Showing papers in "Breast Journal in 2010"

Obesity is a risk factor for developing postoperative lymphedema in breast cancer patients.

Abstract: Lymphedema (LE) is a well-known postoperative complication after axillary node dissection (ALND). Although, sentinel lymph node dissection (SLND) involves more focused surgery and less disruption of the axilla, early reports show up to 13% of patients experience some symptoms of LE. The purpose of this study was to determine predictors of arm LE in our patients under going SLND with or without an ALND. One hundred and thirty-seven breast cancer patients were treated at a comprehensive cancer center. Prospective measurement of arm volume was carried every 6 months from date of diagnosis. This data base was retrospectively reviewed for tumor stage, treatment, and subjective complaints of LE. Objective LE was defined as a change greater than 200 mL compared with the control arm. Univariate and multivariate analyses were performed. Arm volume changes were measured over 24 months (median follow-up 20 months) in 137 women: 82 stage I, 48 stage II, and 5 stage III; median age 56 years. Breast-conserving surgery was performed in 133 patients. All patients underwent SLND for axillary staging and for 52 patients this was the only axillary staging procedure. All node-positive patients (31) and 54 node-negative patients under went an immediate completion ALND, the latter as part of a study protocol. At 24 months, 16 (11.6%) patients were found to have objective LE (>200 mL increase). Patient age, tumor size, number of nodes harvested, or adjuvant chemotherapy was not found to be predictive of LE by univariate analysis. The risk of developing postoperative LE was primarily and significantly related to the patients' BMI (p = 0.003). Multivariate analysis revealed patients with a BMI >30 (obese) had an odds ratio of 2.93 (95% CI 1.03-8.31) compared with those with a BMI of <25 of having LE. Symptomatic LE (SLE), as defined by patient complaints was recorded in six of the above 16 patients, no SLE was recorded in patients without objective signs of edema. Univariate subgroup analysis compared the symptomatic to the nonsymptomatic patients and revealed the median number of nodes removed was higher in the symptomatic patients (17 verses 9, p = 0.045); however, these patients had a lower BMI (p = 0.0012). The mean change in arm volume was not significantly different between the groups. SLE occurs in one third of patients with objective arm swelling and most likely is multi-factorial in etiology. Although patients undergoing SLN were recorded as having objective LE, none reported SLE. The development of LE within 2 years of surgery is associated with the patient's BMI and this should be considered in preoperative counseling.

Progenitor-enriched adipose tissue transplantation as rescue for breast implant complications.

Abstract: n Abstract: Breast enhancement with artificial implants is one of the most frequently performed cosmetic surgeries but is associated with various complications, such as capsular contracture, that lead to implant removal or replacement at a relatively high rate. For replacement, we used transplantation of progenitor-supplemented adipose tissue (cell-assisted lipotransfer; CAL) in 15 patients. The stromal vascular fraction containing adipose tissue progenitor cells obtained from liposuction aspirates was used to enrich for progenitor cells in the graft. Overall, clinical results were very satisfactory, and no major abnormalities were seen on magnetic resonance imaging or mammogram after 12 months. Postoperative atrophy of injected fat was minimal and did not change substantially after 2 months. Surviving fat volume at 12 months was 155 ± 50 mL (Right; mean ± SD) and 143 ± 80 mL (Left) following lipoinjection from an initial mean of 264 mL. These preliminary results suggest that CAL is a suitable methodology for the replacement of breast implants. n

Measuring quality of life in oncologic breast surgery: a systematic review of patient-reported outcome measures.

Abstract: Multiple randomized trials demonstrate equivalent survival between BCT and mastectomy, but clinical outcomes research must also evaluate patient satisfaction and quality of life. This review analyzes existing patient-reported outcome (PRO) measures in oncologic breast surgery to assess utility and make recommendations for future research. We performed a systematic literature review to identify PRO measures used in oncologic breast surgery patients. After applying inclusion and exclusion criteria, qualifying instruments were assessed for adherence to international guidelines for health outcomes instrument development and validation. Ten measures underwent development and psychometric evaluation in an oncologic breast surgery population. Five of ten measures (EORTC QLQ BR-23, FACT-B, HBIS, BIBCQ, and BREAST-Q) reported an adequate development and validation process. Three of these 5 measures (EORTC QLQ BR-23, FACT-B, HBIS) focused on non-surgical treatment issues. A fourth instrument (BIBCQ) did not address aesthetic concerns after breast reconstruction. The fifth instrument (BREAST-Q) was developed for use in patients undergoing mastectomy ± reconstruction, but did not address breast-conserving therapy. Overall, two key limitations were noted: 1) surgery-specific issues of breast-conserving surgery patients were not well represented and 2) measures were largely developed without the aid of newer psychometric methods that may improve their clinical utility. Reliable and valid PRO measures in breast cancer patients exist, but even the best instruments do not address all important surgery-specific and psychometric issues of oncologic breast surgery patients. Newer psychometric methods would facilitate development of scales for use in individual patient care as well as group level comparisons.

Granulomatous Mastitis: Clinical, Pathological Features, and Management

Abstract: This clinical study was conducted to present clinical, radiologic, and histopathologic features of Granulomatous Mastitis (GM) and evaluate the result of surgical and steroid treatment. Sixteen cases diagnosed histologically as GM were reviewed. Patient characteristics, clinical presentation, radiologic imaging, microbiologic, histopathologic assessment, treatment modalities, recurrence, morbidity, and follow-up data were analyzed. Majority of the patients were child bearing age and all of the patients had a history of breast feeding. Radiologic findings were nonspecific. Histopathology showed the characteristic distribution of granulomatous inflammation in all cases. In 12 cases, surgical excision of the lesion with negative margins was performed. Four cases required quadranectomy because of wideness of the disease. Three patients who had local reoccurrence and three resistant patients were treated by oral prednisone after surgical attempt. Complete remission was obtained and no further recurrence was observed in this patients. GM predominantly occurs in premenopausal women and the clinical symptoms might be misjudged as breast cancer. Histopathologic examination remains the gold standard for the diagnosis. Wide excision of the lesions is the recommended therapy and we suggest steroid therapy in resistant or recurrent disease following the idea that the disease has an autoimmune component.

Additional Value of PET–CT in Staging of Clinical Stage IIB and III Breast Cancer

Abstract: To evaluate retrospectively the accuracy of integrated PET/CT, against PET, CT, or conventional staging in breast cancer. Seventy consecutive biopsy proven clinical stage IIB and III breast cancer patients were included. Descriptive statistics of integrated PET/CT for the primary tumor, nodal status and metastasis detection were compared to PET, CT with contrast, and conventional staging (biochemistry, chest X-ray, liver ultrasound, and bone scintigraphy). Sensitivity of PET/CT for primary tumor and nodal status was 97.1% and 62.5%, respectively. Specificity and negative predictive value for nodal status were 100% and 66.6%, respectively. The values for conventional staging for nodal involvement were 100% and 85.7% with a sensitivity of 87.5%. PET/CT showed metastatic disease in seven women despite normal conventional staging. PET/CT is able to visualize most clinical stage IIB and III primary breast cancers. PET/CT is superior to conventional staging for detecting internal mammary chain nodes and metastatic disease, but not for axillary staging. Future studies will have to test whether therapy adjustment based on PET/CT has the potential to improve survival.

Factors affecting nodal status in invasive breast cancer: a retrospective analysis of 623 patients.

Abstract: With increasing numbers of early, screen-detected breast cancers and the emergence of sentinel-node biopsy, surgical management of the axilla is evolving. In recent years many authors have searched for favorable subcategories of tumors in which it may be possible to avoid axillary lymph node clearance. The aim of this study is to determine preoperative factors that might predict lymph node negative axillae. A retrospective analysis of 623 patients with invasive breast cancer was performed. A number of clinical and pathological variables were analyzed. Uni- and multivariate analysis was carried out to determine factors predictive for lymph node metastases. Age, tumor size, grade, histology and lymphovascular invasion were found to be independent predictors of nodal positivity but, contrary to other recent studies, we found no effect of ER/PR (estrogen-receptor/progesterone-receptor) or HER-2 status. The strongest predictor of lymph node metastases was tumor size >50 mm (OR 2.33), followed by the presence of lymphovascular invasion (OR 1.33). Our results could be used for preoperative counseling and planning axillary surgery in patients with invasive breast cancer. We propose that the predictive factors identified in this study could be used in combination with axillary ultrasound to selectively target patients for sentinel-node biopsy or to target the use of ultrasonographic assessment of the axilla. However, no consistent and reliable markers have been identified to predict patients that can safely avoid axillary surgery.

Mammographic Density, Estrogen Receptor Status and Other Breast Cancer Tumor Characteristics

Abstract: n Abstract: The aim of this study was to examine the relationship between mammographic density and histological characteristics of breast tumors within a case–control study population. This study was an expansion of a large size case– control study examining the relationship between breast density and breast cancer risk. Percent and area of breast density was assessed in 370 invasive breast cancer cases and 1904 age-matched controls, using a computer-assisted method. Associations between breast density and estrogen receptor (ER) status, histological grade, histological size, lymph node status, vascular invasion, disease extent, and Nottingham Prognostic Index were evaluated, using logistic regression. Women with 50% or greater mammographic density have a 2.63-fold risk (95% confidence interval [95% CI] = 1.78–3.87; p < 0.001) of developing breast cancer compared to women with less than 10% density. Increase in every category of percentage of breast density is also associated with a 1.45-fold risk in developing ER positive tumors relative to ER negative tumors (odds ratio [OR] = 1.02; 95% CI = 1.00–1.04; p = 0.048), and increase in every quartile of absolute area of density is associated with a 1.48-fold ER positive breast cancer risk [95% CI = 1.06–2.07; p = 0.020]. Furthermore, breast density was found to be associated with specifically ER positivity, invasion as well as invasion with in situ, histological grades 1 and 2, tumor size larger than 1.1 cm, lack of vascular invasion, lymph node positivity and negativity, and NPI less than 4.0. After stratifying the data according to mode of diagnosis, the relationship became slightly stronger in the interval cancer group. Similar results were in observed using percent density and absolute density readings. Mammographic density was a stronger risk factor for ER positive [OR = 2.94; 95% CI = 1.94–4.43; p < 0.001] than ER negative cancers when comparing breasts with greater than 50% dense region to those with less than 10% density. No other tumor characteristic had a significant correlation with breast density. These results suggest that mammographic percent density may be more strongly related to ER positive than ER negative breast cancer, but otherwise is a risk factor for breast cancer independent of other tumor characteristics. n

Sensitivity and specificity of unilateral edema on T2w-TSE sequences in MR-Mammography considering 974 histologically verified lesions.

Abstract: The objective of this investigation was to determine the diagnostic value of unilateral edema in differentiating benign from malignant breast disease on T2w-TSE images in MR-Mammography (MRM). All patients from a 10-year period undergoing surgery in the same institution after having received MRM in our department were included in this prospective analysis of previous acquired examinations. To eliminate bias caused by prior procedures, all patients having had biopsy, operation, radiation therapy, or chemotherapy before MRM were excluded. T2w-TSE images were acquired after a dynamic contrast-enhanced series of T1-weighted images in a standardized examination protocol (1.5 T). Edema was defined as a high-signal intensity on T2w-TSE images and it was categorized as absent, perifocal, or diffuse. Examinations were rated by two experienced observers blinded to all procedures and results following MRM. In cases of disconcordance, the opinion of a third radiologist decided. Statistical testing included Pearson's Chi-squared test and Fisher's exact testing. A total of 1,010 patients with a mean age of 55 years (SD: 11.6 years, range: 16-87 years) with 1,129 histologically verified lesions were included in this investigation. After removing all patients with prior procedures from the patient collective, 974 lesions were left for statistical analysis. Perifocal edema was highly significantly (p < 0.001) associated with malignant disease, leading to a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 33.5%, 93.9%, 89.6, and 57.1%, respectively. Unilateral edema in general showed the following diagnostic parameters: sensitivity 53.0%, specificity 80.5%, PPV 80.9%, and NPV 52.3%. Edema seems to be associated with malignancy in the majority of cases. Especially, specificity and PPV were found to be high. These findings may be helpful in diagnostic decisions on otherwise equivocal cases.

Partial breast irradiation or whole breast radiotherapy for early breast cancer: a meta-analysis of randomized controlled trials.

Abstract: The purpose of the study was to compare treatment outcomes in patients with breast cancer treated with partial breast irradiation (PBI) and of those treated with whole breast-radiation therapy (WBRT). We conducted a systematic review and meta-analysis of published randomized clinical trials comparing PBI versus WBRT. Primary outcome was overall survival and secondary outcomes were locally, axillary, supraclavicular, and distant recurrences. A search of the literature identified three trials with pooled total of 1,140 patients. We found no statistically significant difference between partial and whole breast radiation arms associated with death (OR 0.912, 95% CI 0.674-1.234, p = 0.550), distant metastasis (OR 0.740, 95% CI, 0.506-1.082, p = 0.120), or supraclavicular recurrences (pooled OR 1.415, 95% CI 0.278-7.202, p = 0.560). However, PBI was statistically significantly associated with an increased risk of both local (pooled OR 2.150, 95% CI, 1.396-3.312; p = 0.001) and axillary recurrences (pooled OR 3.430, 95% CI, 2.058-5.715; p < 0.0001) compared with whole breast-radiation. Partial breast irradiation does not seem to jeopardize survival and may be used as an alternative to whole breast-radiation. Nevertheless the issue of loco-regional recurrence needs to be further addressed.

Role of fusion of prone FDG-PET and magnetic resonance imaging of the breasts in the evaluation of breast cancer.

Abstract: The purpose of this study is to report further about the statistically significant results from a prospective study, which suggests that fusion of prone F-18 Fluoro-deoxy-glucose (FDG) positron emission tomography (PET) and magnetic resonance (MR) breast scans increases the positive predictive value (PPV) and specificity for patients in whom the MR outcome alone would be nonspecific. Thirty-six women (mean age, 43 years; range, 24-65 years) with 90 lesions detected on MR consented to undergo a FDG-PET scan. Two blinded readers evaluated the MR and the computer tomography (CT) attenuation-corrected prone FDG-PET scans side-by-side, then after the volumes were superimposed (fused). A semiautomatic, landmark-based program was used to perform nonrigid fusion. Pathology and radiologic follow-up were used as the reference standard. The sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy (with 95% confidence intervals) for MR alone, FDG-PET alone, and fused MR and FDG-PET were calculated. The median lesion size measured from the MR was 2.5 cm (range, 0.5-10 cm). Histologically, 56 lesions were malignant, and 15 were benign. Nineteen lesions were benign after 20-47 months of clinical and radiologic surveillance. The sensitivity of MR alone was 95%, FDG-PET alone was 57%, and fusion was 83%. The increase in PPV from 77% in MR alone to 98% when fused and the increase in specificity from 53% to 97% were statistically significant (p < 0.05). The false-negative rate on FDG-PET alone was 26.7%, and after fusion this number was reduced to 9%. FDG-PET and MR fusions were helpful in selecting which lesion to biopsy, especially in women with multiple suspicious MR breast lesions.

Breast Cancer in Pregnancy

Abstract: Pregnancy-related breast cancer (PBC) is one of the most common malignancies during pregnancy (approx. one in 3,000 pregnancies); up to 3% of breast cancers are diagnosed in pregnancy. As maternal age at the time of pregnancy continues to increase as the incidence of breast cancer, the incidence of PBC is expected to increase. A review of the literature was performed in order to identify optimal treatment strategies. Most of the data surrounding the diagnosis and treatment PBC is small cohort studies, and there are no randomized controlled trials. Diagnostic delays are common. Preoperative histologic confirmation is required. Conservative surgery can be proposed at the end of second and third trimester, and radiotherapy is delayed after childbirth. The safety of sentinel lymph node biopsy has yet to be confirmed, and the axillary dissection is the traditional treatment of choice. The chemotherapeutic agents utilized are the same as those used in non-pregnant patients, but they should not be administered in the first trimester. Radiotherapy and endocrine therapy are recommended to be avoided during pregnancy. The treatment of PBC is multidisciplinary and necessitates active communication among the patient, obstetrician, medical, surgical, and radiation oncologists. Diagnosis is often delayed because of physiologic changes of the breast; obstetricians should perform a thorough breast examination at the first prenatal visit and maintain a high index of suspicion for cancer. Other therapies may need to be considered, although their usage now is not currently recommended owing to the paucity of safety data.

Flat Epithelial Atypia and Atypical Ductal Hyperplasia: Carcinoma Underestimation Rate

Abstract: This study was carried out to determine the underestimation rate of carcinoma upon surgical biopsy after a diagnosis of flat epithelial atypia and atypical ductal hyperplasia and 11-gauge vacuum-assisted breast biopsy. A retrospective review was conducted of 476 vacuum-assisted breast biopsy performed from May 2005 to January 2007 and a total of 70 cases of atypia were identified. Fifty cases (71%) were categorized as pure atypical ductal hyperplasia, 18 (26%) as pure flat epithelial atypia and two (3%) as concomitant flat epithelial atypia and atypical ductal hyperplasia. Each group were compared with the subsequent open surgical specimens. Surgical biopsy was performed in 44 patients with atypical ductal hyperplasia, 15 patients with flat epithelial atypia, and two patients with flat epithelial atypia and atypical ductal hyperplasia. Five cases of atypical ductal hyperplasia were upgraded to ductal carcinoma in situ, three cases of flat epithelial atypia yielded one ductal carcinoma in situ and two cases of invasive ductal carcinoma, and one case of flat epithelial atypia/atypical ductal hyperplasia had invasive ductal carcinoma. The overall rate of malignancy was 16% for atypical ductal hyperplasia (including flat epithelial atypia/atypical ductal hyperplasia patients) and 20% for flat epithelial atypia. The presence of flat epithelial atypia and atypical ductal hyperplasia at biopsy requires careful consideration, and surgical excision should be suggested.

Is pregnancy after breast cancer safe

Abstract: The impact of treatment on subsequent fertility and the safety of childbearing are major complicating factors for young women diagnosed with breast cancer. As national data indicate women are postponing first pregnancy to older ages; therefore, many young patients are seeking clinical guidance regarding the safety of conception and treatment options that may not prevent subsequent pregnancy. Newly developed chemotherapy protocols of brief duration have improved life expectancy enabling some women to consider childbearing. This study was conducted to compare prognosis among breast cancer patients with and without a subsequent pregnancy. Medical record review of female members of a Northern California prepaid health care plan enabled the identification of 107 women with one or more subsequent pregnancies and 344 cases without a pregnancy, who were diagnosed between 1968 and 1995. Sets were matched on age, year and stage at diagnosis, months of survival and recurrence status at conception. Among the matched sets, neither risk of recurrence nor death differed significantly by subsequent pregnancy history during an average 12 years of follow-up (adjusted hazard ratio [HR] recurrence: 1.2 [0.8, 2.0]; adjusted HR death: 1.0 [0.6, 1.9]). Women interested in preserving their fertility and considering pregnancy are a self-selected population; therefore, to reduce potential bias, cases were matched on recurrence status at time of conception. Although the number of cases was limited, subgroup analyzes indicated a small, nonsignificant adverse effect among women who conceived within 12 months of diagnosis. This analysis of carefully matched cases provides reassurance that long-term prognosis was not adversely affected by subsequent pregnancy.

The Use of Oncoplastic Reduction Techniques to Reconstruct Partial Mastectomy Defects in Women with Ductal Carcinoma In Situ

Abstract: The application of oncoplastic techniques to breast conservation therapy (BCT) is thought to improve cosmetic results with some documented oncologic advantages in certain patients. Although present data highlight the oncologic safety of this approach, the role of oncoplastic surgery specific to ductal carcinoma in situ (DCIS) has not been elucidated. In this study, all women in the Emory Healthcare system between January 1991 and June 2006 with biopsy-proven DCIS who underwent lumpectomies combined with simultaneous reduction mammaplasties or mastopexies were identified. Medical records, including office notes, operative and pathology reports were analyzed. Parameters included age, BMI, histologic grade (low, intermediate, high) and type (comedo versus non-comedo) of DCIS, margin status, locoregional recurrence, specimen weight, postoperative complications, and overall outcomes. Pedicle design and contralateral breast pathology were also analyzed. Twenty-eight women were included in the study with an average age of 47. Therapeutic mammaplasty was the definitive procedure for 18 (64%) of these patients. Ten patients (36%) required reoperations: nine for positive margins and one for residual microcalcifications (stereo biopsy DCIS). Overall, seven patients (25%) required completion mastectomy with reconstruction (transverse rectus abdominus myocutaneous flap: n = 3, latissimus flap: n = 4), whereas three patients (11%) underwent re-excisions with confirmation of negative margins. All ten women who required completion mastectomy or re-excisions exhibited either intermediate or high-grade, comedo DCIS. Overall, 50% (6/12) of women diagnosed with high-grade comedo DCIS required completion mastectomy with reconstruction after initial therapeutic mammaplasty. The final positive-margin rate for women diagnosed with intermediate-grade, comedo necrosis was 43% (3/7). The women in this failed group that required reoperations were overall younger (mean: 45.6; median: 43) than those in which oncoplastic surgery was the definitive procedure (mean: 57.8; median: 57). There were no significant differences between the failed and successful groups in terms of biopsy weight (failed: 253 g, successful: 237 g), type of excision (e.g., wire-localized), location of tumor, reduction type (e.g., superior medial), or postoperative complications. There was one case of locoregional recurrence of DCIS 7 months after the initial operation. All 28 patients had no evidence of disease at an average follow-up of 2.7 years. This study suggests that although oncoplastic reduction techniques are a reasonable approach for women with DCIS, stricter patient selection and improved confirmation of negative margins will minimize the need for either re-excisions or completion mastectomy and reconstruction.

Clinical and radiologic data and core needle biopsy findings should dictate management of cellular fibroepithelial tumors of the breast.

Abstract: Fibroepithelial lesions with cellular stroma identified on core needle biopsy (CNB) may prove to be either fibroadenoma or phyllodes tumor at excision; therefore, management of these rare lesions is highly controversial. We aim to assess the management and the outcome of 101 cellular fibroepithelial lesions diagnosed on CNB over a 6-year period in one institution. Consensus on clinical management in each individual patient was reached during multi-disciplinary conferences, based on careful correlation of clinical data with results of imaging studies and pathology of CNB samples. Radiologic findings (mammogram and sonogram) and multiple histologic parameters on CNB specimen were blindly re-evaluated by one experienced breast radiologist and two breast pathologists, respectively, and results were correlated with final diagnosis at excision. Cellular fibroepithelial lesions with indeterminate or suspect imaging findings, with larger size, and with an equivocal comment such as "cannot rule out phyllodes tumor" in the pathology report were excised more frequently (p = 0.05, p = 0.034, and p = 0.01, respectively). Of 43 excised lesions, 13 were classified as benign phyllodes tumors, 23 as fibroadenoma and seven as benign cellular fibroepithelial lesion. The final diagnosis at excision did not significantly correlate with any clinical data, or with retrospective evaluation of imaging findings or comprehensive evaluation of multiple histologic parameters. In 58 patients who had clinical and radiologic follow-up (mean ± SD: 30 ± 21 months) there was no evidence of disease progression. No clinical and radiologic findings and/or comprehensive evaluation of multiple histologic parameters on CNB specimen are distinctive enough to predict final classification of equivocal cellular fibroepithelial lesions. However, careful clinico-pathologic and radiologic correlation may help to select the most clinically significant lesions for proper immediate surgical management. Follow-up alone may be an appropriate alternative for a subset of patients, given a good clinical, pathologic, and radiologic correlation.

Neoadjuvant chemotherapy of breast cancer: tumor markers as predictors of pathologic response, recurrence, and survival.

Abstract: This study reports the value of the tumor markers estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) in predicting the response of breast cancer to neoadjuvant chemotherapy A community cancer center prospectively maintained breast cancer database containing over 8,000 patient records was used Since 1989, 464 patients were treated with neoadjuvant chemotherapy followed by surgical resection and were tested for ER and PR Estrogen receptor and/or PR positive patients were considered hormone receptor (HR) positive Human epidermal growth factor receptor 2 status was available on 368 patients Total, breast, and nodal pathologic complete response (pCR) rates, recurrence, and overall survival were assessed Total and breast pCR rates were higher in HR negative (HR-) patients (26% and 32%, respectively) than in HR positive (HR+) patients (4% and 7%, respectively; p < 0001) Compared to HR+ patients, HR- patients had higher recurrence rates (38% versus 22%; p < 0001), a shorter time to recurrence (128 versus 214 years; p < 0001), and decreased overall survival (67% versus 81%; p < 0001) Human epidermal growth factor receptor 2 positive patients treated with neoadjuvant trastuzumab (NAT) demonstrated higher total pCR (34% versus 13%; p = 0008), breast pCR (37% versus 17%; p = 002), and nodal pCR rates (47% versus 23%; p = 005) compared to HER2+ patients not treated with NAT Furthermore, HER2+ patients who received NAT had lower recurrence rates (5% versus 42%; p < 0001) and increased overall survival (97% versus 68%; p < 0001) In conclusion, breast cancer HR status is predictive of total and breast pCR rates after neoadjuvant chemotherapy Although HR- patients derive greater benefit from neoadjuvant chemotherapy in terms of pathologic response, they have worse outcomes in terms of recurrence and survival Hormone receptor positive patients demonstrate significantly less response to neoadjuvant chemotherapy, but significantly better overall outcome For both HR- and HR+, addition of NAT for HER2+ tumors results in both a superior response and outcome

Older breast cancer survivors: factors associated with self-reported symptoms of persistent lymphedema over 7 years of follow-up.

Abstract: Lymphedema of the arm is a common complication of breast cancer with symptoms that can persist over long periods of time. For older women (over 50% of breast cancer cases) it means living with the potential for long-term complications of persistent lymphedema in conjunction with the common diseases and disabilities of aging over survivorship. We identified women > or =65 years diagnosed with primary stage I-IIIA breast cancer. Data were collected over 7 years of follow-up from consenting patients' medical records and telephone interviews. Data collected included self-reported symptoms of persistent lymphedema, breast cancer characteristics, and selected sociodemographic and health-related characteristics. The overall prevalence of symptoms of persistent lymphedema was 36% over 7 years of follow-up. Having stage II or III (OR = 1.77, 95% CI: 1.07-2.93) breast cancer and having a BMI >30 (OR = 3.04, 95% CI: 1.69-5.45) were statistically significantly predictive of symptoms of persistent lymphedema. Women > or =80 years were less likely to report symptoms of persistent lymphedema when compared to younger women (OR = 0.44, 95% CI: 0.18-0.95). Women with symptoms of persistent lymphedema consistently reported worse general mental health and physical function. Symptoms of persistent lymphedema were common in this population of older breast cancer survivors and had a noticeable effect on both physical function and general mental health. Our findings provide evidence of the impact of symptoms of persistent lymphedema on the quality of survivorship of older women. Clinical and research efforts focused on risk factors for symptoms of persistent lymphedema in older breast cancer survivors may lead to preventative and therapeutic measures that help maintain their health and well-being over increasing periods of survivorship.

Bilateral Breast Carcinoma: Clinical Characteristics and Its Impact on Survival

Abstract: The higher incidence of breast cancer, the improvements in diagnosis and treatment, together with the growing life expectancy have brought about an increase in the number of patients at risk for bilateral breast carcinoma. The aim of this study is to describe the characteristics of patients suffering from bilateral breast carcinoma who underwent surgery at the Breast Pathology Service of the Buenos Aires British Hospital and to analyze impact on survival. Between January 1970 and May 2007, 4,085 cases of breast carcinoma in 3,864 patients were treated at the Breast Diseases Division of the Buenos Aires British Hospital. A retrospective study of 194 patients with bilateral breast carcinoma was carried out: 80 synchronous and 114 metachronous. In order to compare survival, a group of 2,237 patients with unilateral breast carcinoma who had undergone surgery was analyzed. The risk of developing a contralateral breast carcinoma was 0.9% per year, with an accumulated risk at 15 years of 12.75%. The 5-year survival was 85.9% for unilateral carcinomas, 94.6% for metachronous carcinoma, and 63.3% for synchronous carcinoma. The 15-year survival was 65.5% for unilateral carcinomas, 52.3% for metachronous, and 37.2% for synchronous. The incidence of bilateral carcinomas is low. Survival was worse in patients with metachronous carcinoma diagnosed within 5 years of the first malignancy. Survival in patients with metachronous carcinoma diagnosed after 5 years is similar to those with unilateral carcinoma. Synchronous carcinoma was associated to worse survival, being an independent risk factor for mortality.

Axillary ultrasound assessment in primary breast cancer: an audit of 653 cases.

Abstract: Axillary lymph node status is an important factor in determining the prognosis and treatment in patients with invasive breast cancer. The introduction of the sentinel lymph node biopsy technique in the axilla has significantly reduced the number of patients requiring an axillary clearance procedure. However, a proportion of patients will be found to have axillary metastases after a sentinel node biopsy and will then require a second axillary surgical procedure. A retrospective audit of 653 consecutive patients presenting with invasive breast cancer showed a preoperative diagnosis rate of axillary disease of 23% using axillary ultrasound and fine-needle aspiration (FNA) together. We performed 232 axillary FNAs to diagnose 150 positive axillae. This avoided the need for a second operation in 150 women. The negative predictive value for axillary metastases using this technique was 79%. Overall accuracy was 84%.

SPARC (Osteonectin) in Breast Tumors of Different Histologic Types and Its Role in the Outcome of Invasive Ductal Carcinoma

Abstract: The purpose of this study was to characterize the immunohistochemical distribution of secreted protein acidic and rich in cystein (SPARC) in benign and malignant breast tumors of different histologic types and define its association with the outcome of invasive ductal carcinoma (IDC) patients. A total of 286 samples of benign and malignant breast lesions between 1994 and 2005 were retrieved from National Taiwan University Hospital. Up to 11 years clinical follow-up data were available for 185 patients with IDC. Immunohistochemistry staining with SPARC was performed in tissue microarray or whole section. The association of expression of SPARC and cumulative overall survival of IDC patients were analyzed using Kaplan-Meier survival analysis and Cox regression analysis. Secreted protein acidic and rich in cystein was not expressed in benign breast phylloides and all benign breast tumors, while expressed in 17.2% of IDC, 85% of metaplastic carcinoma of the breast (MCB), and all malignant breast phylloides. Secreted protein acidic and rich in cystein was strongly expressed in mesenchymal components of MCB and expression levels in epithelial components were variable. The correlation of positive expression of SPARC and poor long-term survival in IDC is significant (p = 0.004). Individuals with positive SPARC expression had 2.34 times higher hazard of death compared with those with negative SPARC expression after adjusting for factors including positive lymph node, TNM tumor stage, estrogen receptor, and progesterone receptor. Secreted protein acidic and rich in cystein may be useful as a prognostic indicator for IDC.

Imaging Characteristics of Male Breast Disease

Abstract: The purpose of the study was to describe the imaging findings of male breast disease. One hundred and sixty-four male patients, who underwent mammography and ultrasonography (US) between January 1999 and December 2008, were retrospectively evaluated. Seventy-five patients (46%) underwent biopsy, and 89 patients (54%) were diagnosed radiologically. The radiologic and pathologic diagnoses in 164 cases of this series were 13 cancers (8%), including one ipsilateral and one contralateral breast cancers, 147 cases of gynecomastia (90%), one fibroadenoma (0.6%), two cases of fibrocystic disease of the breast (1.2%), and one epidermoid inclusion cyst (0.6%). Three mammographic patterns were adequate to describe all 147 cases of gynecomastia in our series: 53 patients (36%) had nodular gynecomastia, 46 patients (31%) had dendritic gynecomastia, and 48 patients (33%) had diffuse gynecomastia. Gynecomastia was unilateral in 65% of cases (n=95), and bilateral in 35% of cases (n=52). On physical examination, two of the malignant lesions had no clinic features of malignancy (15%). On mammography, 11 of 13 malignant masses were demonstrated (85%). A mass with microcalcifications was seen on mammograms in one case (9%). The contours of the masses were irregular in nine cases (82%), well-circumscribed in two cases (18%). The location of the masses was retroareolar in seven cases (64%) and eccentric to the nipple in four cases (36%). The size of the masses varied between 0.5 cm and 5 cm (mean 2.4 cm). Nipple retraction was evident in five cases (45%), and skin thickening in four cases (36%). All of the malignant masses were demonstrated on ultrasound; however, one of them was seen retrospectively after mammography. All of the masses were hypoechoic and solid, the contours were well-defined and smooth in two masses (15%), and irregular in 11 masses (85%), and five masses (39%) had posterior prominent shadowing. Axillary lymphadenopathia was detected in two cases (15%). One patient had a previous contralateral breast cancer, and one had an ipsilateral. On mammography, breast cancer characteristically exhibits an irregular subareolar mass, nipple retraction, and skin ulceration or thickening, but sometimes breast cancer has a well-circumscribed contour and punctuated microcalcifications. Ultrasonography is essential and useful for further characterization and helpful for demonstrating lymphadenopathies of the axillary region.

Mitochondrial DNA content as a potential marker to predict response to anthracycline in breast cancer patients.

Abstract: Mutations and reduced mitochondrial DNA (mtDNA) content are commonly observed in breast cancer, yet their functional significance is not clear. This study aimed to determine whether the mtDNA content in breast cancer plays an important role in modulating the response to anthracycline treatment in vivo and in vitro. The mtDNA content in tumor cells was analyzed using quantitative polymerase chain reaction in 60 Taiwanese breast cancer patients to correlate with their survival. In addition, human breast cancer MDA-MB-231 cells were treated with ethidium bromide to decrease mtDNA copy number. Cell survival was determined by trypan blue exclusion assay and intracellular reactive oxygen species (ROS) were determined by flow cytometry. After an anthracycline-based regimen, the disease-free survival of patients with higher mtDNA content breast cancer was significantly lower than that of patients with lower mtDNA content breast cancer (p = 0.03). Moreover, the MDA-MB-231 cells with low copies of mtDNA had higher sensitivity to doxorubicin treatment and increased ROS production when compared with higher mtDNA parental cells. Our results suggest that the level of mtDNA copy number in breast cancer may be a potential biomarker for prediction of the response to anthracycline-containing regimens in breast cancer patients.

Clinical Implications of Subcategorizing BI‐RADS 4 Breast Lesions associated with Microcalcification: A Radiology–Pathology Correlation Study

Abstract: Currently radiologists have the option of subcategorizing BI-RADS 4 breast lesions into 4A (low suspicion for malignancy), 4B (intermediate suspicion of malignancy), and 4C (moderate concern, but not classic for malignancy). To determine the clinical significance of BI-RADS 4 subcategories and the common pathologic changes associated with these mammographic lesions, a retrospective review of 239 consecutive stereotactic-needle core biopsies (SNCB) for microcalcifications was performed. All 239 SNCBs were BI-RADS 4 lesions, and of these, 191 were subcategorized to 4A, 4B or 4C. Ninety-four of 191 (49%) were 4A, 73 (38%) were 4B, and 24 (13%) were 4C. Fibrocystic change was the most common finding (66/239; 28%) followed by ductal carcinoma in situ (DCIS) accounting for 23% of cases. This was followed by columnar cell alteration with or without atypia (47/239; 19%), and fibroadenoma (45/239; 19%). While 70% (17/24) of BI-RADS 4C category lesions were DCIS, only 21% (15/73) of BI-RADS 4B and 10% (10/94) of BI-RADS 4A were DCIS. Without sub-categorization, carcinoma was diagnosed in 23% (55/239) of all cases with BI-RADS 4. Therefore, subcategorizing BI-RADS 4 lesions is important since it not only benefits the patient and clinician in understanding the level of concern for carcinoma, but will also alert the pathologist.

High prevalence of low vitamin D and musculoskeletal complaints in women with breast cancer.

Abstract: Reduced vitamin D levels may play a significant role in the development of fractures and musculoskeletal pains reported in patients on aromatase inhibitors (AIs) for breast cancer In this study, we evaluated the vitamin D status in postmenopausal women with non-metastatic breast cancer who were about to start AI therapy This study was conducted on community dwelling postmenopausal subjects, aged 35-80 years, with early non-metastatic breast cancer (up to stage IIIA), who were about to start therapy using third generation AIs Symptoms of joint and muscle pains were obtained using a modified Leuven menopausal questionnaire 25-hydroxyvitamin D [25(OH)D] was evaluated by radioimmunoassay while bone mineral density (BMD) of the lumbar spine and the proximal femur by dual energy x-ray absorptiometry (DXA) Of the 145 participants (mean age = 6096 ± 088 years), 63 of 145 (435%) had baseline levels of 25(OH)D of < 20 ng/mL (deficient), 50 of 145 (345%) had levels between 20 and 29 ng/mL (insufficient), and only 32 of 145 (22%) had ≥ 30 ng/mL (sufficient); thus, 113 of 145 (78%) had low 25(OH)D levels (ie, < 30 ng/mL) Arthralgias and myalgias were found in 613% and 43% of patients, respectively; and of those, 833% and 881% had 25(OH)D of < 30 ng/mL, respectively Prevalence of vitamin D deficiency is high in breast cancer women and this may increase the risk of bone loss and fractures in those who are going to start AIs Moreover, musculoskeletal pains are common in breast cancer women, even before the initiation of AIs and in association with low vitamin D in the majority Future studies may be needed to establish the contribution of low vitamin D, if any, on the prevalence of musculoskeletal pains in women on AIs

Clinical benefits of mastectomy on treatment of occult breast carcinoma presenting axillary metastases.

Abstract: Occult breast carcinoma presenting axillary metastases is uncommon and accounts for less than 1% of newly diagnosed breast carcinoma. However, it continues to be a challenging diagnostic and therapeutic problem. In this study, we analyzed retrospectively on 51 cases of occult breast cancer from 1990 to 2003 in our hospital. All these patients had a palpable axillary nodule, no dominant breast mass, and no abnormal mammograms and breast ultrasonograph. Histological examination of axillary mass revealed metastasis from breast. The positive rate of estrogen receptor, progesterone receptor and the monoclonal antibody M4G3 against human breast cancer showed 62.7%, 66.7%, and 93.1% positive respectively. Among 51 cases, 38 cases received mastectomy whereas 13 cases had no local treatment of the breast. The primary tumors were detected in 28 of 38 cases having mastectomy by pathology. Seventy-seven percent of patients who had no local treatment of the breast had a tumor recurrence, compared with 26% who had a mastectomy. The mean disease-free survival was 23 months in patients who had no local treatment of the breast, compared with 76 months in patients who had mastectomy. Eight of the 13 patients who had no treatment with breast died whereas seven of the 38 who had local treatment died, with a mean follow-up of 73 months. It was found that patients having mastectomy had a better disease-free survival (p < 0.001) and overall survival (p < 0.001) compared with those having no local treatment of the breast. Once the diagnosis of occult breast carcinoma is clarified, an axillary dissection and the local treatment of breast should be carried out.

Breast cancer prevention: patient decision making and risk communication in the high risk setting.

Abstract: The purpose of this study was to investigate prevention decision making among women at high risk for breast cancer, including patient preferences for preventive interventions, patient understanding of disease risk, and patient preferences for risk communication methods, and the corresponding physician understanding of these factors. A prospective interview and survey study was conducted of consecutive new patients seen at a cancer risk and prevention clinic and their physicians. One hundred and forty-six of 217 eligible patients participated and completed all components of the study (67%), and they were seen by a four physicians. Women’s preferences for prevention intervention varied widely across women but were stable across time. Physicians were very often unable to predict their patients’ preferences for prevention efforts. Patients overestimated their risk of disease, and physicians overestimated the decrease in perceived risk resulting from counseling (p < 0.001). As risk stratification for breast cancer improves, and prevention options become more tolerable, it becomes increasingly important to appropriately counsel women considering such options. This study provides insight into the decision making process of women at high risk for breast cancer and highlights the importance of addressing patient preferences for interventions and risk perception during risk assessment and counseling consultations.

An unusual case of primary small cell neuroendocrine carcinoma of the breast.

Abstract: Primary small cell neuroendocrine carcinoma of breast is a rare entity, with only case reports in literature Histologically, these tumors are similar to small cell carcinoma of the lung with some evidence of ductal carcinoma-in-situ with areas of ductal, lobular, or papillary differentiation Immunoreactivity for neuroendocrine markers is present in two thirds of cases, while 33–50% are positive for estrogen receptor or progesterone receptor Her2/neu expression has not been reported in small cell carcinoma of the breast Here we are presenting 53-year-old women with locally advanced primary small cell neuroendocrine carcinoma of breast We will discuss clinicopathological findings, treatment options, prognosis and review of the literature on primary small cell carcinoma of breast

Survival in breast cancer patients undergoing immediate breast reconstruction.

Abstract: Immediate and early-delayed breast reconstruction are the preferred methods of reconstruction in breast cancer patients treated with mastectomy These options for reconstruction allow for superior outcomes through peri-operative planning between the oncologic surgeon and reconstructive team We used the Surveillance, Epidemiology, and End Results (SEER) database to study the overall survival of patients treated with immediate or early-delayed breast reconstruction after mastectomy Population level de-identified data was abstracted from the National Cancer Institute's SEER cancer database We obtained data for all female patients with breast cancer treated with mastectomy from 2000 to 2002 Patients with missing or incomplete data were excluded Univariate and multivariate statistics were performed using Intercooled Stata 70 (College Station, TX) A total of 51,702 patients were included in the study The mean age was 608 (range 20-104) years old Reconstruction was performed in 167% of patients Multivariate analysis showed that patients treated with mastectomy and reconstruction had a significantly lower hazard ratio of death (HR=062, p<0001) compared with patients treated with mastectomy only, when controlling for demographic and oncologic covariates Black patients comprised 75% of the total population, and multivariate analysis showed that black patients had a significantly increased hazard ratio of death (HR=143, p<0001) when compared with white patients, when controlling for all other covariates including reconstruction status We show that women with breast cancer who undergo breast reconstruction after mastectomy do not have a worse overall survival than those not undergoing breast reconstruction This is true when patient age, race, income, and marital status; and tumor stage, histology, grade, use of radiotherapy, and mastectomy site (bilateral or unilateral) are controlled for

Marital Status Predicts Change in Distress and Well-being in Women Newly Diagnosed With Breast Cancer and Their Peer Counselors

Abstract: We conducted a nonrandomized study matching 42 women newly diagnosed with breast cancer (sojourners) with 39 trained breast cancer survivors (navigators) who provided one-on-one peer counseling for 3–6 months. Because little is known about how marital status might impact participants in such an intervention, we tested whether being married/partnered buffered navigators and sojourners from distress at baseline and over time. We examined baseline and slopes over time for change in depression and trauma symptoms, and emotional well-being. We were particularly concerned that being matched with a newly diagnosed breast cancer patient might trigger a re-experiencing of trauma symptoms for the navigator, so we examined a re-experiencing subscale. All participants completed baseline, 3-, 6-, and 12-month assessments. Our hypotheses were tested in separate Analyses of Variance (married versus not) for the 39 sojourners and 34 navigators who provided baseline assessments, and the 29 sojourners and 24 navigators who were matched and provided at least one follow-up. We found no significant baseline associations for navigators or sojourners. Being single/not married was associated with increasing depression symptoms over time in both navigators and sojourners compared with being married/partnered. By 12 months, these increases crossed above the clinical cut-off for significant depression symptoms. Single status did not predict increasing trauma symptoms over time. However, being single/not married predicted a significant increase in navigators’ re-experiencing of trauma symptoms. Over time, married sojourners increased significantly in emotional well-being, whereas single/not married navigators did not differ from married navigators. In addition to providing ongoing training and emotional support to navigators, our findings indicate the importance of providing additional support for women who are not married or partnered.

Have the Organisms that Cause Breast Abscess Changed With Time?––Implications for Appropriate Antibiotic Usage in Primary and Secondary Care

Abstract: Many patients with breast abscess are managed in primary care. Knowledge of current trends in the bacteriology is valuable in informing antibiotic choices. This study reviews bacterial cultures of a large series of breast abscesses to determine whether there has been a change in the causative organisms during the era of increasing methicillin-resistant Staphylococcus aureus (MRSA). Analysis was undertaken of all breast abscesses treated in a single unit over 2003 - 2006, including abscess type, bacterial culture, antibiotic sensitivity and resistance patterns. One hundred and ninety cultures were obtained (32.8% lactational abscess, 67.2% nonlactational). 83% yielded organisms. Staphylococcus aureus was the commonest organism isolated (51.3%). Of these, 8.6% were MRSA. Other common organisms included mixed anaerobes (13.7%), and anaerobic cocci (6.3%). Lactational abscesses were significantly more likely to be caused by S. aureus (p < 0.05). Methicillin-resistant Staphylococcus aureus rates were not statistically different between lactational and nonlactational abscess groups. Appropriate antibiotic choices are of great importance in the community management of breast abscess. Ideally, microbial cultures should be obtained to institute targeted therapy but we recommend the continued use of flucloxacillin with or without metronidazole (or amoxicillin-clavulanate as a single preparation) as initial empirical therapy.