this study was to compare the feasibility, efficacy and safety of microwave ablation and saline-linked radiofrequency (Aquamantys) in liver resection.

METHODS

Sixteen domestic pigs (8 per group) underwent thermoablations. Group A consisted of 8 pigs in which microwave left lateral liver resection was performed. Group B consisted of 8 pigs which underwent left lateral liver resection by the Aquamantys system. After 28 days of close follow-up, the animals were sacrificed in order to study the macroscopic and microscopic findings of each intervention on the liver edge.

RESULTS

An average of 47.13 min was enough for the entire operation to take place using Aquamantys, whereas an average of 59.13 min was needed in the microwave liver resection group. Mean blood loss was 40 ml (range 5-85) with Aquamantys whereas mean blood loss was 72.37 ml (range 42-100) using microwave. Postoperative complications rates were extremely low in both groups. There was no intra- or postoperative mortality.

CONCLUSIONS

Our study demonstrated that left lateral liver resection using Aquamantys system is technically feasible in the porcine model and proved to be highly effective and a safer hemostatic method compared to microwave ablation.

Solid Organ Cool-tip Radiofrequency Ablation: An Experimental Study with Clinicopathological Correlations

BACKGROUND/AIM

Radiofrequency ablation (RFA) with internally cooled electrodes is a technique for the in situ treatment of solid tumors, inducing characteristic pathological changes with limited clinical complications. Our purpose was to assess RFA-induced histological alterations and correlate them with clinical complications.

MATERIALS AND METHODS

Using a porcine model, the pathology of RFA-induced kidney, liver and spleen lesions was associated with the postoperative course and clinical complications recorded.

RESULTS

Complications and relevant histological lesions, including abscess formation, hemorrhage and bile or urinary leakage, were limited or absent. The majority of RFA-induced necrotic tissue exhibited preserved architecture, with relatively limited inflammatory reaction, associated with sealing of blood/bile vessels or urinary tubules along the periphery of the lesions.

CONCLUSION

The preserved architecture of RFA-induced necrotic tissue, its slow clearance, the relatively limited inflammation and the ability of RFA to seal blood/bile/urinary vessels are probably responsible for the minimal complications observed.

Multifocal Bilateral Breast Cancer and Breast Follicular Lymphoma: A Simple Coincidence?

Breast cancer coexisting with lymphoma is a rare condition with various diagnostic and therapeutic implications. In this report, we describe the case of a 55-year-old Caucasian woman who presented with simultaneous ductal carcinoma in situ of the right breast, and follicular lymphoma involving an inguinal lymph node and the left breast. The patient underwent local excision and radiotherapy for the ductal carcinoma in situ, while a watch and wait strategy was adopted for the lymphoma. Two years later, the patient presented with multifocal ductal carcinoma of the left breast and reappearance of the lymphoma in the left axillary lymph nodes. She underwent bilateral mastectomy, left sentinel node biopsy, and chemotherapy. Synchronous follicular lymphoma and bilateral metachronous breast carcinoma has not been described previously. Diagnosis is based on tissue histology after excision or a needle biopsy. Treatment for these two diseases is distinct, and a multidisciplinary approach should be adopted.

Contralateral relapse after surgery for breast cancer: evaluation of follow-up paradigms

BACKGROUND

Early treatment of breast cancer patients with loco-regional relapse or contralateral disease has been shown to improve survival. There is no current consensus on the optimal follow-up strategy. This study estimates the risk of isolated contralateral relapse (CR) after breast cancer surgery and its change over time, together with the efficacy of clinical examination, self-examination and mammography in the detection of CR.

METHODS

Data from patients treated for early breast cancer at Guy's Hospital between 1990 and 1997 were collected and those with isolated contralateral recurrences were analysed. Life table analysis was performed and CR, CR-free and cumulative CR rates were calculated. Correlations were evaluated using Pearson's correlation coefficient.

RESULTS

One thousand one hundred and forty-three women were included in the study and 23 patients had isolated CR. The median probability of CR was a constant 0.24% per year. Only one recurrence was found clinically at follow up, while the majority was detected through mammography and self-palpation.

CONCLUSIONS

The risk of CR is low and constant with time. Contralateral mammography is useful and can detect the vast majority of contralateral recurrences. These findings may have practical implications especially on the planning of postmastectomy follow up.

The three-surgeon technique for liver tissue dissection: towards real bloodless hepatectomy

PURPOSE

Bleeding during hepatectomy remains a major cause of mortality despite recent developments in surgical and anaesthetic techniques. To date there is no single surgical device that combines speed, efficient haemostasis and safety for the adjacent vital structures during parenchymal division. This article presents the Three Surgeon Technique (3ST), a novel method of parenchymal dissection for major hepatectomies and compare it with our standard radiofrequency ablation (RFA) - assisted technique.

METHODS

77 patients who underwent major liver resection were divided into two groups: 38 of them (group A) underwent 41 RFA-assisted liver resections and 39 (group B) underwent 41 hepatectomies with the 3ST. The data for the 3ST were prospectively collected and compared to the already collated RFA patient group.

RESULTS

Blood transfusion was necessary in 28 and 13 patients in group A and B respectively (p=0.016), with an average of 1.7 and 0.6 units of red blood cells (p<0.001). The Pringle maneuver was not required with the 3ST. The mean time of parenchymal dissection was 90.49 and 77.52 min in group A and B, respectively (p=0.007).

CONCLUSION

The 3ST is a novel, reliable and safe alternative to the stand alone RFA-assisted technique. It is a faster procedure, and requires less blood units transfusion.

ZEN and the art of breast health maintenance

Zearalenone (ZEN) is a non-steroidal mycoestrogen that widely contaminates agricultural products. ZEN and its derivatives share similar molecular mechanisms and activity with estrogens and interact with ERα and ERβ leading to changes in the reproductive system in both animals and humans. The reduced form of ZEN, α-ZEA ralenol, has been used as an anabolic agent for animals and also proposed as hormonal replacement therapy in postmenopausal women. Furthermore, both zearelanol ZEN and derivatives have been patented as oral contraceptives. ZEN has been widely used in the United States since 1969 to improve fattening rates in cattle by increasing growth rate and feed conversion efficiency. Evidence of human harm from this practice is provided by observations of central precocious puberty. As a result, this practice has been banned by the European Union. As ZEN has been associated with breast enlargement in humans, it has been included in many bust-enhancing dietary supplements but epidemiological evidence is lacking with regard to breast cancer risk. Extensive work with human breast cancer cell lines has shown estrogenic stimulation in those possessing ER but a reduction in DMBA-induced breast cancers in rodents given ZEN. Protein disulfide isomerase provides a molecular biomarker of dietary exposure to ZEN and its derivatives allowing the detection and control of harmful food intake. The interaction of ZEN with anti-estrogens, anticancer agents and antioxidants requires further investigation.

The effects of mild hypothermia on coagulation tests and haemodynamic variables in anaesthetized rabbits

OBJECTIVE

Hypothermia has been associated with coagulation defects. The purpose of this experimental study was to investigate the effect of mild hypothermia on clinically used coagulation tests and on haemodynamic variables.

METHODS

Nine New Zealand rabbits were subjected to mild core hypothermia by administration of general anaesthesia and exposure to room temperature of 22 degrees C for 60 minutes. Blood samples were obtained at normothermia and mild hypothermia for measurement of prothrombin time, activated partial thromboplastin time, fibrinogen levels, platelet count and haemoglobin concentration. Hypothermic values were compared to the normothermic values. Additionally, the progressive temperature drop and haemodynamic changes (blood pressure, heart rate) were recorded.

RESULTS

Core temperature decreased significantly over time changing from 39.4 +/- 0.27 to 36.6 +/- 0.28 degrees C (p = 0.0001). Prothrombin time and activated partial thromboplastin time increased [corrected] at hypothermia, but the changes were not statistically significant (p = 0.203 and p = 0.109, respectively). Platelet count, fibrinogen levels and haemoglobin concentration decreased significantly (p = 0.0001, p = 0.03 and p = 0.027) but remained within normal limits. Mean arterial pressure and heart rate declined significantly over time (p = 0.0001 and p = 0.0001, respectively).

CONCLUSION

The results of this study suggest that short term mild hypothermia may affect the coagulation mechanism to a clinically nonsignificant extent, while haemodynamic responses are significantly suppressed.

Factors influencing loco-regional relapse in older breast cancer patients treated with tumour resection and tamoxifen

BACKGROUND

In breast cancer patients (≥70 years), tumour resection plus tamoxifen (T + T) has a higher loco-regional relapse (LR) rate than mastectomy. This study examines factors influencing local recurrence in these cases.

METHODS

Clinical records of 71 patients aged ≥70 years, randomised to the T + T arm of 2 randomised trials were reviewed. Cox Proportional Hazards model was used to determine the most significant variables.

RESULTS

After 15-years follow-up, LR relapse occurred in 29/71, of whom 5 had synchronous metastatic disease. Most tumours recurred in the index quadrant. Subsequently 21/24 patients with loco-regional recurrence only had salvage mastectomy. Three variables significantly predicted LR: lympho-vascular invasion (LVI) (HR [95% CI]: 11.18 [4.47, 27.95], p < 0.01), ER negative status (HR [95% CI]: 0.27 [0.10, 0.72] p = 0.01), and tumour necrosis (HR [95% CI]: 2.65 [1.10, 6.37], p = 0.03). Final margin status was not associated with LR.

CONCLUSIONS

Tumour resection + Tamoxifen in older patients results in long-term local control in the majority with most loco-regional failures being salvageable. Risk factors for LR are lympho-vascular invasion, ER status and tumour necrosis. Negative tumour excision margins did not significantly change local outcome in the absence of radiotherapy. In these older patients LVI significantly reduced survival time.

Digital infrared thermal imaging (DITI) of breast lesions: sensitivity and specificity of detection of primary breast cancers

AIM

To determine the sensitivity and specificity of digital infrared thermal imaging (DITI) in a series of women who underwent surgical excision or core biopsy of benign and malignant breast lesions presenting through the symptomatic clinic.

MATERIALS AND METHODS

DITI was evaluated in 63 symptomatic patients attending a one-stop diagnostic breast clinic.

RESULTS

Thermography had 90 true-negative, 16 false-positive, 15 false-negative and 5 true-positive results. The sensitivity was 25%, specificity 85%, positive predictive value 24%, and negative predictive value 86%.

CONCLUSION

Despite being non-invasive and painless, because of the low sensitivity for breast cancer, DITI is not indicated for the primary evaluation of symptomatic patients nor should it be used on a routine basis as a screening test for breast cancer.

Breast Cancer in Patients with Hodgkin's Lymphoma Predominantly Treated with Anthracycline – Based Chemotherapy with or without Radiotherapy: A Preliminary Analysis

BACKGROUND: Hodgkin's lymphoma (HL) is a highly curable neoplasm with &gt;70-80% of the patients becoming long-term survivors. The success of treatment however, is associated with long term complications, namely breast cancer, especially if treated with extended-field radiotherapy (RT) at a curative dose as monotherapy. The oncogenic effect of limited field and relatively low-dose RT combined with anthracycline-based chemotherapy (CT) – the current standard of treatment for early stage disease - is not well investigated. The aim of the study is to describe the incidence of breast cancer in a series of patients treated predominantly with anthracycline-based CT with or without RT of limited field and dose.PATIENTS AND METHODS: Among 1125 patients in our database, 479 were females and were evaluated for the occurrence of breast cancer. Important baseline features were: Median age 28 years (14-81); clinical stage I, II, III, IV 17%, 55%, 15%, 13%; B-symptoms 37%; Nodular sclerosis 77%, mixed cellularity 15%, lymphocyte predominance 6%; Anthracycline based CT 86%, MOPP-based CT 12%, RT only without CT 2%; Radiotherapy 74%, mostly to the involved field, usually 2800-3000 cGy. The cumulative incidence of breast cancer was estimated by the Kaplan-Meier method.RESULTS: The median follow-up of the 479 female patients was 88 months: 36% were followed-up for &gt;10 years. At the time of the analysis 6 cases of breast cancer were recorded for a 5-, 10- and 20-year cumulative incidence of 0.5%, 1.7% and 4.4%. The median age of the 6 patients was 43 years (26-54) at diagnosis of HL and 46.5 years (33-63) at breast cancer diagnosis. Clinical stages were I (n=1), II (n=3), III (n=1) and IV (n=1) and 4/6 patients had B-symptoms at diagnosis. All patients were in their 1st complete remission when breast cancer was diagnosed at a median time of 67 months from HL diagnosis (8-198). All 6 patients had received anthracycline-based CT and had been irradiated at a median dose of 2870 cGy, but the mediastinum or the axillae were included in the RT field only in 3/6 patients. Among 646 male patients, a single case of breast cancer was recorded in a 49 year old patient, 265 months after high-dose (4300 cGy) mantle field RT followed by MOPP/ABVDx6.DISCUSSION: In a series of female patients with HL, a median age of 28 years at diagnosis and a median follow-up of ∼7.5 years (&gt;10 years in 36% of them), who were predominantly treated with modern CT with or without limited field and dose RT, the 10- and 20-year incidence of breast cancer was 1.7% and 4.4%, with 6 cases recorded. Three of the cases developed clearly outside the irradiation field. We also recorded a single case of male breast cancer, which was very likely treatment related. Whether these cases are in excess of those expected for the population studied, as well as the features and outcome of breast cancer in HL survivors are currently being investigated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6069.

Autologous tissue immediate breast reconstruction: desired but oncologically safe?

BACKGROUND

There has been a dramatic increase in the incidence of immediate breast reconstruction after mastectomy for breast cancer over the past few decades and autologous tissue flaps are being used with increasing frequency. Concern has been expressed that these complex procedures may lead to a delay in the delivery of adjuvant therapy, which in turn may adversely affect recurrence and survival rates. Several publications have looked into the effect of immediate reconstruction on the timing of delivery of adjuvant therapy, but all types of immediate breast reconstruction (IBR) tend to be examined as a homogenous group.

AIM

The aim of this review was to search current literature and look specifically at the effect of autologous tissue reconstructions on adjuvant therapy, and identify possible causes of delay.

DISCUSSION

From the data analysed, it appears that there may be a delay in the delivery of adjuvant therapy associated with autologous tissue IBR, especially transverse rectus abdominis muscle (TRAM) flaps. The studies available, however, examine small numbers of patients, which makes proving statistical significance difficult. Moreover, there also appears to be no consensus on what constitutes a delay in the delivery of adjuvant therapy. From 3% to 72% of autologous tissue IBR patients seem to receive their adjuvant treatment with a delay, according to the guidelines of the respective centres. Moreover, the period of time until chemotherapy appears generally increased from 13% to 36% compared with mastectomy alone patients. The most common reasons for delay are wound and flap complications.

CONCLUSION

At the moment, despite the increasing popularity of autologous IBR, these procedures have not proved their oncological safety. Further studies looking at the effect of IBR, especially TRAM flap reconstruction, are needed.