Purpose We review the evidence on magnetic resonance imaging (MRI) in staging the affected breast to determine its accuracy and impact on treatment. Methods Systematic review and meta-analysis of the accuracy of MRI in detection of multifocal (MF) and/or multicentric (MC) cancer not identified on conventional imaging. We estimated summary receiver operating characteristic curves, positive predictive value (PPV), true-positive (TP) to false positive (FP) ratio, and examined their variability according to quality criteria. Pooled estimates of the proportion of women whose surgery was altered were calculated. Results Data from 19 studies showed MRI detects additional disease in 16% of women with breast cancer (N = 2,610). MRI incremental accuracy differed according to the reference standard (RS; P = .016) decreasing from 99% to 86% as the quality of the RS increased. Summary PPV was 66% (95% CI, 52% to 77%) and TP:FP ratio was 1.91 (95% CI, 1.09 to 3.34). Conversion from wide local excision (WLE) to mastecto...

Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer.

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)61950-9.pdf

Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(10)60837-9.pdf

Targeted intraoperative radiotherapy versus whole breast radiotherapy for breast cancer (TARGIT-A trial): an international, prospective, randomised, non-inferiority phase 3 trial

OBJECTIVE. The purpose of our study was to evaluate the accuracy of sonography and sonographically guided biopsy in the preoperative diagnosis of metastatic invasion of the axilla in patients with breast carcinoma.MATERIALS AND METHODS. We performed a MEDLINE search (keywords, “sonography” OR “ultrasound” AND “axillary”) and a manual search of the references of relevant studies and reviews of preoperative diagnosis on sonography of possible axillary metastases. The gold standard required was axillary lymph node dissection; we accepted sentinel node biopsy as an alternative gold standard. Considering the sonographic findings and the results of the sonographically guided biopsy, the sensitivity and specificity were calculated using metaanalysis. We also checked the existence of heterogeneity of the summary results.RESULTS. Sixteen articles were selected. In sonography of axillae without palpable nodes, and using lymph node size as the criterion for positivity, sensitivity varied between 48.8% (95% confidenc...

https://www.ajronline.org/doi/pdfplus/10.2214/AJR.05.0936

Role of sonography in the diagnosis of axillary lymph node metastases in breast cancer: a systematic review.

OBJECTIVE. The purpose of this study was to review MR imaging findings in the ipsilateral breast in women with percutaneously proven breast cancer. MATERIALS AND METHODS. Retrospective review was performed of records of 70 consecutive women with percutaneously proven unilateral breast cancer who were considered candidates for breast conservation surgery and who had preoperative MR imaging of the ipsilateral breast. MR images and medical records were reviewed. RESULTS. MR imaging identified mammographically and clinically occult cancer other than the index lesion in the ipsilateral breast in 19 women (27%), including infiltrating cancer in 11 women (16%) and ductal carcinoma in situ in eight women (11%). These additional sites of cancer were in the same quadrant as the index cancer in 14 women (20%), in a different quadrant in three women (4%), and in both the same and different quadrants in two women (3%). Additional sites of cancer were more likely in women with, rather than in those without, a family history of breast cancer (42% vs 14%, p < 0.02) and in women whose index cancer was infiltrating lobular rather than other histologies (55% vs 22%, p < 0.06). In 17 women (24%), MR imaging detected ipsilateral lesions that were benign. Changes due to prior percutaneous biopsy were infrequently observed on MR images and included a clip in 12 women (17%) and a small hematoma in two women (3%). CONCLUSION. MR imaging identified additional sites of ipsilateral cancer in 27% of women with percutaneously proven breast cancer. The yield was highest in women with a family history of breast cancer or infiltrating lobular histology in the index cancer. Change after biopsy was infrequent and did not interfere with the MR imaging interpretation.

MR Imaging of the Ipsilateral Breast in Women with Percutaneously Proven Breast Cancer

We studied the spatial relationship within the breast between multicentric foci (MCF) and the primary tumour in 30 modified radical mastectomy specimens using Egan's correlated pathological-radiological method using 5 mm slices of the whole breast. The relative positions within the breast of the primary tumour and MCF were used to calculate the relative distribution of primary tumour and MCF in the four quadrants of the breast and the per cent breast volume that would be required to be excised to include all MCF. Nineteen (63%) breast harboured MCF. The relative distribution of primary tumour and MCF in the four breast quadrants was significantly different (P = 0.034). MCF were present beyond the index quadrant (25% of breast volume including the tumour) in as many as 79% (15/19) of breasts that harboured MCF; and in half the cases (15/30) when all breast were considered. This is in variance with the suggestion put forward previously that MCF are contained within the index quadrant in 90% of cases. Although the number of patients in the present series is small, the probability of our finding being due to play of chance is 1 in 1500. In a large series of breast conservation studies > 90% of early breast recurrences have been found to occur in the index quadrant. Our finding, that in half the patients (15/30) MCF are present in quadrants other than the index quadrant, suggests that MCF do not give rise to early breast recurrence.

/pdf/multicentricity-of-breast-cancer-whole-organ-analysis-and-1pi67q9p4l.pdf

Multicentricity of breast cancer: whole-organ analysis and clinical implications

Aims. To find a pre-operative test for nipple and areola involvement in breast cancer.Methods. Areola-tumour distance was measured in 140 consecutive patients (median age 45, range: 23-83) undergoing a mastectomy. We analysed whether nipple and areola correlated with areola-tumour distance, tumour size, nodal status, perinodal involvement and lymphatic embolization.Results. The nipple was involved in 22 (16%) cases and this correlated with tumour size, number of lymph nodes, perinodal extension and presence of lymphatic emboli. In all these 22 cases, the tumour was within 2.5 cm of the areola. Tumour size, however, could not predict nipple involvement in tumours within 2.5 cm of the areolar edge.Conclusions. In the one-fifth of cases where the tumour is over 2.5 cm from the areola, preserving the nipple and areola for reconstruction may be worthwhile. In remaining cases, some other predictive test for nipple involvement would be necessary.

/pdf/prediction-of-nipple-and-areola-involvement-in-breast-cancer-2zllhsvymp.pdf

Prediction of nipple and areola involvement in breast cancer

Prompted by the concern about unnecessary axillary dissections, we prospectively studied the accuracy of clinical examination (CE) and conventional ultrasonography (USG, 7.5 MHz), to diagnose pre-operatively metastatic axillary lymph nodes in 200 operable breast cancer patients, USG had higher specificity (90% vs 77%, P = 0.025) and higher positive predictive value (ppv = 90% vs 76%, P = 0.02) than CE. Together, CE + USG had higher sensitivity (82% vs 58%, P = 0.00005) and higher negative predictive value (npv = 76% vs 58%, P = 0.008) than CE alone, In women 1 positive node were 97% (for both) in women < 45 years compared to 81% and 79% in older women. The high sensitivity of CE + USG (82% for the whole group) is probably due to the higher proportion of young women (median age = 45) in our population. It suggests that using CE + USG to avoid axillary dissection in some patients is feasible.

/pdf/role-of-ultrasonography-to-detect-axillary-node-involvement-36sjpgl705.pdf

Role of ultrasonography to detect axillary node involvement in operable breast cancer

Front loading chemotherapy using methotrexate (200 mg/m2) alone or methotrexate (200 mg/m2) with cisplatin (20 mg/m2 daily for 5 days) was used in epidermoid carcinoma of esophagus. Evaluation after two courses showed objective response of 50% or greater in 48% of patients with metbotrexate alone. Response rate was increased to 76.2% with addition of cisplatin to methotrexate. Small lesions (less than 10 cm) showed better response as compared to advanced cases. Therapy was generally well tolerated and good palliation was obtained even after the first course. Postchemotherapy treatment either with surgery or radiotherapy was tolerated without any major complications. The data confirm the short-term usefulness of initial chemotherapy with methotrexate and cisplatin in esophageal cancer. Results of prolonged follow-up will help to evaluate the role of front loading chemotherapy on long-term survival. Cancer 56: 1502-1506, 1985.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/1097-0142%2819851001%2956%3A7%3C1502%3A%3AAID-CNCR2820560704%3E3.0.CO%3B2-P

Anterior chemotherapy in esophageal cancer

A retrospective study of 177 patients attending Tata Memorial Hospital over a period of 40 years from 1942 through 1981 is presented These patients who had "primary lesions" in the head and neck region, breast, esophagus, lung, and elsewhere as carcinoma or sarcoma developed "second primary" at different sites, after the treatment for the primary lesion after a variable period over years--as "metachronous lesions" (139 patients) Another group of patients presented with "double primary" at initial clinical examination and investigations, and these were "synchronous" lesions (38 patients) The analysis brings out the relationship of these lesions in both groups to each other with reference to habits in Indian population, viz, pan chewing, tobacco smoking, and alcohol consumption and time interval and histological variations among these lesions An interesting relationship has been observed in certain aerodigestive tract primary lesions developing second cancer due to continued effect of "carcinogens," as habits are hard to die even after developing cancer Analysis also brings out an interesting observation of involvement of "physiologically and anatomically" related organs developing second cancer at an interval or concurrently A solitary pulmonary nodule or an opacity in a patient with extrathoracic cancer should not be considered as "metastatic" unless proved otherwise; metachronous lesions need to be treated energetically, adequately, efficiently, and aggressively in certain clinical situations for better results and salvage

J. J. Vyas

Papers

Multicentricity of breast cancer: whole-organ analysis and clinical implications

Prediction of nipple and areola involvement in breast cancer

Role of ultrasonography to detect axillary node involvement in operable breast cancer

Anterior chemotherapy in esophageal cancer

Multiple primary cancers in Indian population: Metachronous and synchronous lesions