Obtaining adequate surgical margin status in breast-conservation therapy: intraoperative ultrasound-guided resection versus specimen mammography

Background and aim

The purpose of breast-conserving surgery (BCS) for women with cancer is to perform an oncological radical procedure with disease-free margins at the final histological assessment and with the best aesthetic result possible. Intraoperative resected specimen ultrasound and intraoperative resected specimen mammography may reduce the rates of positive margins and reexcision among patients undergoing conserving therapy. Our objective is to compare the two methods with the histopathological results for a preset cut off and asses which parameters can influence the positive margin status.

Method

A prospective study was performed on 83 patients who underwent breast conservation surgery for early breast cancer (pT1-3a pN0-1 M0) between 2014 and 2016. After excision the specimen was oriented in the operating room by the surgeon. Metallic clips and threads were placed on margins: one clip and the long thread at 12 o’clock, two clips and the short threads at 9 o’clock. The next step was intraoperative ultrasound assessment of the specimen. For the margins under 2 mm we performed selective margin shaving, followed by mammography to identify and document the lesion and finally histopathological examination of the specimen with reporting the gross and microscopic margins. The positive margins required re-excision or boost of radiation at the posterior or anterior margins, depending on the case.

Results

We set a cut-off at 2 mm. The sensitivity and specificity of the intraoperative margin assessment via the ultrasound method were 90.91% (95% CI 70.84–98.88%) and 67.21% (95% CI 54–78.69%) respectively. The sensitivity and specificity of the intraoperative margin assessment via the mammographic procedure were 45.45% (95% CI 24.39–67.79%) and 85.25% (95% CI 73.83–93.02%) respectively. There was positive correlation between the histopathological and intraoperative ultrasound exam (p=0.018) and negative correlation between the histopathological exam and the post-operative mammographic exam (p=0.68). We found a positive correlation between the positive margin status and age (<40), preoperative chemotherapy, intraductal carcinoma, inflammatory process around the tumor, and the immunohistochemical triple negative profile.

Conclusions

According to our results, the intraoperative ultrasound of the breast specimen for a cutt-off at 2 mm can decrease the rates of margin positivity compared to the mammographic procedure and has the potential to diminish the number of subsequent undesired re-excisions.

Mesenchymal tumors and tumor-like lesions of the breast: a contemporary approach review

The classification of the breast tumors has been revised and recently published in 2012 in the WHO blue book. Contrary to the epithelial tumors in the breast, mesenchymal tumors are rare and the classification for benign and malignant tumors is based on the same criteria in both categories, since no other specific diagnostic criteria, which would have an impact on prognosis, exist to date. The present review deals with minor changes mirroring the recent developments in the benign mesenchymal tumors (new additions are nodular fasciitis and atypical vascular lesions, while the haemangiopericytoma is removed) focusing especially on criteria to diagnose sarcomas, which represent a wide spectrum including very difficult lesions. The majority of sarcomas of the breast arise as a component of a malignant phyllodes tumor, while the pure forms are very rare. When a pure primary sarcoma of the breast is diagnosed, pathologists are encouraged to categorize the lesion according to the type of differentiation and to provide to the clinicians all the important prognostic parameters for the best treatment choice.

Review on Practical Approach in Multiple Breast Carcinomas: Does Each Focus Matter?

Breast carcinoma is the most frequent form of cancer encountered in women worldwide. In the routine practice, most of breast carcinomas are diagnosed as unifocal, however, a variable proportion is represented by multiple tumor foci. Since data regarding the incidence, definition, morphological and molecular profile, treatment and prognosis of multiple breast carcinomas are currently contradictory we are presenting a practical approach for pathologists dealing with such a lesion, which may display morphological and molecular heterogeneity among multiple foci with an impact on management and prognosis. Multiple tumor foci should be reported separately and taken into account when establishing the treatment.

The Accuracy of the Preoperative Axillary Ultrasound Examination in Predicting the Status of the Sentinel Lymph Node Involvement in Patients with Infiltrating Breast Carcinoma

Background: we aimed to determine the accuracy of preoperative axillary ultrasound (US) in predicting the presence of sentinel lymph node (SLN) metastasis in breast cancer patients. Methods and Results: out of 54 cases, visible nodes on US were identified in 35 cases of which, 15 had metastasis. In 19 cases no axillary lymph nodes were visible on US. Of these, only 3 had metastasis. Moreover, our results demonstrated that neither the maximum diameter (p=0.738 Fisher exact test) nor the ratio between the longitudinal and transverse axes (p=0.728 Fisher exact test) can predict the positivity of the SLN. Conclusion: US cannot predict the positivity of the SLN.

Can Morphological and Molecular Parameters of the Primary Breast Tumor Predict the Positivity of Nonsentinel Lymph Nodes After Positive Sentinel Lymph Node Biopsy?

Background: Sentinel lymph node (SLN) biopsy is the gold standard in the evaluation of the axillary status in patients with breast cancer. In cases meeting the Z0011 criteria, no further surgery is needed, while in the remaining cases axillary dissection is required. The aim of the study was to evaluate which morphological and molecular parameters of primary breast tumor or positive SLN can predict the positivity of nonsentinel lymph nodes (NSLN) in order to avoid unnecessary axillary lymphadenectomy. Methods: We conducted a retrospective study on 170 consecutive invasive breast carcinomas, in which SLN biopsy was performed for staging. Results: 42 (24%) cases presented SLN metastases, of which 11 were micrometastases, 6 cases met the Z0011 criteria, requiring no subsequent surgery. 25 patients underwent subsequent ANLD, but only 7 cases (28%) had positive NSLN. In this series, only the tumor diameter 20 mm can predict positive nonsentinel lymph nodes (p= 0.058; CI: 0.05787 to 0.8224). Other parameters such as patient's age (p=0.280; CI:0.7544 to 7.998), histological type (p=0.231; CI: 0.05374 to 9.271), histological grade (p=0.929; CI: 0.2351 to 3.515), molecular profile of the tumor (p=0.362; CI: 0.2416 to 4.663), number of positive SLN (p=0.378; CI: 0.1083 to 1.570), presence of extracapsular extension (p=0.625; CI: 0.5066 to 13.96) and lymph node ratio (p=0.656; CI: 0.5068 to 5.768) cannot predict the presence of metastasis in the NSLN. Conclusion: In cases in which the patient does not meet the Z0011 criteria and/or these criteria are not used, axillary lymph node dissection is the surgical treatment of choice.

[Surgical emergencies in elderly]

BACKGROUND

A higher number of elderly are seeking surgical care in the last years for different affections. The aim of the study was to analyze the characteristics of surgical emergency pathology in elderly and to establish several prognostic factors.

MATERIALS AND METHODS

We did a retrospective study on 22.803 patients admitted in the First and the Third Clinic of Surgery from Targu-Mures between 1999 and 2006. The data were statistically processed.

RESULTS

The elderly (> or =70 years) represented 15.10% of all cases and 20.70% of all emergencies. Almost half of them (47.80%) were admitted in emergency conditions, compared to only a third (32.53%) of the younger group. The malignancies represented 16.72%, meanwhile in the younger group only 6.98 %. Abdominal emergencies represented 83.59%, mostly due to intestinal occlusion and digestive hemorrhages. The operability ratio was 68%, close to the younger group (72%). The global mortality rate was 3.95%.

CONCLUSIONS

Surgical emergencies affect elderly in a higher percentage than the younger group. The emergency condition, the elder age and neoplasia are the most important factors of negative prognosis, and more important when they cumulate, increasing the mortality rate up to fivefold compared to the elderly admitted in elective condition.

Clinical implications of multifocality as a prognostic factor in breast carcinoma - a multivariate analysis study comprising 460 cases

BACKGROUND

Multifocality is not listed among prognostic factors in international breast cancer guidelines. This study aims to analyze survival in multiple breast carcinomas (MFMC cc) compared to unifocal ones (UF cc), in order to assess the prognostic impact of multifocality.

METHODS

The study included 460 breast carcinomas (2002-2006) with a median follow-up time of 104 months (74-134 months). We assessed mortality rates, overall survival at 5 years and 10 years in general, overall survival at 5 and 10 years in MFMC cc compared to UF cc, as well as median survival and survival rate according to age, T status and axillary lymph node status in MFMC cc compared to UF cc. We carried out a multivariate analysis in order to identify independent predictor factors for survival.

RESULTS

69/460 (15%) of cases were MFMC cc. Mortality rates were 56.5% in MFMC cc versus 45.1% (UF cc) (P = 0.08). 5-year overall survival was 55.9% in MFMC cc vs. 64.7% UF cc, and the 10-year overall survival was 34.9% MFMC cc vs. 52.7% UF cc (P = 0.27). Median survival in MFMC cc was 78 months (6.5 years), whereas in UF cc it was 126 months (10.5 years). However, in the multivariate analysis, survival was independently influenced only by tumor size and the presence of axillary lymph node metastases (P < 0.0001).

CONCLUSION

Breast cancer multifocality is associated with higher general mortality rates, lower 5 and 10-year overall survival, yields a lower median survival, but it does not constitute an independent prognostic factor in multivariate analysis.

Possibilities and limits in the treatment of congenital diaphragmatic hernia

AIM

to establish a therapeutic strategy that will improve the prognosis and increase the survival rate in congenital diaphragmatic hernia.

MATERIAL AND METHOD

14 congenital diaphragmatic hernias (incidence 1/1597 live births, 12 boys and 2 girls with a sex ratio of 6/1, 10 term infants and 4 preterm first degree, 11 natural births and 3 by caesarean section) admitted to the Clinic of Pediatric Surgery Craiova, in a 5-year period (2007-2012), were analyzed from the therapeutic point of view. The "tension free" primary suture was the main surgical procedure to repair the diaphragmatic defect in all cases, preceded by a period of preoperative resuscitation and stabilization (2.8 days on average).

RESULTS

We registered a survival rate of 64.29% and a postoperative mortality rate of 35.71%.

CONCLUSIONS

delayed surgery preceded by a period of the preoperative respiratory resuscitation and stabilization (24-72 hours on average) significantly reduced postoperative mortality and increased the survival rate.

[The epidemiology of Lyme borreliosis]

Lyme borreliosis (LB) is a multisystem disease caused by infection with Borrelia burgdorferi sensu lato (B.b). LB is the most common human tick-borne disease, transmitted principally by species of Ixodes ricinus in Europe, I. persulcatus in Eurasia, I. scapularis and I. pacificus in North America. B.b has been isolated or detected in 24 different species of mammals or birds. The B31 strain of B.burgdorferi sensu stricto is predominant in United States and in Europe B. garinii, B. afzelii and B. burgdorferi sensu stricto.

On the synthesis and physical properties of iron doped SnO2 nanoparticles

The synthesis of iron doped tin oxide by pulsed laser pyrolysis is reported. The as obtained nanoparticles have a dominant SnO2 phase (as revealed by Wide Angle X-ray Scattering), with particles of the order of 10 nm. The doping with iron or iron oxide triggers magnetic properties as confirmed by SQUID experiments. EDX measurements supported the presence of Fe while Wide Angle X-ray Scattering failed to sense any iron or iron-oxide phase. It is concluded that Fe is well dispersed within the tin-oxide nanoparticles. The coercitive field has a complex dependence on the Fe/Sn content suggesting that the magnetization is not controlled solely by the amount of Fe dispersed within the nanoparticles.

Preliminary research on possible relationship of NO with agmatine at the vascular level

The comparative study of the vascular effects of agmatine and L-arginine as physiological precursors of NO indicated the following: When administered intravenously, both vasoactive substances produced a decrease of the systemic blood pressure in rats and rabbits, diminished in the case of agmatine and suppressed in that of arginine by the previous administration of L-NAME. Myorelaxing vascular effects were obtained in isolated thoracic aorta rings, precontracted with phenylephrine and noradrenaline. Endothelium removal suppressed the myorelaxing properties of L-arginine, without affecting the effects of agmatine, both before and after administration of L-NAME or yohimbine. The persistence of the relaxing effects of agmatine after NOS and guanylate-cyclase inhibition with methylene blue excludes the participation of NO and cGMP in their occurrence. The enhancement of agmatine myorelaxation by moxonidine pleads for the stimulation of imidazoline receptors.

Conventional Tools for Predicting Satisfactory Response to Neoadjuvant Chemotherapy in HR+/HER2- Breast Cancer Patients

Aim

The aim of the study was to assess the role of Magee Equation 3 (MagEq3), IHC4 score, and HER2-low status in predicting "satisfactory response (SR)" to neoadjuvant chemotherapy (NAC) in HR+/HER2- breast cancer (BC) patients.

Methods

In a retrospective study, female patients of any age with T1-4, N0-2, M0 HR+/HER2- BC who received NAC and underwent adequate locoregional surgical treatment were included. Patients were grouped according to 2 outcomes: (a) overall response to NAC in breast and axilla by using residual cancer burden (RCB) criteria and (b) axillary downstaging after NAC by using N staging. 2 cohorts for overall response were overall SR (RCB 0-1) and no SR (RCB 2-3). On the other hand, for axillary downstaging, 2 cohorts constituted from axillary SR (ypN0 and ypN0i+) and no SR (ypNmic-N3). MagEq3 and IHC4 scores were calculated from their pathological tumor slides in each patient. HER2 status was categorized as either "no" or "low." In addition, patient age, family history, tumor histology, stage at admission, and Ki-67 status were compared between cohorts according to predefined outcomes.

Results

In a total of 230 BC patients, 228 patients were included to compare according to their RCB levels. The mean age of patients with overall SR was significantly lower than those without. Patients with high Ki-67 expression, high (>30) MagEq3 score, high ICH4 quartile, and HER2-low status had significantly more overall SR. On the other hand, only patients with high Ki-67 expression had significantly more axillary SR. MagEq3 score levels, ICH4 quartiles, and HER2 status were similar between patients with axillary SR and not.

Conclusion

MagEq3 and IHC4 tools seemed to be useful to predict those HR+/HER2- BC patients who are most likely to get benefit from NAC. But, only high Ki-67 expression level significantly predicted satisfactory axillary downstaging in HR+/HER2- BC patients.