Ultrasound-guided radiofrequency ablation of early breast cancer in a resection specimen: Lessons for further research

PurposeTo assess the feasibility and effectiveness of radiofrequency ablation (RFA) in breast cancer, using different histopathologic staining methods to evaluate tissue viability.Materials and methodsIn twenty patients with unifocal small (≤1, 5 cm) invasive ductal carcinoma, ultrasound-guided RFA was performed immediately after surgery. Cell viability was assessed using cytokeratin 8 (CK 8) and nicotinamide adenine dinucleotide diaphorase (NADHD) in addition to hematoxylin–eosin (HE).ResultsAt histopathological examination, ex vivo RFA resulted in complete cell death of the target lesion in 17/20 patients. In two cases viable ductal carcinoma in situ (DCIS) was found just outside the completely ablated lesion.ConclusionRFA of small invasive breast cancer seems to be a feasible treatment option. Both NADHD and CK 8 demonstrate a clear and comparable demarcation between viable and non-viable tissue. A high level of accuracy is required in proper positioning of the needle electrode and a “hot retraction” is mandatory.     

Nicotinamide adenine dinucleotide staining immediately following radio frequency ablation of renal tumors-is a positive stain synonymous with ablative failure?

PURPOSE: Nicotinamide adenine dinucleotide diaphorase staining is arguably the standard for assessing tissue viability following radio frequency ablation, yet the accuracy of this test is questionable. Thus, it is imperative to examine the reliability of nicotinamide adenine dinucleotide to predict ablation success. To evaluate the observation that immediate nicotinamide adenine dinucleotide staining may not be clinically reliable, we compared results from immediate post-ablation biopsies of renal tumors to radiological and clinical followup. MATERIALS AND METHODS: Laparoscopic radio frequency ablation was performed in 9 patients and 10 tumors using a temperature modulated radio frequency system. Cold cup biopsies were taken immediately following ablation, and processed for nicotinamide adenine dinucleotide and hematoxylin and eosin staining. Patients were then followed using contrast enhanced computerized tomography at regular intervals. RESULTS: Median tumor size was 2.3 cm. Hematoxylin and eosin stain diagnosed 8 renal cell carcinomas and 2 angiomyolipomas. A quarter of the renal cell carcinomas and both angiomyolipomas stained positive for scattered nicotinamide adenine dinucleotide diaphorase activity immediately after RFA. Mean followup for the nicotinamide adenine dinucleotide positive tumors was 28.5 months (range 24 to 30) and for the nicotinamide adenine dinucleotide negative tumors was 25 months (range 18 to 30). There was no evidence of local tumor recurrence in any patient. CONCLUSIONS: Four lesions had nicotinamide adenine dinucleotide diaphorase activity on post-ablation biopsy suggesting retained viable tissue, yet there has been no recurrence during an average 2-year followup. While negative nicotinamide adenine dinucleotide staining is consistent with nonviability, these results suggest that false-positive staining can occur immediately following RFA, making the predictive value of positive nicotinamide adenine dinucleotide diaphorase staining unclear.     

Pathologic Correlation Study of Microwave Coagulation Therapy for Hepatic Malignancies Using a Three-Ring Probe

Microwave coagulation therapy (MCT) for the ablation of unresectable hepatic malignancies is a promising alternative to radiofrequency and cryoablation techniques. There are few data on the clinical effectiveness of MCT. In vivo pathologic evaluation of ablated tumor tissue is not well described for the three-ring microwave probe. The study design was a prospective trial enrolling patients with resectable hepatic malignancies. Lesions underwent in vivo MCT with the three-ring probe prior to liver resection. Gross and histologic evaluations of the tumor were performed, including nicotinamide adenine dinucleotide (NADH) vital staining. A total of nine patients with metastatic colon cancer were enrolled and had NADH stains performed of their pathologic specimens. The median size of the metastasis being ablated was 3.5 cm (range, 1.5–12.3). Fifty-six percent of the tumors demonstrated evidence of spontaneous coagulative necrosis on immediate histologic examination. The median dimensions of the ablation zones were 5 cm (range, 3–7) × 4.5 cm (range, 2.5–5.2) × 4.2 cm (range, 2–5) with a 5-min ablation at 60 W. The median ablation volume was 50.6 cm³ (range, 9–78). NADH vital staining was performed of the ablation zones with 100% absence of staining in the tumor tissue and in benign hepatic parenchyma, which is consistent with irreversible cellular damage. In conclusion, in vivo MCT of hepatic malignancies with the three-ring probe produces nonviable tumor cells after a 5-min ablation. The ablation time is significantly shorter than other available ablative techniques. Immediate histologic exam produces some evidence of coagulative necrosis. Further study of this promising technology is warranted. Poster presentation at the Society of Surgical Oncology annual meeting, March 24, 2006, San Diego, CA.     

Radiofrequency Thermal Ablation of Breast Cancer Local Recurrence: A Phase II Clinical Trial

Background  The role of radiofrequency (RF) ablation to treat local recurrence of breast cancer is unknown. Methods  We conducted a two-stage phase II clinical trial. Eligible patients had a histologically confirmed noninflammatory and ≤3 cm ipsilateral breast tumor recurrence. The tumor site was identified by intraoperative sonography. A LeVeen needle electrode (RadioTherapeutics Corp, Mountain View, Calif) was inserted into a single site within the tumor and radiofrequency ablation was performed using a RF-2000 generator (RadioTherapeutics Corp). After completion of radiofrequency, a mastectomy was performed. Conventional staining and nicotinamide adenine dinucleotide-diaphorase (NADH-diaphorase) cell viability staining were performed. Results  During the first stage, procedures were uneventful. Conventional, cytokeratin, and NADH-diaphorase staining identified persistent viable tumor cells in the RF-ablated region in three patients. This phase II trial was stopped after completion of the first stage because of insufficient efficacy. Conclusion  We demonstrate in this study that RF ablation is a potential technique to destroy local recurrence of breast tumors but the technique we tested in this phase II clinical trial had insufficient efficacy to recommend its use in routine.     

Phase II trial of radio frequency ablation of renal cancer: evaluation of the kill zone

PURPOSE: We report on the pathological evaluation of renal tumors after intraoperative radio frequency ablation performed immediately before surgical nephrectomy. MATERIALS AND METHODS: Ten patients with renal tumors were enrolled in a prospective, Institutional Review Board approved phase II trial of radio frequency ablation. Following surgical exposure of the kidney a single 12-minute radio frequency ablation of the tumor was performed using the Radionics Cool-tip RF Radio Frequency Ablation System (Radionics, Burlington, Massachusetts). The tumor was then excised via radical or partial nephrectomy. Gross and histological evaluations of the tumor were performed, including evaluation with nicotinamide adenine dinucleotide vital staining. RESULTS: All 10 tumors were confirmed histologically to be renal cell carcinoma. Mean tumor size was 3.2 cm. (range 1.4 to 8.0). Of the 10 tumors 8 were completely ablated with a mean treatment margin of 6.75 mm. (range 2 to 13). Of the 2 tumors that were incompletely treated 1 never attained a temperature sufficient for tissue destruction and the other measured 8 cm., far exceeding the expected ablation volume of treatment protocol. CONCLUSIONS: This study represents the initial report of the histological outcome of saline cooled radio frequency ablation of renal tumors. Our data indicate that it can completely destroy renal cancers while transmitting minimal collateral damage to surrounding renal parenchyma. Further investigation is required to determine long-term oncological outcome.     

Radiofrequency Ablation of Invasive Breast Carcinomas: A Phase II Trial

Background Local ablative therapy of breast cancer represents the next frontier in the minimally invasive breast-conservation treatment. We conducted a phase II trial to evaluate radiofrequency ablation (RFA) of invasive breast carcinomas. Methods Consecutive patients from two Mexican Institutions with invasive breast cancers < 4 cm, with no multicentric tumors and no previous chemotherapy were included in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RFA electrode followed by surgical resection. Routine pathologic analysis and viability evaluation with NADPH-diaphorase stain were performed to assess tumor ablation. Procedure-associated morbidity was recorded. Results Twenty-five patients were included. Mean patient age was 55.3 years (range 42–89 years). Mean tumor size was 2.08 cm (range 0.9–3.8 cm). Fourteen tumors (56%) were <2 cm. The mean ablation time was 11 minutes using a mean power of 35 W. During ablation, the tumors become progressively echogenic that corresponded with the region of severe RFA injury at pathologic examination. Of the 25 patients treated, NADPH stain showed no evidence of viable malignant cells in 19 patients (76%), with significant difference between tumors <2 cm (complete necrosis in 13 of 14 cases, 92.8%) vs. those >2 cm (complete necrosis 6 of 11 cases, 54.5%) (P < .05). No significant morbidity was recorded. Conclusions RFA is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further studies are necessary to optimize the technique and evaluate its future role as local therapy for breast cancer.     

Image and Pathological Changes after Radiofrequency Ablation of Invasive Breast Cancer: A Pilot Study of Nonsurgical Therapy of Early Breast Cancer

Background

The surgical treatment of early breast cancer has proceeded to less invasive approaches with better cosmetic results. The current study was undertaken to evaluate the clinical and pathological findings after radiofrequency ablation (RFA) without resection for a longer period of time.

Method

A total of 14 patients with breast cancer were enrolled. All patients were diagnosed to have invasive ductal carcinoma, and the median breast tumor size was 12 mm (range, 6–20 mm). Six patients received RFA treatment followed by immediate resection and eight patients without resection. The patients without resection were evaluated by ultrasound, MRI, and the pathological findings of a core needle biopsy after RFA. The removed specimens were examined by hematoxylin-eosin (HE) staining and nicotinamide adenine dinucleotide (NADH) diaphorase staining. The median follow-up of the patients was 39.9 months.

Results

NADH staining was necessary to diagnose complete tumor cell death in the tissue for 3 months after RFA. However, HE staining alone could confirm the effect without NADH staining more than 6 months after RFA. Post-RFA, MRI scans clearly demonstrated the area as a complete ablated lesion in all patients without resection. The ablated area detected by MRI or ultrasound became gradually smaller. All patients that underwent RFA with no resection were alive without relapse.

Conclusion

RFA therefore could be an effective alternative to partial mastectomy for early breast cancer. Further research will be necessary to establish the standardization of the indications, as well as the optimal techniques and post treatment evaluation modalities.     

Predictors of Axillary Lymph Node Metastases in Breast Cancer: Is There a Role for Minimal Axillary Surgery?

Introduction  Axillary nodal status is one of the most important prognostic factors in breast cancer. In the present study we used it to determine the predictors of axillary lymph node metastases in breast cancer and to determine if there is a group of patients in whom minimal axillary surgery is indicated. Methods  This article reports a retrospective study of 953 patients with T1 and T2 invasive breast carcinomas seen in the University Malaya Medical Centre between January 2001 and December 2005, where axillary dissection was done. Results  Of the 953 patients, 283 (29.7%) had breast-conserving surgery, and the rest had mastectomies. In this series, 463 patients (48.6%) were younger than 50 years of age; 365 patients (38.3%) had lymph node involvement. The Malays tend to have more axillary node metastases (45.1%) than the Chinese (36.9%); however, there was no significant relationship between age and race and lymph node involvement. Some 23.9% of grade 1 cancers were node positive, compared to 42.9% of grade 2/3 cancers. Tumor size ranged from 0.2 cm to 5 cm; 55.5% of tumors were T2 (>2–5 cm). There were only 13 (1.4%) T1a tumors (>0.1–0.5 cm). Node involvement was documented in 7.7% of T1a tumors, 12.3% of T1b tumors (>0.5–1 cm), 29.2% of T1c tumors, and 48.2% of T2 tumors. In patients who had no lymphovascular invasion (LVI), 24.4% had axillary node metastases, compared with 52.2% of patients where LVI was reported. On univariate analysis, our study found that tumor diameter >2 cm, presence of lymphovascular invasion, and higher tumor grade (2 & 3) were factors significantly associated with a higher risk of nodal metastases. On multivariate analysis, however, only lymphovascular invasion and tumor size were independent predictors based on the logistic regression. Conclusions  In T1 tumors, axillary lymph node dissection will overtreat almost 75% of cases; therefore a sentinel lymph node biopsy is justified in these tumors. Sentinel lymph node biopsy has been shown to reduce the complications of formal axillary dissection, such as shoulder stiffness, pain, and lymphedema. In patients with T2 tumors, where almost 45% have lymph node involvement, sentinel node biopsy may not be cost effective.     

Nipple-Sparing Mastectomy: Critical Assessment of 51 Procedures and Implications for Selection Criteria

Background  Retrospective studies have shown that occult nipple–areolar complex (NAC) involvement in breast cancer is low, occurring in 6–10% of women undergoing skin-sparing mastectomy (SSM). The cosmetic result and high patient satisfaction of nipple-sparing mastectomy (NSM) has prompted further evaluation of the oncologic safety of this procedure. Methods  We conducted a retrospective chart review of 36 self-selected patients who underwent 51 NSM procedures between 2002 and 2007. Criterion for patient selection was no clinical evidence of nipple–areolar tumor involvement. All patients had the base of the NAC evaluated for occult tumor by permanent histologic section assessment. We also evaluated tumor size, location, axillary node status, recurrence rate, and cosmetic result. Results  Malignant NAC involvement was found in 2 of 34 NSM (5.9%) completed for cancer which prompted subsequent removal of the NAC. Of the 51 NSM, 17 were for prophylaxis, 10 for ductal carcinoma in situ (DCIS), and 24 for invasive cancer. The average tumor size was 2.8 cm for invasive cancer and 2.5 cm for DCIS. Nine patients had positive axillary nodes. Overall, 94% of the tumors were located peripherally in the breast. After mean follow-up of 18 months, only two patients (5.9%) had local recurrence. Conclusion  Using careful patient selection and careful pathological evaluation of the subareolar breast tissue at surgery, NSM can be an oncologically safe procedure in patients where this is important to their quality of life. A prospective study based on focused selection criteria and long-term follow-up is currently in progress.     

Combined Hepatectomy and Radiofrequency Ablation for Multifocal Hepatocellular Carcinomas: Long-term Follow-up Results and Prognostic Factors

Background For multifocal hepatocellular carcinomas (HCCs) that are untreatable with resection only, locoregional therapies added to hepatectomy have been introduced. However, some preliminary reports have documented average survival results and relatively high complication rates. We evaluated the long-term survival results and safety of combined hepatectomy and radiofrequency ablation (RFA) in patients with HCCs and assessed the prognostic factors affecting their survival. Methods A total of 53 patients who had 148 HCCs in their livers underwent hepatectomy combined with ultrasound-guided intraoperative RFA. The mean diameter of the 82 resected tumors was 4.8 cm (range 1.3–21.0 cm) and that of 66 ablated tumors was 1.5 cm (range 0.8–3.5 cm). We evaluated the primary effectiveness rates, survival rates, and complications. In addition, we assessed the prognostic factors associated with the survival rates using Cox proportional hazard models. Results The primary effectiveness rate of RFA was 98% (65 of 66). Local tumor progression was observed in two (3%) ablation zones of 65 tumors with complete primary effectiveness. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 87, 83, 80, 68, and 55%, respectively. Patients with smaller resected tumors (≤5 cm) demonstrated better survival results (P = 0.004). No procedure-related deaths occurred. We observed hepatectomy-related complications in 4 patients (8%, 4 of 53) and an RFA-related complication in 1 patient (2%, 1 of 53). Conclusions Combined hepatectomy and RFA is an effective and safe treatment modality for multifocal HCCs. Resected tumor size was a significant prognostic predictor of long-term survival.     

Ablation of High-Intensity Focused Ultrasound Assisted with SonoVue on Rabbit VX2 Liver Tumors: Sequential Findings with Histopathology, Immunohistochemistry, and Enzyme Histochemistry

Background  We investigated sequential effects of HIFU ablation combined with contrast agent SonoVue by using histopathology examination, immunohistochemistry, and enzyme histochemistry. Materials and Methods  Forty rabbits with VX2 liver tumors were subjected to HIFU ablation. Before ablation, a bolus injection of 0.2 mL SonoVue was administrated in group II (n = 20), and normal saline solution was injected in group I (n = 20). On day 0, 3, 7, and 14 after ablation, 5 animals in each group were sacrificed. The tissue in ablated zone, transient zone (within 3 mm around ablated area), and surrounding zone (beyond 3 mm around ablated area) were collected. Coagulated volume measurement, hematoxylin-eosin staining, immunohistochemistry of Ki 67, Bcl-2, CD54, and MMP-2 to determine cell proliferation and tissue repair, and nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) and succinic dehydrogenase (SDH) staining to evaluate tissue viability were performed. Results  The coagulated volume in group II at each time point was larger than that in group I (P < .05). After day 3, hematoxylin-eosin staining demonstrated necrosis in ablated zones and increasing surrounding fibra bands in group I and group II, while increasing expression of Ki 67, Bcl-2, CD54, and MMP-2 in transient zones was detected using immunohistochemistry in both groups (P > .05). NADPH-d and SDH staining showed dramatic decrease of enzyme activities in ablated zones immediately after ablation, while residual viable tissues in ablated zones of group II were less than those of group I (P < .05). Conclusion  Contrast agent SonoVue enables improvement of HIFU ablation on rabbit VX2 liver tumors.     

Evaluating the validity of model for end‐stage liver disease exception points for hepatocellular carcinoma patients with multiple nodules <2 cm

Liver transplant allocation policy does not give model for end‐stage liver disease (MELD) exception points for patients with a single hepatocellular carcinoma (HCC) <2 cm in size, but does give points to patients with multiple small nodules. Because standard‐of‐care imaging for HCC struggles to differentiate HCC from other nodules, it is possible that a subset of patients receiving liver transplant for multiple nodules <2 cm in size does not have HCC. We evaluate risk of post‐transplant HCC recurrence and wait‐list dropout for patients with multiple small nodules using competing risks regression based on the Fine and Gray model. We identified 5002 adult HCC patients in the OPTN/UNOS dataset diagnosed and transplanted between January 2006 and September 2010. Compared to patients with >1 tumor <2 cm, risk of developing recurrence was significantly higher in patients with one or more tumors with only one tumor ≥2 cm (SHR 1.63, p = 0.009), as well as in patients with 2–3 tumors ≥2 cm (SHR 1.84, p = 0.02). Dropout risk was not significantly different among size categories. HCC recurrence risk was significantly lower in patients with multiple nodules <2 cm in size than in those with larger tumors, supporting the possibility that some patients received unnecessary transplants. The priority given to these patients must be re‐examined.     

A Prospective, Multi-Institutional Study of Adjuvant Radiotherapy After Resection of Malignant Phyllodes Tumors

Background  Malignant phyllodes tumors of the breast are unusual neoplasms, with an incidence of approximately 500 cases annually in the United States. Published local recurrence rates after margin-negative breast-conserving resections of borderline malignant and malignant phyllodes tumors are unacceptably high, at 24 and 20%, respectively. It is uncertain whether radiotherapy after resection of phyllodes tumors is beneficial. Methods  We prospectively enrolled patients who were treated with a margin-negative breast-conserving resection of borderline malignant or malignant phyllodes tumors to adjuvant radiotherapy. The primary endpoint was local recurrence. Results  Forty-six women were treated at 30 different institutions. The mean patient age was 49 years (range, 18–76 years). Thirty patients (65%) had malignant phyllodes tumors; the rest were borderline malignant. The mean tumor diameter was 3.7 cm (range, .8–11 cm). Eighteen patients had a negative margin on the first excision. The median size of the negative margin was .35 cm (range, <.1–2 cm). Twenty-eight patients underwent a re-excision because of positive margins in the initial resection. Two patients died of metastatic phyllodes tumor. During a median follow-up of 56 months (range, 12–129 months), none of the 46 patients developed a local recurrence (local recurrence rate, 0%; 95% confidence interval, 0–8). Conclusions  Margin-negative resection combined with adjuvant radiotherapy is very effective therapy for local control of borderline and malignant phyllodes tumors. The local recurrence rate with adjuvant radiotherapy was significantly less than that observed in reported patients treated with margin-negative resection alone.     

Laser therapy for small breast cancers

BACKGROUND: Widespread mammography has resulted in the increased detection of breast cancer <1.5 cm. It may be possible to treat these small tumors with in-situ laser ablation. Prior to ablation tumor size is determined by ultrasound and mammogram. Histologic diagnosis and determination of prognostic factors are obtained from image-guided needle core samples. Invasive and in-situ tumors may be percutaneously ablated by a stereotactically guided laser needle and subsequently evaluated by imaging methods and needle biopsy. METHODS: Fifty-four patients (50 invasive, 4 in-situ); 51 mass, 3 microcalcification; mean diameter 12 (5 to 23) mm were treated by a stereotactically guided 805 nm laser beam via a fiber in a 16G needle delivered to the cancer. One to 8 weeks later the coagulated lesions were surgically removed for pathologic evaluation. In 2 additional patients, the laser-treated tumors were not removed but were monitored by mammography, ultrasonography, and needle core biopsy. RESULTS: None of the patients sustained any adverse effect. The average treatment time was 30 minutes. Pathology analysis revealed a 2.5 to 3.5 hemorrhagic ring surrounding the necrotic tumor. Under steady conditions, in two groups of 14 patients, 93% and 100% of the tumors showed complete destruction, with no residual cancer report. In the 2 unresected cases kept under surveillance for 6 to 24 months, the laser-treated tumors first showed shrinkage, followed by a 2 to 3 cm oil cyst. Fibrosis was demonstrated on needle core biopsies. CONCLUSIONS: Laser energy delivered through a stereotactically guided needle appears to ablate mammographically detected breast cancer. A multicenter clinical trail is planned.     

A Phase II Trial of Image-Guided Radiofrequency Ablation of Small Invasive Breast Carcinomas: Use of Saline-Cooled Tip Electrode

Background Local ablative therapy of breast cancer represents the next frontier in the evolution of minimally-invasive breast conservation therapy. We performed this Phase II trial to determine the efficacy and safety of Radiofrequency (RF) ablation of small invasive breast carcinomas. Methods Seventeen patients with biopsy-proven invasive breast cancer, ≤ 1.5 cm in diameter were enrolled in this trial. Under ultrasound guidance, the tumor and a 5 mm margin of surrounding breast tissue were ablated with saline-cooled RF electrode followed by surgical resection. Pathologic and immunohistochemical stains were performed to assess tumor viability. We examined whether loss of ER, PR receptor and pancytokeratin expression following RF ablation would correlate with non-viability. Results Fifteen patients completed the treatment. The mean tumor size was 1.28 cm. The mean ablation time was 21 minutes using a mean power of 35.5 watts. During ablation, the tumors became progressively echogenic that corresponded with the region of severe electrocautery injury at pathological examination. Of the 15 treated patients, NADPH viability staining was available for 14 patients and in 13 (92.8%), there was no evidence of viable malignant cells. ER, PR expression and pancytokeratin immunohistochemistry analysis were unreliable surrogates for determining non-viability. Following RF ablation, 2 patients developed skin puckering. Conclusions RF ablation is a promising minimally invasive treatment of small breast carcinomas, as it can achieve effective cell killing with a low complication rate. Further research is necessary to optimize this image-guided technique and evaluate its future role as the sole local therapy.     

Heat fixation of cancer cells ablated with high-intensity-focused ultrasound in patients with breast cancer

BACKGROUND: High-intensity-focused ultrasound (HIFU) is a noninvasive thermal ablation technique. This study reports the use of histological techniques for the pathological assessment of HIFU effects in patients with breast cancer. METHODS: Twenty-three patients with biopsy-proven breast cancer underwent HIFU treatment for primary breast lesion. Mastectomy was performed on all patients after HIFU. By using histological examinations, the surgical specimens were assessed to explore HIFU effects on breast cancer. RESULTS: Coagulation necrosis of targeted tumors was confirmed by microscopy in 23 patients. Tumor cells presented typical characteristics of coagulation necrosis in the peripheral region of the ablated tumor in all patients. However, in 11 of 23 patients, hematoxylin and eosin staining showed normal cellular structure in the central ablated tumor. By using electronic microscopy and nicotinamide adenine dinucleotide-diaphorase stain, those who had normal-appearing cancer cells were not viable. CONCLUSIONS: HIFU can cause the heat fixation of ablated tumor through thermal effect.     

Value of the Sentinel Lymph Node Procedure in Patients With Large Size Breast Cancer

Background Widely used in routine for small breast cancers, the sentinel lymph node (SN) biopsy is still discussed in tumors ≥ 3 cm. Methods From 2000 to 2005, 152 patients with invasive breast tumor pT ≥ 3 cm had a SN biopsy systematically followed by complete level I/II axillary dissection. Surgery was always the first stage of the treatment. Detection was done after injection of radioisotope followed by a lymphoscintigraphy and injection of Patent Blue. The SN procedure systematically included palpation of the axilla with removal of any enlarged (>1 cm) and/or abnormally firm node even if neither blue nor radioactive. The sentinel lymph node status was compared with the final axillary status. Results Tumor size ranged from 30 to 200 mm (median 42 mm). Lymphoscintigraphy was positive in 98% of the cases. At least one labeled sentinel node was retrieved in 97.4% of the patients. The median number of SN cleared out was 2 (range 1–9). The false negative risk was 4% (4/99). The false negative risk was not related to the tumor size and not related to the number of SN removed. Conclusions This study shows that the SN procedure is feasible in patients with breast tumors ≥ 3 cm with an acceptable false negative risk <5%, similar to false negatives reported for smaller tumors.     

Breast cancer tumor size: correlation between magnetic resonance imaging and pathology measurements

Background

As physicians increasingly use magnetic resonance imaging (MRI) for the evaluation of newly diagnosed breast cancers, a review of the correlation between MRI and pathology tumor size is imperative.

Methods

A retrospective review of 91 breast tumors comparing preoperative MRI tumor size to final pathology tumor size was performed.

Results

MRI and pathology tumor size were positively correlated (R = .650), but with an average overestimation by MRI of .63 cm (P <.0001). When stratified by MRI tumor size (≤2.0 cm and >2.0 cm), a significant difference was found only in tumors greater than 2.0 cm (average overestimation = 1.06 cm; P <.0001). This trend continued for the histological subtypes of ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma (ILC).

Conclusions

MRI tumor size correlates with pathology size; however, a significant overestimation exists, particularly for tumors >2.0 cm. Clinicians should therefore use caution in relying on MRI tumor size in determining candidacy for breast conservation therapy (BCT).     

Benefit of Ultrasonography in the Detection of Clinically and Mammographically Occult Breast Cancer

Objective  The purpose of this study was to evaluate the performance of high-resolution ultrasonography in the detection of clinically and mammographically occult breast cancer. Materials and methods  From September 2003 to November 2006, a total of 1485 patients were confirmed to have in situ or invasive breast cancer in Hong Kong Sanatorium and Hospital Breast Care Centre. All patients underwent mammography (MMG) and/ or sonography (USG) evaluation. Patients’ age and size of tumor detected by USG alone were compared with those detected by MMG. Results  Altogether, 222 patients (17%) had positive imaging findings on USG only, among which 22 (13%) patients had nonpalpable tumors. Performing USG increased the cancer detection rate among clinically and mammographically occult breast lesions by 14.3%. The mean size of the tumors detected only by USG was 1.98 cm, which was not significantly different from the mean size of tumor detected by MMG (1.46) (p = 0.23). This remains true in the group of patients with nonpalpable tumors (1.36 vs. 1.46 cm, p = 0.88). The sensitivity of USG is 91%, which is significantly higher than that of MMG (78%) (p = 0.001). This remains true in patients age <40 or ≥40, tumor grading I toIII, and LVI +/− cases. However, MMG had higher sensitivity in the group of patients with nonpalpable tumors (73% vs. 62%, p = 0.01) and noninvasive cancers (72% vs. 69%, p = 0.01). Conclusions  The use of high-resolution USG may lead to detection of a significant number of occult cancers that are no different in size from nonpalpable mammographically detected lesions.     

Percutaneous Radiofrequency Ablation for Recurrent Hepatocellular Carcinoma After Hepatectomy: Long-term Results and Prognostic Factors

Background We evaluated the long-term survival results and safety of percutaneous radiofrequency ablation (RFA) for recurrent hepatocellular carcinoma (HCC) after hepatectomy, and assessed the prognostic factors that can influence its long-term therapeutic results. Methods One hundred and two patients, who had 119 recurrent HCC in their livers, underwent ultrasound-guided percutaneous RFA. All the patients had a history of hepatic resection as a first-line treatment modality for HCC. The mean diameter of the recurrent tumors was 2.0 cm (range, 0.8–5.0 cm). We evaluated the effectiveness rates, local tumor progression rates, survival rates, and complications. We also assessed the prognostic factors of the survival rates by using Cox proportional hazard models. Results The primary effectiveness rate was 93.3% (111 of 119). The cumulative rates of local tumor progression at 1, 3, and 5 years were 6.0, 8.6, and 11.9%, respectively. The cumulative survival rates at 1, 2, 3, 4, and 5 years were 93.9, 83.7, 65.7, 56.6, and 51.6%, respectively. Patients with a lower serum α-fetoprotein (AFP) level (≤100 μg/L) before RFA or with small resected tumors (≤5 cm) demonstrated better survival results (P < .05). There was only one major complication (liver abscess, 1.0% per treatment) during the follow-up period. There were no procedure-related deaths. Conclusions Percutaneous RFA is an effective and safe treatment modality for intrahepatic recurrent HCC after hepatectomy. Serum AFP level before RFA and resected tumor size were significant prognostic predictors of long-term survival.