Factors affecting breast cancer treatment delay in Turkey: a study from Turkish Federation of Breast Diseases Societies

BACKGROUND

One of the most important factors in breast cancer (BC) mortality is treatment delay. The primary goal of this survey was to identify factors affecting the total delay time (TDT) in Turkish BC patients.

METHODS

A total of 1031 patients with BC were surveyed using a uniform questionnaire. The time between discovering the first symptom and signing up for the first medical visit (patient delay time; PDT) and the time between the first medical visit and the start of therapy (system delay time; SDT) were modelled separately with multilevel regression.

RESULTS

The mean PDT, SDT and TDT were 4.8, 10.5 and 13.8 weeks, respectively. In all, 42% of the patients had a TDT >12 weeks. Longer PDT was significantly correlated with disregarding symptoms and having age of between 30 and 39 years. Shorter PDT was characteristic of patients who: had stronger self-examination habits, received more support from family and friends and had at least secondary education. Predictors of longer SDT included disregard of symptoms, distrust in success of therapy and medical system and having PDT in excess of 4 weeks. Shorter SDT was linked to the age of >60 years. Patients who were diagnosed during a periodic check-up or opportunistic mammography displayed shorter SDT compared with those who had symptomatic BC and their first medical examination was by a surgeon.

CONCLUSION

TDT in Turkey is long and remains a major problem. Delays can be reduced by increasing BC awareness, implementing organized population-based screening programmes and founding cancer centres.

A new and simple predictive formula for non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph nodes, and validation of 3 different nomograms in Turkish breast cancer patients

BACKGROUND

Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement.

PATIENTS AND METHODS

Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement.

RESULTS

The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64-0.8), 0.665 (95% CI 0.59-0.73), and 0.696 (95% CI 0.59-0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63-0.81).

CONCLUSION

The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.

Factors affecting time to seeking medical advice and start of treatment in breast cancer (BC) patients in Turkey

e17529

Background: One of the most important reasons of BC mortality is delay in treatment. Due to lack of BC awareness and organized screening programs, total delay time (from first symptoms of BC to initiation of treatment; TDT) is longer in low-middle income countries. The primary goal of this survey was to identify factors affecting TDT in patients with BC. Methods: As a part of previously presented multinational survey, a total of 1.031 BC patients from 12 cities of 5 districts in Turkey were surveyed using a uniform questionnaire. TDT was determined using 8 individual scales, including one pertaining to patient delay and 7 related to subsequent steps in a typical diagnostic process. Regression models were constructed using 17 variables concerning diverse contextual and personal patient characteristics. Time between first symptom and first medical visit (Patient Delay Time; PDT) and time between first medical visit and start of therapy (System Delay Time; SDT) were modeled separately with multilevel regression. Results: Mean PDT, SDT and TDT were 4.8, 10.5 and 13.8 weeks respectively, with 42% of the patients with a delay of >12 weeks. Multilevel regression equation indicated that disregard of discovered symptoms (p<0.001) and having at least secondary level of education (p=0.021) were significantly correlated with longer PDT. Patients with stronger self-examination habits (p=0.009), reporting more support from friends and family (p<0.001) and living in metropolitan areas (>500k) (p=0.006) had shorter PDT. Predictors of longer SDT included disregard (p<0.001) and having a PDT>4 weeks (p<0.001). Shorter SDT was correlated to being older than 60 years of age (p=0.027). Results revealed that diagnosis during periodic check-up or opportunistic mammography vs. symptomatic BC (p<0.001) and having first medical examination by a surgeon resulted in shorter SDT. Conclusions: TDT in Turkey is unacceptably long and system delay accounted for a substantial part of the total delay experienced by breast cancer patients. This points to a need for shortening clinical pathways if possible. A long patient delay calls for research into patient awareness of BC.

p53 protein accumulation and presence of visceral metastasis are independent prognostic factors for survival in patients with metastatic inflammatory breast carcinoma

OBJECTIVE

The aim of this study was to determine the markers of prognosis in metastatic inflammatory breast cancer (IBC).

SUBJECTS AND METHODS

The prognostic value of patients' clinical characteristics and expression of c-erbB-2, p53, Ki-67, ER and PgR were assessed in the 45 patients with IBC who had developed distant metastasis. Immunohistochemical methods were used to detect the expression of c-erbB-2, p53, Ki-67, ER and PgR in surgical resection specimens of the patients' primary tumor.

RESULTS

The median overall survival (OS) measured from the diagnosis of metastatic disease was 23 months. In the univariate analysis, p53 protein accumulation and the presence of visceral metastasis were predictive of poor survival (p = 0.01 and 0.003, respectively). In the multivariate analysis, accumulation of p53 protein and the presence of visceral metastasis correlated with OS (p = 0.02 and 0.008, respectively).

CONCLUSION

In metastatic IBC, accumulation of p53 protein and presence of visceral metastasis are independent prognostic factors for OS. Established prognostic factors in non-IBC patients such as patient age, histologic grade, hormone receptor status and c-erbB-2 status did not have independent significance in IBC in this study.

Screening for metastasis in primary breast cancer patients having four or more axillary lymph node involvement: is it really necessary?

PURPOSE

To evaluate the necessity and direct cost effectiveness of screening and staging procedures in breast cancer patients having ≥4 positive axillary lymph nodes and to identify further possible biopathological risk factors associated with increased risk of metastasis.

METHODS

We reviewed the demographic and clinicopathological data from the medical records of 1897 newly diagnosed breast cancer patients. Patients having ≥4 positive axillary lymph nodes after primary surgery for breast cancer and who had staging examinations for metastasis were eligible. The impact of staging procedures (thoracoabdominal CT, bone scan etc.) for detecting metastasis, decision of adjuvant treatment and direct costs were analyzed in 329 patients with operable breast cancer.

RESULTS

Thirty-five (10.6%) patients were found with metastasis at diagnosis. Seven (20.0%) among them had multiple metastases. Eighteen (51.4%) had lung, 17 (48.6%) bone, and 7 (20.0%) liver metastasis. Twenty-one (60.0%) patients needed further radiological investigation for metastasis confirmation. Treatment decision was changed in 27 (77.1%) patients. No statistically significant risk factor was identified among the metastatic patients by means of conventional demographic and biopathological parameters. The cost of screening was lower when compared to the cost of treatment without any screening procedure.

CONCLUSION

Since the conventional clinicopathological data seems not sufficient to define the risk of developing metastasis in breast cancer patients with ≥4 axillary lymph node involvement, all of them should undergo full staging examinations until new parameters based on genomic level are defined. Staging procedures need modification for high risk breast cancer patients.

Fine needle aspiration cytologic features of medullary carcinoma of the breast: a study of 20 cases with histologic correlation

OBJECTIVE

To analyze fine needle aspiration cytology (FNAC) material from 20 cases of histologically verified medullary carcinoma (MC) of the breast and correlate the cytomorphologic features with histologic appearance to improve the diagnostic sensitivity and specificity of FNAC.

STUDY DESIGN

We reviewed the cytologic features of 20 cases of MC of the breast in the archives of Ege University Hospital between 1994 and 2006.

RESULTS

Twenty patients with an aspirate and confirmed diagnosis of MC were identified. Patient age was 30-74 years (mean, 48). The initial cytologic diagnoses were positive for cancer in 17 cases, atypical/suspicious for cancer in 2 cases and negative for cancer in 1 case. The cytologic picture was characterized by cellular smears composed of highly atypical epithelial tumor cells in loosely cohesive sheets and lying singly, admixed with polymorphous lymphocytes, plasma cells and neutrophils. Tumor cells had predominantly abundant finely granular, eosinophilic cytoplasm and moderate to marked nuclear pleomorphism with prominent nudcleoli. Histologic examination confirmed that 11 cases were atypical MC and 9 were pure MC.

CONCLUSION

Breast MC is a rare, distinct category that appears to have rather characteristic cellular features. Familiarity with the cell components is a prerequisite in cytologic accuracy.

Do clinical and immunohistochemical findings of pure mucinous breast carcinoma differ from mixed mucinous breast carcinoma?

Mucinous carcinoma of the breast is a relatively rare histologic type with two subtypes: pure and mixed. It has a favourable prognosis with a low risk of axillary metastases. The prognosis for pure mucinous carcinoma (PMC) was much better than for the mixed mucinous carcinoma (MMC). The aim of the study is to determine suitable candidates for breast or axillary conservation in mucinous carcinoma subtypes. The slides of 26 pure and 23 mixed mucinous carcinomas of the breast were evaluated. The clinical, pathological and immunohistochemical features between PMCs and MMCs were compared. MMC displayed greater metastatic potential (p < 0.05), p53 positivity (p < 0.05) and c-erbB-2 positivity (p <0.001) than PMCs. PMCs smaller than 2 cm had less metastatic capacity and extranodal invasion compared to MMCs smaller than 2 cm (p < 0.001 and p < 0.01, respectively). MMCs smaller than 2 cm displayed weaker ER positivity but greater c-erbB-2 positivity than PMCs smaller than 2 cm (p < 0.01). In conclusion, MMC had worse prognostic factors than PMC with both types of mucinous carcinoma showing similar ER and PR positive status. Even if PMCs and especially smaller PMCs display more favourable prognostic features, including less axillary lymph node involvement, it is appropriate to use sentinel lymph node biopsy to make better axillary assessment.

Comparison of the clinical and pathological features between patients with recurrent metastatic breast carcinoma and patients with initially metastatic breast carcinoma

OBJECTIVE

To compare initial metastatic breast carcinoma (MBC) with recurrent MBC and assess their biologic phenotypes and clinical behaviors.

METHODS

A comparison of clinical and biological characteristics and median overall survival times were assessed in the 251 patients with MBC at the Division of Medical Oncology, Ege University School of Medicine, and the Division of Radiation Oncology, Tepecik Government Hospital, Izmir, Turkey between 1995 and 2004. Hormone receptors, c-erbB-2, Ki-67, and p53 expressions were performed by immunohistochemistry.

RESULTS

Out of 251 MBC patients, 206 patients had recurrent MBC, and 45 had initial MBC. Regarding survival, there was no difference between the recurrent MBC group and the initial MBC group. The initial MBC group had a higher proportion of T4 tumors (46% versus 27%), a lower proportion of T1-2 tumors (31% versus 55%; p=0.01), and a higher percentage of patients with high Ki-67 expression (64% versus 49%; p=0.05). Multivariate analysis showed that T stage was an independent prognostic factor (p=0.02).

CONCLUSION

Patients with initial MBC tended to present with larger tumors. This relationship can be explained by delayed diagnosis. The potential for reducing death rates from breast cancer is contingent on educational improvement and increased screening rates.

Fine needle aspiration cytology of mammary carcinoma with choriocarcinomatous features: a report of 2 cases

BACKGROUND

Neoplasms of the breast containing multinucleated giant cells (MGCs) include both benign and malignant entities, such as benign soft tissue giant cell tumors, atypical fibrous histiocytoma, sarcomas, metaplastic carcinomas and the uncommon carcinomas containing osteoclast-like giant cells (OGC). Breast carcinoma with choriocarcinomatous features (BCCF) is a distinct variant of breast cancer.

CASES

We report the cytologic features, pathologic findings and immunohistochemical profile in 2 cases of this unusual variant of breast carcinoma. Two women aged 53 and 50 years women presented with a history of left and right breast lump but no local lymphadenopathy, respectively. Fine needle aspiration cytology (FNAC) of both cases revealed abundant MGC with highly pleomorphic tumor cells in the hemorrhagic necrotic background. Both of the cases were histopathologically diagnosed as BCCF.

CONCLUSION

Choriocarcinomatous differentiation with multinucleated syncytiotrophoblast-like giant cells is extremely rare in breast tumors. Although rare, FNAC of breast cancer with pleomorphic MGC requires careful search for differential diagnosis; breast carcinoma with giant cell features (choriocarcinomatous features, OGC features) must be differentiated from metastatic tumors and other breast lesions containing giant cells.

Comparison of inflammatory breast cancer and noninflammatory breast cancer in Western Turkey

OBJECTIVE

The study was aimed at investigating the clinical and biological features and survival outcomes of patients who were treated for metastatic inflammatory and noninflammatory breast carcinoma.

SUBJECTS AND METHODS

One hundred and sixty-seven metastatic breast cancer patients were enrolled into this study and divided into two groups: inflammatory (n = 46) and noninflammatory (n = 121). The clinical and hormone receptor status, c-erbB-2, Ki-67, and p53 expression, based on the immunohistochemical staining patterns, were compared between the two groups.

RESULTS

The inflammatory breast carcinoma group had a younger patient population, higher rate of adjuvant anthracycline therapy, number of lymph node metastases, rates of extranodal extension and c-erbB-2 overexpression than noninflammatory breast cancer patients (p < 0.05). With regard to survival, there were slightly better outcomes in the noninflammatory breast carcinoma group (30 months) compared to the inflammatory breast carcinoma group (23 months), but the difference was not statistically significant (p = 0.08). While survival results of p53-negative inflammatory and noninflammatory breast carcinoma patients were similar, p53-positive survival was significantly worse (p < 0.05) in inflammatory breast cancer carcinoma patients.

CONCLUSION

Because of c-erbB-2 overexpression in inflammatory breast carcinoma patients, treatment options including trastuzumab could have given better survival outcomes. Survival of inflammatory breast carcinoma patients with a low p53 immunohistochemistry staining appeared similar to that for noninflammatory breast carcinoma. For this reason, new treatment options are needed especially in inflammatory breast carcinoma patients with high p53 positivity.

Fine needle aspiration cytology of glycogen-rich clear cell carcinoma of the breast: review of 37 cases with histologic correlation

OBJECTIVE

To analyze fine-needle aspiration cytology (FNAC) material from 37 cases of breast glycogen-rich clear cell cancer (GRCC) and correlate cytomorphologic features with histologic appearance to determine characteristics of GRCC on FNAC.

STUDY DESIGN

We reviewed cytologic features of 37 cases of breast GRCC from the archives of Ege University Hospital diagnosed between 1994 and 2006.

RESULTS

Thirty-seven patients with available aspirate and confirmed GRCC were identified. The female patients ranged from 32 to 81 years (mean 52 years). The initial cytologic diagnoses were adenocarcinoma for 27 and atypical or suspicious for cancer for 10. The cytologic picture was characterized by hypercellular tumor cells in loosely cohesive syncytial groups and some single cells. Most tumor cells had abundant, finely granular eosinophilic cytoplasm or foamy to clear cytoplasm with well-defined cytoplasmic membranes and moderate to marked nuclear pleomorphism with prominent nucleoli. Histologic examination confirmed all cases to be pure GRCC.

CONCLUSION

Breast GRCC is a rare, distinct category with cytologic features that overlap considerably with those of other carcinomas. Awareness of variability in cytomorphologic appearance of GRCC and routine assessment for glycogen facilitate accurate diagnosis of these lesions by FNAC and enable prompt treatment of these poor-prognosis breast cancers.

The use of periareolar intradermal Tc-99m tin colloid and peritumoral intraparenchymal isosulfan blue dye injections for determination of the sentinel lymph node

PURPOSE

The purpose of the present study was to evaluate the use of lymphoscintigraphy, blue dye, and gamma probe detection methods for determination of the sentinel lymph node (SLN) using both periareolar intradermal injection of Tc-99m tin colloid and peritumoral intraparenchymal injection of isosulfan blue dye.

METHODS

One hundred patients with T1-2 breast cancer and clinically negative nodes were enrolled in the present study. The study was composed of 2 groups. Backup axillary lymph node dissection (ALND) was mandatory in group 1 (20 patients) regardless of their lymph node status. In group 2 (80 patients), complete ALND was performed when intraoperative frozen section analysis of SLN revealed metastases. Otherwise, only SLN biopsy was performed without ALND. One day before surgery, Tc-99m tin colloid was injected at 4 periareolar sites intradermally. Lymphoscintigraphy was performed 1 to 2 hours after injection of the radiocolloid. Twenty minutes before surgery, isosulfan blue dye was injected into parenchyma surrounding the tumor or the biopsy cavity.

RESULTS

The detection rates of SLN and false-negative rate of lymphoscintigraphy, blue dye, and gamma probe detection were 85%, 95% 100%, and 0% in group 1, 91%, 87%, and 95% in group 2, respectively. Detection rate by the combination of blue dye and radio tracer was 98%.

CONCLUSIONS

According to the results of our study, we conclude that perioareolar intradermal injection of Tc-99m tin colloid combined with peritumoral intraparenchymal injection of blue dye is an accurate and easy method of locating the sentinel node with very high detection rates. It is recommended that the combination of all methods such as lymphoscintigraphy, blue dye, and gamma probe application will increase the success rate of SLN detection in patients with breast cancer.

A clinicopthologic study of a rare clinical entity mimicking breast carcinoma: idiopathic granulomatous mastitis

Idiopathic granulomatous mastitis (IGM) is a rare chronic inflammatory lesion of the breast clinically simulating carcinoma. The purpose of this report is to review the clinicopathological features of this clinical entity in a series of 18 cases diagnosed in our institute. The notes of patients and the slides of the biopsy specimens of 18 cases with IGM were reviewed. Special stains for organisms and immunohistochemistry for T and B markers using the primary antibody was done. The diagnosis of IGM was made according to the criteria of Kessler and Wolloch. All but two patients were of reproductive age and all were parous. The main clinical finding was a unilateral, firm, discrete mass. All patients underwent excisional biopsy and recurrence was seen in three patients. In two of these patients who had recurrences, the prolactin level was high and reexcision combined with antiprolactinemic therapy was performed. The third patient was treated by reexcision and oral prednisone. There was granulomatous inflammation, centered mainly on breast lobules in all patients. T cell domination was observed. Exclusion of the other causes of a granulomatous lesion is necessary to make the diagnosis of IGM. The treatment of choice is unclear. Because of the clinical concern of malignancy, fine-needle aspiration cytology or core biopsy can be useful in some cases. To differentiate it from other granulomatous lesions, incisional biopsy or surgical excision of the lesion is necessary. In patients with delayed wound healing or recurrence after excisional biopsy, or those patients who have had an incisional biopsy only, if prolactin level is normal, reexcision and oral prednisone usage may be curative. In patients with a high prolactin level who have recurrence, medical treatment to control prolactin level may be useful in the management of these women.

Granulomatous mastitis: imaging findings with histopathologic correlation

OBJECTIVE

The purpose of this study is to evaluate the mammographic and ultrasonographic characteristics of granulomatous mastitis and to correlate the imaging features with the histologic findings.

MATERIALS-METHODS

15 patients with diagnosis of idiopathic granulomatous mastitis were examined with mammography and ultrasonography. The clinical, pathologic and imaging features were retrospectively reviewed and correlated in all patients.

RESULTS

Mammographic examination showed an asymmetric density with no distinct margins in 8 patients and an ill-defined mass in 3 patients. In 4 cases, no abnormal finding was detected on the mammography. Sonographic examination demonstrated an irregular mass with tubular connections in 5 patients, single or multiple hypoechoic tubular/nodular structures in 6, and focally or segmentally decreased parenchymal echogenity with acoustic shadowing in 4 patients. The imaging findings suggested a malignant tumor in 7 patients, while an inflammatory process or intraductal papilloma was considered in the differential diagnosis of the other patients.

CONCLUSION

Granulomatous mastitis usually presents with clinical findings mimicking a carcinoma. The most common mammographic appearance of the lesion is an asymmetrically increased density, which is not characteristic for this entity. Sonographic patterns of the disease are varied and appear to relate to the histologic features. Findings include a mass-like appearance, tubular/nodular hypoechoic structures and focal decreased parenchmal echogenicity with acoustic shadowing. With awareness of the findings granulomatous mastitis can be considered in the differential diagnosis.

Effects of somatostatin analogues and vitamin C on bacterial translocation in an experimental intestinal obstruction model of rats

The passage of viable endogenous bacteria and their products across the intact intestinal mucosal barrier, disseminating to the mesenteric lymph nodes, peritoneal cavity, spleen, liver, and circulation, is defined as bacterial translocation. Intestinal obstruction induces bacterial translocation due to mucosal disruption, motility dysfunction, and increased intestinal volume, leading to bacterial overgrowth. In a rat model of intestinal obstruction, the effects of both high-dose vitamin C (350 microg/kg), an antioxidant agent known to have a cytoprotective effect in ischemia-reperfusion injury, and somatostatin (20 microg/kg), a gastrointestinal antisecretory agent, in preventing bacterial translocation were studied. Both intestinal and liver samples from the rats was observed, and it was found that the rate of bacterial translocation was 100% in the control group, and only 43% for the rats who were given intraperitoneal vitamin C and somatostatin. The difference was statistically significant. In conclusion, we are convinced that vitamin C and somatostatin analogues may have protective effects against bacterial translocation in mechanical bowel obstruction.

Esophagocoloplasty in the management of postcorrosive strictures of the esophagus

BACKGROUND/AIMS

Esophageal replacement therapy has developed an increasing role in the management of severe esophageal strictures due to caustic ingestion. The aim of this study is to discuss methods of reconstruction and results of them in corrosive esophagitis at our Institute.

METHODOLOGY

Thirty-three patients underwent 34 esophagocoloplasties for benign strictures of the esophagus over a 17-year period. The left colon was used in 8 patients, the right colon in 3 patients, and the right colon with the terminal ileum in 23 patients.

RESULTS

Three patients died in the first postoperative month, and there was an overall mortality rate of 9%. The most severe complication was graft necrosis (2 patients). The remainder of the patients survived without any deleterious complications.

CONCLUSION

Esophageal replacement therapy using the right colon with the terminal ileum is superior to the modalities in terms of the continuity of peristalsis of the interposed bowel segment with an intact ileocecal valve, which decreases the hazard of regurgitation from the colon. It is also easier to perform an anastomosis between the ileum and the cervical esophagus from the point of view of surgical manipulation.