The Breast - Articles in Press

Angiosarcoma of the breast: A difficult surgical challenge - Corrected Proof

Aaron Hui, Michael Henderson, David Speakman, Anita Skandarajah — 2012-02-06

Abstract: Background and objectives: Breast angiosarcoma presents following radiotherapy after breast conserving surgery, in the setting of chronic lymphoedema after axillary dissection or as a primary tumour. The Peter MacCallum Cancer Centre has significant experience due to large breast and sarcoma units and as a primary radiotherapy centre. Our aims were to evaluate the management and locoregional and distant outcomes after breast angiosarcoma.Methods: Retrospective study of all patients from the prospective breast and sarcoma databases with a diagnosis of primary or secondary breast angiosarcoma at Peter MacCallum Cancer Centre was performed between January 2000 and December 2010. Mode of presentation, management, loco-regional recurrence and survival rates were reviewed.Results: Eight women developed angiosarcoma in the setting of breast conservation with a median latency of 7 years post radiotherapy. Six patients had primary breast angiosarcoma. All breast angiosarcomas were managed with total mastectomy with 5 patients requiring autologous tissue transfer. Four patients had adjuvant radiotherapy and three patients had adjuvant paclitaxel. The median follow-up was 2.5 years (6 month-10 years) with 7 episodes of local recurrence in four patients and 7 patients with distal metastases including two deaths from distant disease.Conclusions: Primary angiosarcoma occurs de novo, presenting as a breast mass. Secondary angiosarcoma presents predominantly as a skin lesion, in the setting post-operative radiotherapy for breast conserving therapy. Angiosarcoma remains a rare and difficult management problem with poor loco-regional and distal control. Secondary AS is an iatrogenic condition that warrants close follow-up and judicial use of radiotherapy in breast conserving therapy.

A meta-analysis of male breast cancer in Africa - Corrected Proof

2012-02-02

Abstract: To characterize male breast cancer in Africa in recent decades, we systematically reviewed literature and conducted a meta-analysis of available data on male breast cancer in Africa. A paper was included if both male and female breast cancer were available. If two publications covered the same geographic area, only the publication with a longer study period was included. Random effects models and mixed effect meta-regressions were used to analyze data of 1201 male and 36,172 female breast cancer patients from 27 African countries. We showed that the male-to-female breast cancer ratio was 0.042 overall and it has decreased in recent years. Additionally, male breast cancer patients in Africa had the disease at age 54.6 on average, 7 years older than female patients. In conclusion, male breast cancers in Africa are characterized as late onset and male-to-female breast cancer ratio in Africa is higher than populations in developed countries.

A comparison of systemic breast cancer therapy utilization in Canada (British Columbia), Scotland (Dundee), and Australia (Western Australia) with models of “optimal” therapy - Corrected Proof

2012-02-01

Abstract: Background: Different jurisdictions report different breast cancer treatment rates. Evidence-based optimal utilization models may be specific to the derived population. We compared predicted optimal with actual endocrine and chemotherapy utilization in British Columbia, Canada; Dundee, Scotland; and Perth, Western Australia.Design: Data were analyzed for differences in demography, tumour, and treatment. Epidemiological data were fitted to published Australian optimal radiotherapy utilization trees and region-specific optimal treatment rates were calculated. Optimal and actual systemic therapy rates from 2 population-based and 1 institution-based cancer registries were compared for patients diagnosed with breast cancer between 2000–2004, and 2002 for British Columbia.Results: Chemotherapy rates differed between British Columbia (32%), Perth (29%), and Dundee (24%, p = 0.014). Endocrine therapy rates were similar between British Columbia (56%), Perth (59%), and Dundee (64%, p > 0.05). Actual utilization rates were lower than optimal estimates for chemotherapy, but higher for endocrine therapy.Region-specific optimal utilization rates at diagnosis varied between 50–56% for chemotherapy, and 49–54% for endocrine therapy. Variation was attributed to local differences in demographics, and tumour stage.Conclusion: Actual treatment rates varied. There was lower than estimated optimal chemotherapy use but higher than expected use of endocrine therapy.

Outcome of mammography in women with large breasts - Corrected Proof

2012-01-30

Abstract: Mammography has been established as an effective screening tool for the early detection of breast cancer. Obesity may lead to increased breast size and has been linked to increased rates of breast cancer. As women with larger breasts may be predisposed to developing cancer, it is important that mammography is an appropriate test in these women. This study investigated the sensitivity and specificity of mammography in women with larger breasts in a population screening program.Method: Data was obtained from 848 648 eligible screening episodes of women aged over 40. Of these episodes, 758 860 were eligible for the study, with 7.2% (54 879 screens) deemed to have large breasts. Large breasts were defined as those for whom at least one large cassette was used in the mammographic process. Those women having only four standard cassettes per screen were classified as having average size breasts (703 981 screens, 92.8%). Cancer detection rates, interval cancer rates (false negatives) and recall to assessment rates were compared for women examined on standard sized cassettes versus large cassettes. Chance corrected measures of sensitivity and specificity and 95% confidence intervals (CI) were calculated for women with and without large breasts.Results: The study found that the sensitivity and specificity of mammography was greater for larger breasted woman. The incidence of breast cancer was also found to be higher in woman with larger breasts in the combined population (73.1 per 100,000 (95% CI 65.9–80.2) in large breasted women versus 52.8 (95% CI 51.1–54.5) in other women) and in each of the specific age groups. This study confirms the appropriateness of mammographic screening for women with large breasts.

Breast cancer early detection methods for low and middle income countries, a review of the evidence - Corrected Proof

Marilys Corbex, Robert Burton, Hélène Sancho-Garnier — 2012-01-30

Abstract: Organized national mammographic screening has been adopted as the gold standard for breast cancer early detection in western countries; however it may not be the most cost-effective approach to early detection in low and middle income countries (LMC) as it is very demanding in terms of human and financial resources. Moreover, its benefit to harm ratio has been questioned lately, particularly in women <50 years, the age group which produces the majority of breast cancer cases in LMC.In the past few years, evidence about alternatives to mammographic screening that would benefit LMC populations have been produced. They are reviewed and discussed in the present paper, together with evidence about mammographic screening relevant to LMC. Alternative screening tests (clinical breast-exam and self breast-exam) are examined, then the pro- and cons- for various strategies (opportunistic screening, population based screening and clinical downstaging) are discussed.

A first evaluation of breast radiological density assessment by QUANTRA software as compared to visual classification - Corrected Proof

2012-01-30

Abstract: Breast radiological density is a determinant of breast cancer risk and of mammography sensitivity and may be used to personalize screening approach. We first analyzed the reproducibility of visual density assessment by eleven experienced radiologists classifying a set of 418 digital mammograms: reproducibility was satisfactory on a four (BI-RADS D1–2–3–4: weighted kappa = 0.694–0.844) and on a two grade (D1-2 vs D3-4: kappa = 0.620–0.851), but subjects classified as with dense breast would range between 25.1 and 50.5% depending on the classifying reader. Breast density was then assessed by computer using the QUANTRA software which provided systematically lower density percentage values as compared to visual classification. In order to predict visual classification results in discriminating dense and non-dense breast subjects on a two grade scale (D3-4 vs, D1-2) the best fitting cut off value observed for QUANTRA was ≤22.0%, which correctly predicted 88.6% of D1-2, 89.8% of D3-4, and 89.0% of total cases. Computer assessed breast density is absolutely reproducible, and thus to be preferred to visual classification. Thus far few studies have addressed the issue of adjusting computer assessed density to reproduce visual classification, and more similar comparative studies are needed.

Erratum to ‘Goodwin PJ, Stambolic V. Obesity and insulin resistance in breast cancer – chemotherapy strategies with a focus on metformin. The Breast, 2011: 20; S31–S35.’ - Corrected Proof

2012-01-27

The publisher regrets that that there were two errors in the article referenced above, which was published as part of the Proceedings of the 12th St Gallen Primary Therapy of Early Breast Cancer Conference.

Erratum to ‘Sheri A, Dowsett M, Predicting response to cytotoxic drugs – The endocrine part of the story. The Breast, 2011: 20; S28 – S30.’ - Corrected Proof

Amna Sheri, Mitch Dowsett — 2012-01-27

The publisher regrets that there were two errors in the article referenced above, which was published as part of the Proceedings of the 12th St Gallen Primary Therapy of Early Breast Cancer Conference.

The differences in the histological types of breast cancer and the response to neoadjuvant chemotherapy: The relationship between the outcome and the clinicopathological characteristics - Corrected Proof

2012-01-25

Abstract: Although effective regimens have been established for invasive ductal carcinoma-not otherwise specified (IDC), the efficacy and prognosis of other minor types of breast cancer are unknown because of their rareness. The clinicopathological features and prognosis of other minor types concerning the response to neoadjuvant chemotherapy (NAC) were evaluated in this study.A total of 562 patients were classified according to the Japanese and the World Health Organization (WHO) classifications, and the number of IDC and other special types (SP) was 500 and 62. The SP patients had a significantly poorer clinicopathological response to NAC and less breast-conservative therapy than those with IDC. According to the WHO classification, mucinous carcinoma, metaplastic carcinomas and apocrine carcinoma also responded poorly, and patients with metaplastic carcinomas and invasive lobular carcinoma had a significantly poorer prognosis. Despite the poor response to chemotherapy, patients with mucinous carcinoma and apocrine carcinoma had a good prognosis.The response to NAC and the prognosis vary for each histological type. For some types, the prognosis was not related to the clinicopathological response to NAC.Background: In the treatment of breast cancer, neoadjuvant chemotherapy (NAC) has become the standard treatment modality for downstaging purposes. Although effective regimens have been established for the treatment of invasive ductal carcinoma-not otherwise specified (IDC), the data about the efficacy and prognosis for patients with other minor types of breast cancer are insufficient because of the rareness of these tumors. Defining the relationship between each histological type and the clinicopathological response to NAC is essential to optimizing individualized treatment.Methods: We retrospectively evaluated the clinicopathological features and classification of the histological types based on the Japanese and the World Health Organization (WHO) classifications before and after NAC in 562 patients with primary breast cancer who underwent curative treatment after NAC between 1998 and 2008. The prognosis was estimated for each histological type.Results: Of the 562 patients, the number of cases of IDC and other special types (SP) was 500 and 62. In the SP group, the clinicopathological response to NAC was significantly poorer, and the patients underwent breast-conservative therapy less frequently than did the IDC patients. According to the WHO classification, mucinous carcinoma, metaplastic carcinomas and apocrine carcinoma responded poorly to NAC. The disease-free survival and overall survival were significantly worse for patients with metaplastic carcinomas (p < 0.001 and p < 0.001) and with invasive lobular carcinoma (p = 0.03 and p < 0.001) than other cancers. Despite their poor response to treatment, patients with mucinous carcinoma and apocrine carcinoma had a good prognosis.Conclusions: The response to standardized NAC and prognosis varies for each histological type. For some types, the prognosis was not associated with the clinicopathological response to NAC. Innovative regimens should therefore be investigated for each histological type to achieve the best response.

Breast surgeons performing immediate breast reconstruction with implants – Assessment of resource-use and patient-reported outcome measures - Corrected Proof

S. Robertson, Y. Wengström, C. Eriksen, K. Sandelin — 2012-01-25

Abstract: Oncoplastic surgery, including immediate breast reconstruction (IBR), is expanding as a result of public demand. IBR in women with breast carcinoma is resource intense and the reconstruction is often completed concurrently with adjuvant oncological treatment. A series of 223 patients with implant-based IBRs, performed by breast surgeons 2005–2008, were analysed for use of resources and outcome. Low overall major complication rates (19,7%) were identified, even though 41% of the patients had received post-mastectomy radiation. A total of 1.1 reoperations per patient were required. Patient-reported outcomes using the EQ-5D and a disease-specific questionnaire at a median of four years follow-up were analysed. Patients’ general health-state was high (0.83), whereas negative impact on intimate situations and the sensibility of the breast was reported. Our audit concludes that trained breast surgeon specialists perform implant-based IBRs with a satisfactory outcome when evaluated by subjective and objective analyses.

Epirubicin: Is it like doxorubicin in breast cancer? A clinical review - Corrected Proof

Mustafa Khasraw, Richard Bell, Chau Dang — 2012-01-19

Abstract: Anthracyclines are among the most effective chemotherapy treatments available for various types of cancer. The anthracyclines commonly used in treatment of breast cancer are either epirubicin or doxorubicin. Epirubicin is an epimer of doxorubicin with important role in the chemotherapy treatment of both early and metastatic breast cancer. The efficacy of epirubicin is similar to doxorubicin while epirubicin has a different toxicity profile particularly in regard to cardiotoxicity. Epirubicin has been incorporated into most of the anthracycline containing chemotherapy combinations in well-conducted clinical trials involving large numbers of patients. It has also been investigated in studies involving the administration of epirubicin in dose-dense chemotherapy schedules. Short term follow up of dose-dense clinical trials demonstrated safety comparable to that of doxorubicin. This review summarizes published clinical trials investigating epirubicin in the treatment of early and advanced breast cancer.

The Neoadjuvant Net: A patient- and surgeon-friendly device to facilitate safe breast-conserving surgery in patients who underwent neoadjuvant treatment - Corrected Proof

2012-01-11

Abstract: The primary goal of the study was to describe an innovative and helpful tool in defining the minimal surgical margins necessary during breast-conserving surgery (BCS) after neoadjuvant treatment: the Neoadjuvant Net (NN). The secondary endpoint was to assess its usefulness in achieving postoperative disease-free margins and reducing Ipsilateral Breast Tumor Recurrences (IBRTs). The breast-conserving surgical technique together with the use of the Neoadjuvant Net is herein reported. Age, stage at diagnosis, clinical and pathological response, lymph node status, type of surgery, margin status, and incidence of local and distant recurrence were retrospectively analyzed. Seventy-five patients underwent BCS following medical treatment from 2000 to 2011. The majority of the patients had significant size reduction (63/75, 84%). Twenty-two had a complete clinical response but only 11 (11/75, 14.7%) showed a complete pathological response. Two patients (2/75, 2.67%) had infiltrated surgical margins. After a mean follow-up of seventy months, 3 patients (3/75, 4%) had IBRTs and 4 women had distant metastases (4/75, 5.34%). The NN is an easy-to-use, non-invasive instrument designed with the purpose of facilitating the surgeon’s task of reducing infiltrated margins and IBTRs.

Local breast cancer recurrence after mastectomy and immediate breast reconstruction for invasive cancer: A meta-analysis - Corrected Proof

M. Gieni, R. Avram, L. Dickson, F. Farrokhyar, P. Lovrics, S. Faidi, N. Sne — 2012-01-09

Abstract: Background: The main priorities in the surgical treatment of patients with breast cancer are to achieve cure, local control and prevent recurrence. It is increasingly important to address quality of life and self-image with women undergoing surgical intervention for breast cancer. There is a lack of consensus as to the oncologic safety of immediate breast reconstruction (IBR). The purpose of this paper is to systematically review the literature and compare the frequency of recurrence in patients with and without IBR following mastectomy for breast cancer.Methods: Two independent investigators searched PubMed, Embase, and the Cochrane database using predefined search terms. After application of inclusion and exclusion criteria, 10 articles remained. Each article was assessed for quality. Relevant data was collected including recurrence rates, cancer stage, type of mastectomy and reconstruction, adjuvant treatments, and duration of follow-up.Results: Inter-rater reliability was good at 74% (95% CI: 0, 93%). There was no evidence of study heterogeneity (p for Q-statistic=0.34 and I2=12%). The OR ratio for recurrence of breast cancer for mastectomy with IBR as compared to mastectomy alone was 0.98 (95% CI: 0.62, 1.54).Conclusion: This meta-analysis demonstrated no evidence for increased frequency of local breast cancer recurrence with IBR compared with mastectomy alone

Is three better than two? The use of 3D scanners in the assessment of aesthetic results in local breast cancer treatment - Corrected Proof

Maria João Cardoso — 2012-01-05

Aesthetic results of local treatment of breast cancer, comprising surgery and radiotherapy, have always been difficult to evaluate in a concise way. The obstacles to aesthetical evaluation are familiar to all clinicians working in the field, and since the establishment of conservative breast cancer treatment as an alternative to mastectomy a myriad of methodologies have been used to evaluate aesthetic outcomes. But while oncological results are more easily measurable aesthetic outcomes are difficult to evaluate. Who should evaluate, what needs to be evaluated, when should results be measured and how should this be performed have remained unanswered questions in the topic of aesthetic evaluation.

DNA damage induced by mammography in high family risk patients: Only one single view in screening - Corrected Proof

Catherine Colin, Nicolas Foray — 2012-01-04

Abstract: Women with high risk of breast or ovarian cancers might be more susceptible to radiation-induced cancer because most of tumor suppressor genes are also implicated in the radio-induced DNA damage repair and signaling. Recent radiobiological advances may help to re-consider the potential cellular and molecular consequences of the standard two-view mammographic screening. A major radiobiological effect exacerbated in high family risk women caused by mammographic repeated doses was pointed out on relevant cellular model (untransformed and non tumoral human breast epithelial cells): the Low and Repeated Dose (LORD) effect. In parallel, while magnetic resonance imaging (MRI) is reported to be less sensitive than mammography for detection of ductal carcinoma in situ, a recent study highlighted the increased ability of MRI to detect them related to the experience both of radiologists and MRI centers. Hence, along with studies confirming improvement of the sensitivity of MRI to detect ductal carcinoma in situ, the supra-additivity effect induced by the two-view mammographic screening in high family risk patients suggests that mammographic exposures can be limited seriously. Consequently, a single view (oblique) per breast in association with annual MRI, with the sole aim to detect calcifications reflecting carcinoma in situ non detectable by MRI, might represent currently a compromise.

Biopsy of liver metastasis for women with breast cancer: Impact on survival - Corrected Proof

2012-01-04

Abstract: Background: Biopsy of metastatic site of disease can influence treatment decisions, but its impact on survival remains uncertain.Patients and methods: One-hundred patients with first metachronous liver metastases (LM) from breast cancer (BC) who underwent liver biopsy between 1999 and 2009 were identified. One-hundred matched control patients with LM from BC and no biopsy were selected.Results: Liver biopsy had no statistically significant impact on survival when comparing biopsied patients to controls [HR 0.82 (95% CI 0.58–1.16)]. Patients with early metastasis (within 3 years) undergoing liver biopsy had a better survival [HR 0.60 (95% CI 0.38–0.97)] compared to those who did not. Liver biopsy had no statistically significant impact on survival in patients with late LM (after 3 years) [HR 1.09 (95% CI 0.69–1.74)]. We observed that 18 out of 100 biopsied patients (18.0%) had a conversion of predictive factors which allowed adjusting for therapy, specifically new expression of ER (n=5), overexpression of HER2 (n=12) or both (n=1). Fourteen out of 18 (77.8%) received anti-HER2 treatment for the first time at the time of metastasis and 3 others (16.7%) received hormone therapy. Those 18 patients showed a better survival compared to the other 82 biopsied patients [HR 0.55 (95% CI 0.28–1.10)] and compared to the 13 biopsied patients with disappearance of features which predicted responsiveness to a given treatment [HR 0.19 (95% CI 0.06–0.62)].Conclusions: Liver biopsy can impact survival of patients with early metastases from BC. Discordance between primary and distant lesions can offer the patients new treatment options.

No correlation between plasma D-dimer levels and lymph node involvement in operable breast cancer - Corrected Proof

2011-12-30

Still unexplored is the correlation between plasma D- dimer levels and axillary node involvement, as detected following SNB investigation, in operable breast cancer. This prospective study attempts to verify the correlation between D - dimer level and lymph node involvement, including patients with positive Sentinel Node.

Effect of hospital volume on processes of care and 5-year survival after breast cancer: A population-based study on 25 000 women - Corrected Proof

2011-12-28

Abstract: Purpose: To compare processes of care and survival for breast cancer by hospital volume in Belgium, based on 11 validated process quality indicators.Methods: Three databases were linked at the patient level: the Cancer Registry, the population and the claims databases. All women with a diagnosis of invasive breast cancer between 2004 and 2006 were selected. Hospitals were classified according to their annual volume of treated patients: <50 (very low), 50–99 (low), 100–149 (medium) and ≥150 patients (high). Cox and logistic regression models were used to test differences in 5-year survival and in achievement of process indicators across volume categories, adjusting for age, tumor grade and stage.Results: A total of 25 178 women with invasive breast cancer were treated in 111 hospitals. Half of the hospitals (N = 57) treated <50 patients per year. Six of eleven process indicators showed higher rates in high-volume hospitals: multidisciplinary team meeting, cytological and/or histological assessment before surgery, use of neoadjuvant chemotherapy, breast-conserving surgery rate, adjuvant radiotherapy after breast-conserving surgery, and follow-up mammography. Higher volume was also associated with improved survival. The 5-year observed survival rates were 74.9%, 78.8%, 79.8% and 83.9% for patients treated in very-low-, low-, medium- and high-volume hospitals respectively. After case-mix adjustment, patients treated in very-low- or low-volume hospitals had a hazard ratio for death of 1.26 (95% CI 1.12, 1.42) and 1.15 (95% CI 1.01, 1.30) respectively compared with high-volume hospitals.Conclusion: Survival benefits reported in high-volume hospitals suggest a better application of recommended processes of care, justifying the centralization of breast cancer care in such hospitals.

A critical review of women's sleep–wake patterns in the context of neo-/adjuvant chemotherapy for early-stage breast cancer - Corrected Proof

Grigorios Kotronoulas, Yvonne Wengström, Nora Kearney — 2011-12-22

Abstract: Complaints of poor nocturnal sleep and daytime dysfunction may be frequent among women receiving chemotherapy for breast cancer. A critical review of the literature was conducted, which aimed at summarising and critically analysing findings regarding sleep in women with early-stage breast cancer across neo-/adjuvant chemotherapy treatment. A systematic search of three electronic databases (Medline, CINAHL, EMBASE) was conducted from January 1980 to July 2011. Twenty-one articles reporting on 12 studies were included for analysis based on pre-specified selection criteria. Varying deficits in sleep parameters may be evident in a significant part of this population. Yet, research data are not equally distributed among the different sleep components, or across all major time points throughout chemotherapy. More systematic investigation of the experience of disrupted sleep in this population with longitudinal mixed-methods studies is warranted to ensure that person-tailored and clinically meaningful care is delivered.

Isosulfan blue-induced anaphylactic reaction during sentinel lymph node biopsy in breast cancer - Corrected Proof

2011-12-21

In patients with breast cancer, the most important prognostic factor is whether there exists a metastatic involvement in axillary lymph nodes. Histopathological examination of the sentinel lymph node (SLN) provides information about presence of metastasis in the remaining lymph nodes without application of axillary lymph node dissection. Radiolymphoscintigraphy and/or blue dye is/are used for detection of SLN in breast cancer. Isosulfan blue is the first dye approved by the United States Food and Drug Administration (FDA) in terms of sentinel lymph node biopsy (SLNB), and it is also one of the most commonly used blue dyes. Allergic and anaphylactic reactions to the Isosulfan blue used for SLNB in breast cancer may develop. In our article, we present a case of anaphylactic reaction induced by Isosulfan blue.

Updated follow-up of patients treated with the oncoplastic “Crescent” technique for breast cancer - Corrected Proof

2011-12-20

Abstract: Background: Conservative treatment of lower pole breast cancer in small or medium sized breasts could be attended with poor cosmetic outcomes. The purpose of this study was to assess the results of the “Crescent” Oncoplastic technique in this indication.Material and methods: Prospective study in 54 breast cancer patients undergoing the technique.Results: Post-operative recovery was uneventful except 1 hematoma and 6 breast seromas. With a mean follow-up period of 45 months (range 27–64), no local recurrences was detected. Five patients had fat necrosis. Cosmetic results were assessed as being excellent (39%), good (35%), fair (20%) and mediocre (6%).Conclusion: We therefore advise this technique as a first step oncoplastic surgery technique for tumors situated near the inframammary fold. We also recommend the systematic check of the final cosmetic results in the standing position in order to obtain the best possible results.

Racial disparity in estrogen receptor positive breast cancer patients receiving trimodality therapy - Corrected Proof

2011-12-19

Abstract: Introduction: We assessed racial differences in progression-free survival (PFS) and overall survival (OS) in relation to subtype in uniformly treated stage II–III breast cancer patients.Methods: We reviewed records of 582 patients receiving post-mastectomy radiation (PMRT) between 1/1999 and 12/2009 and evaluated the effect of demographic, tumor, and treatment characteristics on PFS and OS.Results: Median follow up was 44.7 months. 24% of patients were black and 76% white. All had mastectomy and PMRT; 98% had chemotherapy; Estrogen receptor (ER)+ patients received endocrine therapy. Black patients were more likely to have ER− (56% vs. 38%, p = 0.0001), progesterone receptor (PR)− (69% vs. 54%, p = 0.002), and triple negative (TN) (46% vs. 24%, p < 0.0001) tumors. Overall, black patients had worse PFS (60.6% vs. 78.3%, p = 0.001) and OS (72.8% vs. 87.7%, p < 0.0001). There was no racial difference in PFS (p = 0.229 and 0.273 respectively) or OS (p = 0.113 and 0.097 respectively) among ER− or TN. Among ER+, black patients had worse PFS (55% vs. 81%, p < 0.001) and OS (73% vs. 91%, p < 0.0001). The difference in PFS was seen in the ER+/PR+/HER2− subgroup (p = 0.002) but not ER+/PR−/HER2− (p = 0.129), and in the post-menopausal ER+/HER2− subgroup (p = 0.004) but not pre/peri-menopausal ER+/HER2− (p = 0.150).Conclusions: Black women had worse survival outcomes in this cohort. This disparity was driven by (1) a higher proportion of ER− and TN tumors in black women and (2) worse outcome of similarly treated black women with ER+ breast cancer. The underlying causes of racial disparity within hormone receptor categories must be further examined.

Clinical review – Breast adenoid cystic carcinoma - Corrected Proof

2011-12-12

Abstract: Objectives: To review the published literature on the diagnosis and management of adenoid cystic carcinoma (ACC) of the breast.Materials and Methods: Papers were identified by searching PubMed using the terms « adenoid cystic carcinoma » and « breast ». Additional papers were identified by reviewing references of relevant articles.Results: ACC of the breast is a rare tumour comprising less than 0.1% of breast malignancies. Its cellular origin in the breast remains unclear. The histological characteristics of ACC in the breast are similar to those of ACC of the salivary glands. However the prognosis of ACC of the breast is better than that of other localizations with prolonged survival. Breast-conserving treatment including postoperative radiotherapy seems to be equivalent to mastectomy alone with respect to survival. The value of adjuvant systemic therapies is not established. Late relapses can occur, so long-term follow-up is mandatory for these patients.Conclusions: ACC of the breast has a favourable prognosis. An accurate diagnosis and appropriate treatment are therefore important.

Impact of body mass index on compliance and persistence to adjuvant breast cancer therapy - Corrected Proof

2011-12-07

Abstract: Several authors found that the prognosis of overweight and obese breast cancer (BC) patients was lower than that of normal weight patients. We present the first study which evaluates the impact of body mass index (BMI) on compliance (i.e. to start a recommended therapy) and persistence to adjuvant BC therapy. An unselected cohort of 766 patients (≤75 years) diagnosed from 1997 to 2009 was analyzed in relevance to the four adjuvant therapy modalities: (A) radiation, (B) chemotherapy, (C) therapy with trastuzumab, and (D) endocrine therapy. With respect to compliance, multivariate analyses calculated Odds ratios (ORs) >1 for increased BMI in all four therapy modalities, i.e. increased BMI had a positive influence on compliance. The results were significant for radiotherapy (OR,2.37;95%CI,1.45–3.88;p < 0.001) and endocrine therapy (OR,1.92;95%CI,1.21–3.04;p = 0.002) and showed a trend in chemotherapy (OR,1.42;95%CI,0.97–2.08;p = 0.063). Analyzing persistence, increasing BMI had ORs <1 for chemotherapy and therapy with trastuzumab, both not reaching statistical significance. For endocrine therapy, increasing BMI was a significant predictor for persistence (OR,1.35;95%CI,1.08–1.80;p = 0.042).Failure of compliance and persistence to adjuvant therapy does not pose a contributing factor for the observed unfavorable prognosis in overweight/obese BC patients. In most therapy modes, patients with increasing BMI demonstrated a higher motivation and perseverance to the recommended treatment.

SPECT/CT scans allow precise anatomical location of sentinel lymph nodes in breast cancer and redefine lymphatic drainage from the breast to the axilla - Corrected Proof

2011-12-07

Abstract: Background: Historical studies of lymphatic drainage of the breast have suggested that the lymphatic drainage of the breast was to lymph nodes lying in the antero-pectoral group of nodes in the axilla just lateral to the pectoral muscles. The purpose of this study was to confirm this is not correct.Methods: The hybrid imaging method of SPECT/CT allows the exact anatomical position of the sentinel lymph node (SLN) in the axilla to be documented during pre-operative lymphoscintigraphy (LS) in patients with breast cancer. We have done this in a series of 741 patients. The Level I axillary nodes were defined as anterior, mid or posterior. This was related to the anatomical location of the primary cancer in the breast.Results: A SLN was found in the axilla in 97.8% of our patients. Just under 50% of SLNs located in the axilla were not in the anterior group and lay in the mid or posterior group of Level I axillary nodes. There was a SLN in a single node field in 460 patients (63%), two node fields in 261(36%), three node fields in 6 and four node fields in 1 patient.Conclusion: Axillary lymphatic drainage from the breast is not exclusively to the anterior (or antero-pectoral) group of Level I nodes.Synopsis: SPECT/CT lymphoscintigraphy shows that the breast does not always drain to the anterior group of Level I lymph nodes in the axilla but may drain to the mid axilla and/or posterior group in about 50% of patients with breast cancer regardless of the location of the cancer in the breast. These data redefine lymph drainage from the breast to axillary lymph nodes.

Incidence and risk factors of anemia in patients with early breast cancer treated by adjuvant chemotherapy - Corrected Proof

2011-11-28

Abstract: Background: The study’s objective was to assess the predictive factors of anemia induced by chemotherapy in early breast cancer patients.Patients and methods: Patients treated by adjuvant or neo-adjuvant anthracyclin-based regimens with or without taxanes between 1998 and 2006 in a French university hospital were studied. Chemotherapy included. Anemia was defined as a hemoglobin (Hb) concentration lower than 12 g/dL. Multivariate analysis by logistic regression was used to search for baseline risk factors linked to the occurrence of anemia.Results: Among 378 patients, anemia was observed in 64% of cases. The occurrence of anemia was significantly related to 6 risk factors: exposure to taxanes (HR 11.5, 95% CI, 2.5–52.6), high dose of anthracyclin (epirubicin 100 mg/m²)(HR 4.3; 95% CI, 2.8–8), Hb at baseline 60 (HR 2.5; 95% CI, 1.4–5) years old (HR 2.5; 95% CI, 1.4–5) and Body Mass Index (BMI) ≤ 25 kg/m² (HR 1.7; 95% CI, 1.0–2.8).Conclusion: Taking into account the following factors: type of chemotherapy, BMI, age, Hb at baseline should allow a better identification of patients at risk of anemia.

The effect of introducing an in-theatre intra-operative specimen radiography (IOSR) system on the management of palpable breast cancer within a single unit - Corrected Proof

2011-11-28

Abstract: Introduction: Intra-operative specimen radiography (IOSR) is used to screen specimens during breast-conserving surgery and attempt to identify incompletely excised lesions. Universal use of IOSR during surgery for impalpable breast cancer is advocated by current guidelines. This study evaluates the role of IOSR during breast-conserving surgery for palpable breast cancer.Methods: Two cohorts of patients who underwent wide local excision for palpable breast cancer were identified. Retrospective analysis of histological margins, intra-operative cavity shaves, secondary re-excision rates and specimen weight was completed comparing performance prior to the introduction of IOSR (October 2003–April 2005) with that since its introduction (April 2006–October 2007).Results: 224 Patients were included, 111 in the pre-IOSR cohort (PF) and 113 in the IOSR cohort (F). Patient demographics, tumour size and histology were comparable. No difference in margin involvement prior to intra-operative cavity shaving was noted, PF–26, F–31 (p=0.60). Intra-operative cavity shaves were carried out more frequently in the IOSR group, PF–9, F–32 (p=0.001). When compared with histological findings, IOSR identified margin compromise with sensitivity=58.1%, specificity=80.8%, positive-predictive value=56.25% and negative predictive value=81.9%. Re-operation rate was similar between the 2 groups, PF–26, F–31 (p=0.65). Significantly less tissue was excised following use of IOSR; PF–110g, F–70g (p=0.001).Conclusion: Introduction of IOSR significantly reduced specimen weights without increasing re-excision rates. As volume of breast tissue removed is the most significant determinant of cosmetic outcome following breast-conserving surgery, the use of IOSR should be advocated in the surgical management of palpable breast cancer.

Sentinel lymph node biopsy using indigo carmine blue dye and the validity of ‘10% rule’ and ‘4 nodes rule’ - Corrected Proof

Tomoya Nagao, Takayuki Kinoshita, Takashi Hojo, Hiroaki Kurihara, Hitoshi Tsuda — 2011-11-28

Abstract: This is the study which assessed sentinel lymph node biopsy (SNB) using indigo carmine blue dye and the validity of the ‘10% rule’ and ‘4 nodes rule’. Patients (302) were performed SNB using the combined radioisotope (RI)/indigo carmine dye method. Excised SLNs were confirmed whether they were stained and numbered in order of RI count and the percentage of radioactivity as compared to the hottest node was calculated. The relationship between histological diagnosis, dyeing and RI count was assessed. All the patients were detected SLN. Positive nodes were identified in 84 (27.8%) patients and were identified up to the third degree of hottest. All the hottest positive nodes were stained by indigo carmine. From the results, removing the three most radioactive SLNs identified all cases of nodal metastasis without complications. These stopping rules were valid and useful under indigo carmine use too.

Predictive value of peripheral blood lymphocyte count in breast cancer patients treated with primary chemotherapy - Corrected Proof

2011-11-28

Abstract: Peripheral blood lymphocyte (PBL) count may reflect the immune status of cancer patients. We retrospectively analyzed the predictive and prognostic impact of baseline and post-chemotherapy PBL counts in a homogeneous group of 103 breast cancer patients treated with neoadjuvant chemotherapy (anthracyclines and taxanes). In univariate analysis, baseline PBL under 1500 × 106/L (p = 0.013; hazard ratio [HR]: 2.80, 95%CI 1.24–6.61), and PBL decrease >200 × 106/L after the first cycle of chemotherapy (p = 0.047; HR: 2.82, 95%CI 1.01–7.86) were significantly related to disease free survival. In multivariate analysis, both baseline PBL count less than 1500 × 106/L (p = 0.034; HR: 3.32, 95%CI 1.09–10.02) and PBL decrease >200 × 106/L after first cycle (p = 0.032; HR: 3.25, 95%CI 1.10–9.56) showed independent prognostic value for worse disease free survival. No effect was observed for overall survival. Our data support the relevance of pre- and post-chemotherapy PBL for breast cancer recurrence after neoadjuvant chemotherapy.

Breast clinic triage tool: Telephone assessment of new referrals - Corrected Proof

Leila Cusack, Meagan Brennan, Leisha Weissenberg, Katrina Moore — 2011-11-23

Abstract: Efficient systems to triage increasing numbers of new referrals to breast clinics are needed, to optimise the management of patients with cancer and benign disease. A tool was developed to triage the urgency of referrals and allocate the most appropriate clinician consultation (surgeon or breast physician (BP)).259 consecutive new referrals were triaged using the tool. 100% new cancers and 256 (98.8%) referrals overall were triaged to both appropriate category of urgency and the appropriate clinician.This triage tool provides a simple method for assessing new referrals to a breast clinic and can be easily delivered by trained administrative staff by telephone.

Lymphatic mapping after previous breast surgery - Corrected Proof

2011-11-21

Abstract: Background: To assess the feasibility of lymphatic mapping and determine the lymphatic drainage pathways in patients previously treated with breast conserving therapy (BCT).Methods: We included patients without current breast cancer that previously received BCT with sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND) for primary breast cancer. The study population consisted of 44 patients and was divided into two groups according to previous surgical treatment of the axilla: 22 patients after previous SNB and 22 patients after previous ALND. Standard lymphatic mapping was performed and the lymphatic drainage pattern was registered. Drainage located outside the ipsilateral axilla was recorded as aberrant.Results: Lymphoscintigraphy revealed a drainage pattern in 17 of 44 patients (39%). The identification rate in the SNB-group was 41% and 36% in the ALND-group (P=0.760). 8 patients (18%) showed aberrant drainage, which tended to be more frequent in the ALND-group than in the SNB-group (27% versus 9%, P=0.122). Lymphatic drainage to the contralateral axilla was observed in 2 patients, both previously treated with ALND.Conclusions: Lymphatic mapping seems feasible after previous BCT with axillary treatment, in spite of a relatively low identification rate. Aberrant drainage tends to be more frequent after previous treatment with ALND.

Evaluation of the evidence on staging imaging for detection of asymptomatic distant metastases in newly diagnosed breast cancer - Corrected Proof

M.E. Brennan, N. Houssami — 2011-11-17

Abstract: While guidelines recommend against routine use of staging imaging to detect asymptomatic distant metastases (DM) in newly diagnosed breast cancer (BC), modern imaging technologies may have improved detection capability and may have a role in some cases. We performed a systematic review of studies (1995–2011) evaluating the prevalence of DM and the accuracy of staging imaging for detection of asymptomatic DM. Twenty-two studies reporting on 14,824 BC subjects (median age 53 years) undergoing staging imaging were eligible. Median prevalence of DM was 7.0% (range 1.2–48.8%); prevalence increased with increasing BC stage. Conventional imaging studies had lower DM prevalence than studies of PET(PET/CT). Imaging median sensitivity/specificity respectively were: combined conventional imaging 78.0%/91.4%; bone scintigraphy 98.0%/93.5%; chest X-ray 100%/97.9%; liver ultrasound 100%/96.7%; CT chest/abdomen 100%/93.1%; FDG-PET 100.0%/96.5%; FDG-PET/CT 100%/98.1%. Low prevalence of DM was seen in Stage I–II BC with much higher prevalence in more advanced disease. Accuracy of PET modalities was very high however the high proportion of detected asymptomatic DM partly reflects selection bias.

Accuracy of needle biopsy of breast lesions visible on ultrasound: Audit of fine needle versus core needle biopsy in 3233 consecutive samplings with ascertained outcomes - Corrected Proof

2011-11-16

Abstract: Introduction: Core needle biopsy (CNB) has progressively replaced fine needle aspiration cytology (FNAC) in the diagnosis of breast lesions. Less information is available on how these tests perform for biopsy of ultrasound (US) visible breast lesions. This study examines the outcomes of CNB and FNAC in a large series ascertained with surgical histology or clinical-imaging follow-up.Materials and methods: Retrospective five-year audit of 3233 consecutive US-guided needle samplings of solid breast lesions, from self-referred symptomatic or asymptomatic subjects, performed by six radiologists in the same time-frame (2003–2006): 1950 FNAC and 1283 CNB. The probability of undergoing CNB as a first test instead of FNAC was evaluated using logistic regression. Accuracy and inadequacy were calculated for each of CNB and FNAC performed as first test. Accuracy measures included equivocal or borderline/atypical lesions as positive results.Results: The probability of CNB as a first test instead of FNAC increased significantly over time, when there was a pre-test higher level of suspicion, in younger (relative to older) women, with increasing lesion size on imaging, and for palpable (relative to impalpable) lesions. Inadequacy rate was lower for CNB (B1 = 6.9%) than for FNAC (C1 = 17.7%), p < 0.001, and specifically in malignant lesions (B1 = 0.9% vs. C1 = 4.5%; p < 0.001). False negative rate was equally low for both CNB and FNAC (1.7% each test). CNB performed significantly better than FNAC for absolute sensitivity (93.1% vs. 74.4%; p < 0.001) and complete sensitivity (97.4% vs. 93.8%; p = 0.001), however specificity was lower for CNB than FNAC (88.3% vs. 96.4%; p < 0.001). Absolute diagnostic accuracy was higher for CNB than FNAC (84.5% vs. 71.9; p < 0.001) while FNAC performed better than CNB for complete diagnostic accuracy (95.4% vs. 93.2; p < 0.008). In the small subgroup assessed with CNB after an inconclusive initial FNAC (231 cases) there was improved complete sensitivity (from 93.8% to 97.0%) however this also increased costs.Conclusion: FNAC and CNB were generally performed in different patients, thus our study reported indirect comparisons of these tests. Although FNAC performed well (except for relatively high inadequacy), CNB had significantly better performance based on measures of sensitivity, but this was associated with lower specificity for CNB relative to FNAC. Overall, CNB is the more reliable biopsy method for sonographically-visible lesions; where FNAC is used as the first-line test, inadequate or inconclusive FNAC can be largely resolved by using repeat sampling with CNB.

Developing and measuring a set of process and outcome indicators for breast cancer - Corrected Proof

2011-11-07

Abstract: Purpose: This study aimed at developing and measuring a set of indicators to monitor the quality of breast cancer care, to make comparisons over time and to support quality improvement for all practitioners and centres involved in the care of breast cancer women.Methods: Quality indicators were identified from a systematic literature search and the 2010 Belgian evidence-based clinical practice guideline. The selection process involved an expert panel evaluating reliability, relevance, interpretability and actionability of each indicator. The quality indicators were tested using the Belgian Cancer Registry data linked with claims data for all women registered with breast cancer in Belgium between 2001 and 2006 (n = 50,039).Results: The selection process led to a final set of 32 indicators. Of these, 12 were measurable using the available data, while 1 indicator was measurable using proxy information. Five-year relative survival was 98%, 87%, 68% and 29% for pStage I, II, III and cStage IV respectively. Overall 5-year survival slightly improved for pStage II, III and cStage IV between 2001 and 2004. Of the surgically treated women, 60% underwent breast conserving surgery, 85% received adjuvant systemic treatment and 86% were irradiated postoperatively. In 80% of women treated for breast cancer, at least one mammography was performed within one year after the last treatment.Conclusion: The present study demonstrates the feasibility to develop a multidisciplinary set of quality indicators for breast cancer. Using national cancer registry data linked to claims data, 13 indicators were measurable, showing results that largely correspond to other studies in the field.

Editorial - Corrected Proof

Alberto Costa — 2011-11-07

For more than one hundred years cancer was considered an external entity growing into the body and acting against it. The approach to treatment was: seek and destroy. Aggressive surgery, heavy radiotherapy, intensive chemotherapy were the norm. We now know that cancer cells result from genetic changes to normal cells, and we now try to ‘cure’ them without causing too much damage to healthy cells. Consequently, surgery has become more and more conservative.

Enhancing the clinical pathway for patients undergoing axillary lymph node dissection - Corrected Proof

M. Barry, W.P. Weber, S. Lee, A. Mazzella, L.M. Sclafani — 2011-10-31

Abstract: Background: Day-case axillary lymph node dissection (ALND) is not standard practice. Here we assess the feasibility of converting this traditional inpatient procedure to an outpatient procedure without compromising the quality or continuity of patient care, identify barriers to introducing an enhanced clinical pathway based on this conversion, and report strategies employed to overcome these barriers.Methods: Consecutive patients (n=282) undergoing ALND alone or with a concurrent breast procedure (excluding mastectomy/reconstruction) over a 12-month period were recorded in a prospective database. Assessed outcomes were successful discharge the day of surgery, early postoperative complication rates, and readmission rates.Results: From July 2009 to June 2010, 282 ALNDs were performed at Memorial Sloan-Kettering Cancer Center. 240 (85.1%) were performed as an outpatient procedure and 42 (14.9%) had inpatient ALND. The readmission rate was 0.8% (2/240), and the reoperation rate was 0.7% (2/282). Outpatient ALND procedure implementation created 240 additional beds over the 12-month study period. Identified barriers to implementing this new clinical pathway included patient expectations, reducing narcotic administration while optimizing postoperative pain control, and facilitating preoperative patient education.Conclusion: ALND may be safely performed as a day-case procedure. The key to successfully implementing ALND as a day-case procedure is a multidisciplinary team approach combined with enhanced pre and postoperative patient education. In addition, changes in the mindsets of patients and health care providers are essential.

Immunophenotyping analysis in invasive micropapillary carcinoma of the breast: Role of CD24 and CD44 isoforms expression - Corrected Proof

2011-10-24

Abstract: We analyzed immunohistochemically the expression of CD24 and spliced variants of CD44v5 and v9 in invasive micropapillary carcinoma (IMPC) of the breast that is a rather aggressive tumor characterized by alteration of cells adhesion molecules, early lymph node metastases and poor prognosis. We analyzed 31 high-grade IMPCs and compared their expression to 22 high grade (G3) invasive ductal carcinomas of the breast (IDCs). We found a higher expression of CD24 in high-grade IMPCs with a peculiar inverted apical localization, compared to IDCs, showing a strong cytoplasmic staining; normal breast tissue resulted completely negative. IMPCs showed reduced expression of CD44v5 and CD44v9 compared with IDCs, but without a statistical significant difference. This study demonstrated that IMPC represents a distinct entity of breast carcinoma with high expression of CD24 with a typical inverted apical membrane pattern and reduction of CD44 isoforms v5 and v9, compared to IDCs. These features could explain the high lymph-vascular invasion propensity and higher metastatic capability of these tumors and could be a useful tool for a future targeted therapy.

Pregnancy after treatment of breast cancer in young women does not adversely affect the prognosis - Corrected Proof

2011-10-24

Abstract: We assessed whether pregnancy after breast cancer in patients younger than 36 years of age affects the prognosis. Of 115 women with breast cancer followed for a mean of 6 years, 18 became pregnant (median time between diagnosis and the first pregnancy 44.5 months). Voluntary interruption of pregnancy was decided by 8 (44.4%) women. Significant differences in prognostic factors between pregnant and non-pregnant women were not observed. Pregnant women showed a lower frequency of positive estrogen receptors (41%) than non-pregnant (64%) (P = 0.06). At 5 years of follow-up, 100% of women in the pregnant group and 80% in the non-pregnant group were alive. The percentages of disease-free women were 94% and 64%, respectively (P = 0.009). Breast cancer patients presented a high number of unwanted pregnancies. Pregnancy after breast cancer not only did not adversely affect prognosis of the neoplasm but also may have a protective effect.

Non sentinel node involvement prediction for sentinel node micrometastases in breast cancer: Nomogram validation and comparison with other models - Corrected Proof

2011-10-20

Abstract: Purpose: The risk of non sentinel node (NSN) involvement varies in function of the characteristics of sentinel nodes (SN) and primary tumor. Our aim was to determine and validate a statistical tool (a nomogram) able to predict the risk of NSN involvement in case of SN micro or sub-micrometastasis of breast cancer. We have compared this monogram with other models described in the literature.Methods: We have collected data on 905 patients, then 484 other patients, to build and validate the nomogram and compare it with other published scores and nomograms.Results: Multivariate analysis conducted on the data of the first cohort allowed us to define a nomogram based on 5 criteria: the method of SN detection (immunohistochemistry or by standard coloration with HES); the ratio of positive SN out of total removed SN; the pathologic size of the tumor; the histological type; and the presence (or not) of lympho-vascular invasion.The nomogram developed here is the only one dedicated to micrometastasis and developed on the basis of two large cohorts. The results of this statistical tool in the calculation of the risk of NSN involvement is similar to those of the MSKCC (the similarly more effective nomogram according to the literature), with a lower rate of false negatives.Conclusion: this nomogram is dedicated specifically to cases of SN involvement by metastasis lower or equal to 2 mm. It could be used in clinical practice in the way to omit ALND when the risk of NSN involvement is low.

Combination of two local flaps for large defects after breast conserving surgery - Corrected Proof

Jeeyeon Lee, Youngtae Bae, Werner Audretsch — 2011-10-17

Abstract: Purpose: Oncoplastic surgery is a technique for wide excision of breast cancer without compromising the natural shape of the breast. We have combined two local flaps, referred to as a ‘combined local flap’, for large defects of the breast after a partial mastectomy.Patients and methods: Twenty-one patients with breast cancer underwent a partial mastectomy with immediate reconstruction when the surgical margin was positive and further excision was required or the tumor size was larger than the pre-operative evaluation. Reconstruction was consisted of a rotational local flap and a thoraco-epigastric flap (TEF), so-called a combined local flap. The cosmetic results were self-estimated after chemotherapy and radiotherapy according to a four-point scoring system.Results: The mean age of patients was 53.3 years and the mean tumor size was 2.2 cm. The mean excised breast volume was 133.8 mm3 and the percentage of excised volume was 20.4%. The cosmetic outcomes were judged as excellent, good, and fair in 11, 8, and 2 cases, respectively.Conclusion: The combined local flap, consisting of a rotational local flap and a TEF is a useful oncoplastic technique for large defects after breast-conserving surgery.

The use of 3D laser imaging and a new breast replica cast as a method to optimize autologous breast reconstruction after mastectomy - Corrected Proof

Uros Ahcan, Drago Bracun, Katarina Zivec, Rok Pavlic, Peter Butala — 2011-10-10

Abstract: Aesthetically pleasing and symmetrical breasts are the goal of reconstructive breast surgery. Sometimes, however, multiple procedures are needed to improve a reconstructed breast’s symmetry and appearance. In order to avoid additional corrective procedures, we have developed a new method that uses a reverse engineering technique to produce what we call a new breast replica cast (NBRC). The NBRC is a mould of the contralateral healthy breast, designed according to preoperative laser 3D images. During surgery, the mould is used to help shape the new breast. With this method, we are able to achieve breast symmetry in terms of volume, projection, contour, and position on the chest wall more accurately, more quickly, and more safely than before.

Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy - Corrected Proof

T. Rattay, M. Muttalib, E. Khalifa, A. Duncan, S.J. Parker — 2011-10-10

Abstract: In patients with operable breast cancer, pre-operative evaluation of the axilla may be of use in the selection of appropriate axillary surgery. Pre-operative axillary ultrasound (US) and fine needle aspiration cytology (FNAC) assessments have become routine practice in many breast units, although the evidence base is still gathering. This study assessed the clinical utility of US+/−FNAC in patient selection for either axillary node clearance (ANC) or sentinel lymph node biopsy (SLNB) in patients undergoing surgery for operable breast cancer.Over a two-year period, 348 patients with a clinically negative axilla underwent axillary US. 67 patients with suspicious nodes on US also underwent FNAC. The sensitivity and specificity of axillary investigations to determine nodal involvement were 56% (confidence interval: 47–64%) and 90% (84–93%) for US alone, and 76% (61–87%) and 100% (65–100%) for FNAC combined with US, respectively. With a positive US, the post-test probability was 78%. A negative US carried a post-test probability of 25%. When FNAC was positive, the post-test probability was greater than unity. A negative FNAC yielded a post-test probability of 52%.All patients with positive FNAC and most patients with suspicious US were listed for axillary node clearance (ANC) after consideration at the multi-disciplinary team (MDT) meeting. With pre-operative axillary US+/−FNAC, 20% of patients were saved a potential second axillary procedure, facilitating a reduction in the overall re-operation rate to 12%.In this study, a positive pre-operative US+/−FNAC directs patients towards ANC. When the result is negative, other clinico-pathological factors need to be taken into account in the selection of the appropriate axillary procedure.

Influence of catechol-o-methyltransferase genotype (Val158Met) on endocrine, sympathetic nervous and mucosal immune systems in breast cancer survivors - Corrected Proof

2011-10-05

Abstract: Stress can play an important role in development of cancer-related fatigue (CRF) by activating the hypothalamic-pituitary-adrenal (HPA) axis, the sympathetic nervous system (SNS), and altering the immune system. This study examined the influence of catechol-O-methyltransferase (COMT) Val158Met genotypes on salivary markers of HPA axis (cortisol), SNS (α-amylase) and immune (IgA) systems, as well as on CRF in breast cancer survivors (BCS). One-hundred BCS participated. After amplifying Val158Met COMT polymorphisms by polymerase chain reaction, three COMT genotypes were considered: Val/Val, Val/Met, Met/Met. Salivary cortisol, α-amylase activity, salivary flow rate, and IgA concentration were collected from non-stimulated saliva. CRF was assessed with the fatigue subscale of the Profile of Mood State (POMS) questionnaire. We found that BCS carrying Met/Met genotype reported higher cortisol concentration, α-amylase activity and greater CRF than those with Val/Met (P 0.20) were found. The results suggest that BCS carrying Met/Met genotype exhibit greater dysfunction of the HPA axis and SNS system associated with severe CRF. This study is important because it strives to understand biological factors that predispose some BCS to higher levels of CRF.

Improved sub-areolar breast tissue removal in nipple-sparing mastectomy using hydrodissection - Corrected Proof

2011-10-04

Abstract: We report on a new technique of dissection of the nipple-areola-complex (NAC) in nipple-sparing mastectomy (NSM). NACs removed due to the presence of tumor cells beneath them were histologically examined for the presence of normal breast glandular tissue. Cases were divided into cohort 1, where NACs were dissected by sharp isolation, coring the nipple, and cohort 2, where the same procedure was preceded by hydrodissection of the areola. In 20 (17.4%) cases the planned NSM was converted to skin-sparing mastectomy (SSM) because of intraoperative findings of cancer in retro-areolar tissue. Histological examination of 20 NSMs converted to SSM showed the presence of glandular tissue in 12 out of 13 cohort 1 cases (92%) and in 1 out of 7 cohort 2 cases (14%). We conclude that hydrodissection creates a subdermal plane facilitating NAC dissection and permitting a more complete removal of breast tissue in NSM. Such radicality could prove important in the treatment of breast cancer and in BRCA 1–2 mutation carriers because of its potential for reducing the risk of relapse.

mTOR in breast cancer: Differential expression in triple-negative and non-triple-negative tumors - Corrected Proof

S. Walsh, L. Flanagan, C. Quinn, D. Evoy, E.W. McDermott, A. Pierce, M.J. Duffy — 2011-09-30

Abstract: Triple-negative breast cancer (TNBC) is defined by the absence of estrogen receptors (ER), progesterone receptors (PR) and overexpression of HER2. Targeted therapy is currently unavailable for this subgroup of breast cancer patients. mTOR controls cancer cell growth, survival and invasion and is thus a potential target for the treatment of patients with TNBC. Using immunohistochemistry, mTOR and p-mTOR were measured in 89 TNBCs and 99 non-TNBCs. While mTOR expression was confined to tumor cell cytoplasm, p-mTOR staining was located in the nucleus, perinuclear area and in the cytoplasm. Potentially important, was our finding that nuclear p-mTOR was found more frequently in triple-negative than non triple-negative cancers (p < 0.001). These results suggest that mTOR may play a more important role in the progression of TNBC compared to non-TNBC. Based on these findings, we conclude that mTOR may be a new target for the treatment of triple-negative breast cancer.

Radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy: Analysis of 49 cases from a single-centre and review of the literature - Corrected Proof

2011-09-26

Abstract: The purpose of this study was to evaluate the reliability of image-guided 14-gauge needle core biopsy in the diagnosis of radial scar without associated atypical epithelial proliferation, by comparison with definitive histological diagnosis on surgical excision. The records of 8792 consecutive image-guided 14-gauge needle core biopsy of the breast performed from January 1996 to December 2009 were reviewed. Forty-nine cases of radial scar without associated atypical epithelial proliferation were identified and compared with definitive histological diagnosis on surgical excision.The definitive histological diagnosis on surgical excision confirmed the results of image-guided 14-gauge needle core biopsy in 36 of 49 cases (73.5%), in 9 cases (18.3%) radial scar was associated with atypical epithelial proliferation, while 4 cases out of 49 cases were upgraded to carcinoma (3 cases of ductal carcinoma in situ and one case of invasive lobular carcinoma), with an underestimation rate of 8.2%.A diagnosis of radial scar without associated atypical epithelial proliferation on image-guided 14-gauge needle core biopsy does not exclude a malignancy on surgical excision; consequently during the multidisciplinary discussion further assessment by surgical excision or vacuum-assisted excision, as recently reported, needs to be considered to obtain a definitive histological diagnosis.

Survival of patients with bilateral versus unilateral breast cancer and impact of guideline adherent adjuvant treatment: A multi-centre cohort study of 5292 patients - Corrected Proof

2011-09-26

Abstract: This retrospective multi-centre study is focussed on recurrence free and overall survival of bilateral breast cancer (BBC) versus unilateral breast cancer (UBC). The impact of BBC on survival is stratified to guideline adherence, according to the German national S3-guideline. Another aim of the study is to identify the influence of various guideline violations in adjuvant treatment on survival of BBC patients. 229 (4.3%) patients had BBC and 5063 (95.7%) had UBC. There is a significant association between BBC/UBC and recurrence free (RFS: p < 0.001) and overall survival (OAS: p = 0.003). Only 15.7% of patients with BBC are treated 100% guideline adherent (index- + contralateral tumour). 31.0% (30.5%) were guideline adherent with respect to the index (contralateral) tumour. The outcome decreases significantly with the number of guideline violations. There was no significant difference in RFS and OAS between BBC and UBC after adjusting for tumour size, nodal status, grading and if guideline adherent treatment was applied.Conclusion: 1. Patients with BBC have primarily a worse prognosis in terms of RFS and OAS than patients with primarily UBC.2. There is a strong association between guideline adherence and RFS/OAS of patients with BBC or UBC. The outcome decreases with the number of guideline violations.3. If guideline adherent treatment was applied (for both tumours in case of BBC) there was no significant difference in RFS and OAS between BBC and UBC after adjusting for tumour size, nodal status, grading.

Sponsors - Corrected Proof

2011-09-19

ESO wishes to extend its appreciation to the following sponsors for having granted their participation and support to ABC1: ESO is particularly grateful to the following sponsors for having provided grants to support the participation of several participants:

Erysipelas after breast cancer treatment - Corrected Proof

Kikkeri Narayanashetty Naveen, Varadraj V. Pai, Tukaram Sori, Srinivas Kalabhavi — 2011-09-19

Erysipelas is a distinct type of superficial cutaneous cellulitis with marked dermal lymphatic vessel involvement caused by group A beta hemolytic streptococcus (very uncommonly group C or C streptococcus) and rarely caused by S. aureus. Lymphedema, venous stasis, web intertrigo, and obesity are risk factors in the adult patient. Erysipelas of the upper extremity following breast cancer treatment was vaguely described as a complication in a German-language journal and as a case report in a Dutch-language journal. In a French-language Tunisian medical journal in 2002, erysipelas was described in 20 out of 700 breast cancer patients seen over 6 years with a 20% recurrence rate, and 40% had local trauma as a predisposing injury; however, only 40% had redness, 35% had fever, and 20% had edema. In English language journal 7 cases have been reported out of 310 patients seen over a period of 5 years.

Objective breast symmetry evaluation using 3-D surface imaging - Corrected Proof

2011-08-18

Abstract: This study develops an objective breast symmetry evaluation using 3-D surface imaging (Konica-Minolta V910® scanner) by superimposing the mirrored left breast over the right and objectively determining the mean 3-D contour difference between the 2 breast surfaces. 3 observers analyzed the evaluation protocol precision using 2 dummy models (n = 60), 10 test subjects (n = 300), clinically tested it on 30 patients (n = 900) and compared it to established 2-D measurements on 23 breast reconstructive patients using the BCCT.core software (n = 690). Mean 3-D evaluation precision, expressed as the coefficient of variation (VC), was 3.54 ± 0.18 for all human subjects without significant intra- and inter-observer differences (p > 0.05). The 3-D breast symmetry evaluation is observer independent, significantly more precise (p < 0.001) than the BCCT.core software (VC = 6.92 ± 0.88) and may play a part in an objective surgical outcome analysis after incorporation into clinical practice.