Focused Microwave Phased Array Thermotherapy for Ablation of Early-Stage Breast Cancer: Results of Thermal Dose Escalation

Background: Tumor ablation as a means of treating breast cancer is being investigated. Microwave energy is promising because it can preferentially heat high-water-content breast carcinomas, compared to adipose and glandular tissues.Methods: This is a prospective, multicenter, nonrandomized dose-escalation study of microwave treatment. Thermal dose was measured as (1) thermal equivalent minutes (cumulative equivalent minutes; CEM) of treatment relative to a temperature of 43°C and (2) peak tumor temperature. Microwaves were guided by an antenna-temperature sensor placed percutaneously into the tumor. Outcomes measured were pathologic response (tumor necrosis) side effects.Results: Twenty-five patients (mean age, 57 years) were enrolled. The mean tumor diameter was 1.8 cm. Tumoricidal temperatures (>43°C) were reached in 23 patients (92%). Tumor size was unchanged after thermotherapy (P = not significant). Pathologic necrosis was achieved in 17 (68%) patients. Complete necrosis of the invasive component was achieved in two patients. One hundred forty CEM is predictive of a 50% tumor response, and 210 CEM is predictive of a 100% tumor response (P = .003). Univariate linear regression predicts that peak tumor temperatures of 47.4°C and 49.7°C cause a 50% tumor response and a 100% tumor response, respectively.Conclusions: Thermotherapy causes tumor necrosis and can be performed safely with minimal morbidity. The degree of tumor necrosis is a function of the thermal dose. Future studies will evaluate the impact of high doses of thermotherapy on margin status and complete tumor ablation.Presented at the 2003 Society of Surgical Oncology Cancer Symposium, Los Angeles, California, March, 5–9, 2003.     

Focused Ultrasound Ablation for the Treatment of Breast Cancer

Advances in technology and changes in our understanding of tumor biology have allowed breast cancer treatment to evolve toward less disfiguring procedures. Noninvasive ablative therapy is a natural continuation of this trend. The following paper presents the concepts underpinning focused ultrasound ablation therapy for the treatment of breast cancer and reviews the investigative experience to date in the evaluation of this promising technique.     

Preoperative Systemic Treatment in BRCA-Positive Breast Cancer Patients: Case Report and Review of the Literature

BACKGROUND: In vitro and in vivo analyses have shown differences in chemosensitivity between breast cancers associated with BRCA1/2 mutations compared to sporadic variants. In the preoperative setting, the tumor response can be directly measured. Therefore, preoperative systemic treatment (PST) offers the opportunity to assess the chemosensitivity in vivo. However, there have been neither clear guidelines for mutation carriers in terms of choice of chemotherapy regimen nor recommendations how to proceed in case of an inadequate response to PST. CASE REPORT: Herein, we present the history of a 39-year-old woman with bilateral breast cancer who was tested positive for germ-line BRCA1 mutation while under PST. We performed a comprehensive literature review covering the MEDLINE database from 1992 to 2010 on published data regarding PST options for BRCA mutation carriers. CONCLUSIONS: If results of genetic testing are obtained during PST, individual therapy adaptations can be discussed with respect to mainly retrospective data of response to specific drugs. However, larger studies with longer follow-up are eagerly needed to draw firm conclusions before any specific treatment recommendations can be given for BRCA mutation carriers. PST is an ideal setting to evaluate such treatment options and to describe predictive markers that can help define subgroups that benefit most.     

A Systematic Review of Vinorelbine for the Treatment of Breast Cancer

The purpose of this study was to investigate the efficacy and safety profile of vinorelbine‐based chemotherapy in different settings for the treatment of breast cancer. We performed a computerized search using combinations of the following keywords: “breast cancer”, “breast neoplasms”, “trial”, “vinorelbine” and “navelbine”. A total of 20 trials were included in this analysis, with a total of 5,080 patients accrued. Taxane was associated with enhanced overall survival (OS; p = 0.027) and response rate (RR; p = 0.037) as compared with vinorelbine in monotherapy, but did not show significantly favored progression‐free survival (PFS; p = 0.136). Vinorelbine alone was equivalent to fluoropyrimidine treatment in RR (p = 0.79) for the treatment of metastatic breast cancer. For vinorelbine‐combined regimens, the analysis showed that the vinorelbine group gave similar results as other regimens for OS (p = 0.849) and PFS (p = 0.143). The RR of vinorelbine‐combined regimens was slightly better than that of the other regimens (OR, 1.17), but the difference was not statistically significant. In neoadjuvant setting, vinorelbine treatment was as active as AC (doxorubicin, cyclophosphamide) or DAC (doxorubicin, cyclophosphamide, docetaxel) regimens with respect to RR (p = 0.76) and pathologic complete response (pCR; p = 0.77), but showed lower occurrence of grade 3/4 adverse effects. The analysis also demonstrated that vinorelbine‐containing therapy is effective as adjuvant, front‐line or salvage therapy of metastatic breast cancer, even for patients who were previously treated with anthracyclines or taxanes.     

The Influence of Preoperative MRI on Breast Cancer Treatment

Background  

Breast magnetic resonance imaging (MRI) is increasingly used for breast cancer treatment planning. The aim of this study was to evaluate rates of mastectomy and breast-conserving surgery (BCS) in patients who undergo preoperative MRI.     

Cost Modeling of Preoperative Axillary Ultrasound and Fine-Needle Aspiration to Guide Surgery for Invasive Breast Cancer

Purpose  

Preoperative axillary lymph node ultrasound (US) and fine-needle aspiration (FNA) biopsy can identify a proportion of node-positive patients and avoid sentinel lymph node (SLN) surgery and direct surgical treatment. We compared the costs with preoperative US/FNA to without US/FNA (standard of care) for invasive breast cancer.     

Accuracy of Axillary Ultrasound in the Diagnosis of Nodal Metastasis in Invasive Breast Cancer: A Review

Axillary lymph node status is the most important prognostic factor in early-stage breast cancer. Sentinel lymph node biopsy is used to determine the need for axillary node dissection. This technique incurs cost associated with radio-isotope administration and use of the operating room. Accordingly, there is a need to preoperatively identify patients with nodal metastases who can proceed directly to axillary dissection. Axillary ultrasound has increasingly been used to determine nodal status prior to surgery. It has been shown to be a sensitive and specific modality in the detection of nodal metastases. When combined with fine-needle aspiration, the specificity of this modality significantly increases. Here we present a current review of the usefulness of preoperative axillary ultrasound in early and locally advanced breast cancer patients with and without fine-needle aspiration biopsy. Based on this review, we estimate the proportion of patients that can be spared a sentinel lymph node biopsy and the concomitant benefit of axillary ultrasound in terms of cost.     

Invasive Breast Cancer: Recognition of Molecular Subtypes

SUMMARY: Molecular profiling has fundamentally changed our understanding of breast cancer in the last 10 years, by creating a new taxonomy of breast cancers based on the expression patterns of so-called 'intrinsic genes'. Hierarchical clustering analyses performed on microarray-based gene expression profiles of breast cancers defined distinct breast cancer subgroups (luminal type A/B, HER2-enriched type, basal-like type). Since the initial landmark study by Perou et al., the concept of intrinsic breast cancer subtypes has been corroborated and expanded by several independent research groups. Further studies revealed individual properties of the intrinsic subgroups regarding the clinical course and the responsiveness to chemotherapy. The new gene expression profile-based taxonomy of breast cancer has been enthusiastically embraced by the scientific community and hailed as a major breakthrough on the way to individually tailored therapies. However, validation of the gene signatures in prospective studies is necessary before accepting these new technologies in daily clinical practice. In this review, the current data regarding the intrinsic subtypes and the associated clinical implications as well as the methodology of molecular profiling and possible use of immunohistochemistry in identifying intrinsic subtypes are discussed.     

Impact of Preoperative Breast MRI on Surgical Decision Making and Clinical Outcomes: A Systematic Review

Background

Preoperative magnetic resonance imaging (MRI) is increasingly used in the workup of breast cancer patients and could lead to changes in surgical management. It is unclear how the information gained from MRI studies affects surgical decision making and influences clinical outcomes. These issues are addressed in this review.

Methods

PubMed database searches were performed to retrieve and analyze respective original research and review articles on preoperative MRI in the evaluation of breast cancer patients.

Results

Preoperative MRI is a highly sensitive but nonspecific method that leads to changes in surgical management with increased numbers of more extended surgical interventions. It appears that a relatively large proportion of MRI-driven changes in surgical management result in overtreatment without conclusively proven beneficial effects on such clinical outcomes as decrease in reoperation rates or improved patient survival.

Conclusions

Thus, routine use of supplementary preoperative breast MRI should be discouraged until compelling evidence of its effectiveness is available.     

乳癌手术患者术前访视方法的改进

目的 提高术前访视效果.方法 将112例行手术治疗的乳癌患者随机分为观察组(58例)和对照组(54例),对照组行常规访视,观察组由手术室巡回护士及病区管床护士共同进行术前访视和心理支持,并于术后回访.结果 术后1 d观察组焦虑评分显著低于对照组(P＜0.01);术后3 d观察组心理状态评分及患者满意度显著优于对照组(均P＜0.01).结论 改进后的访视方法能有效降低乳癌患者心理应激水平及焦虑水平,提高手术室护理满意度.     

回压静脉法在静脉穿刺困难患者中的应用

目的：提高术前访视效果。方法：将112例行手术治疗的乳癌患者随机分为观察组（58例）和对照组（54例），对照组行常规访视，观察组由手术室巡回护士及病区管床护士共同进行术前访视和心理支持，并于术后回访。结果：术后1d观察组焦虑评分显著低于对照组（P＜0．01）；术后3d观察组心理状态评分及患者满意度显著优于对照组（均P＜0．01）。结论：改进后的访视方法能有效降低乳癌患者心理应激水平及焦虑水平，提高手术室护理满意度。     

ASO Author Reflections: Impact of Preoperative MRI on Patients With Screen-Detected Invasive Breast Cancer Undergoing Breast-Conserving Surgery

Annals of Surgical Oncology -     

Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer

Purpose To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins. Materials and Methods Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45), grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative). Results Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus 61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional biopsy (79 and 78%, respectively). Conclusions Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation. Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of negative margins at initial excision.     

Clinical Evidence for Treatment of Distal Tibiofibular Syndesmosis Injury: A Systematic Review of Clinical Studies

No consensus had been reached about the optimal treatment for syndesmotic fixation. We performed a review of randomized controlled trials (RCTs) to assist in clarifying many of the controversies that were debated for years despite new technology and options. PubMed, Embase, and the Cochrane Library were searched through specific terms and limits. Only RCTs were selected for final inclusion. Study screening and data extraction were performed independently by 2 reviewers. Thirteen RCTs, including 828 cases, met the inclusion criteria and are summarized in this review. Pooled results demonstrated that dynamic fixation had better functional outcomes as well as lower rates of malreduction and complications compared with syndesmotic screw fixation. Both absorbable screw and tricortical screw fixation showed similar results to quadricortical metallic screws. Therefore, dynamic fixation is recommended for the treatment of syndesmosis injuries.     

Transurethral Microwave Thermotherapy for Management of Benign Prostatic Hyperplasia: A Single-Institution Experience

Objectives. This is the first and largest single institution retrospective study in the United States to examine the effects of transurethral microwave thermotherapy (TUMT) for the treatment of benign prostatic hyperplasia (BPH).Methods. From September 1996 to June 1997, 78 men with moderate to severe symptomatic BPH were treated with the Prostatron at our institution. Patient age ranged from 52 to 85 years. Prostate volume ranged from 23 to 110 cc, and mean total energy applied during the treatment was 156.17 kJ. Patients were re-evaluated at 3 months and were asked to answer a questionnaire regarding their opinion about the treatment.Results. At 3 months there was a significant decrease in mean symptom score from 19.6 to 11.2 (P <0.0001). Mean peak flow rate increased from 8.5 to 12.8 mL/s (P <0.0001). Mean postvoid residual urine decreased from 56.8 to 22.0 mL (P <0.0001). We did not observe any severe complications. Unlike prior studies, we removed the Foley catheter, and patients performed clean intermittent catheterization (CIC) when necessary. There was no significant differences in subjective and objective parameters between these patients and those who did not need CIC. Patient opinion about the treatment was not affected by CIC. About two thirds (67.2%) of the patients in the study group were satisfied with the results of treatment, and 60.3% would undergo the same procedure again.Conclusions. TUMT of the prostate is an effective, safe, and acceptable form of treatment for patients with BPH. Longer follow-up is needed to examine the durability of TUMT treatment.     

Preoperative MRI of the Breast (POMB) Influences Primary Treatment in Breast Cancer: A Prospective,Randomized, Multicenter Study

Background

Breast magnetic resonance imaging (MRI) has shown high sensitivity in determining tumor extent, multifocality, and occult contralateral breast cancer. Low specificity, unnecessary mastectomies, and costs are arguments against MRI. The purpose of this study was to determine whether preoperative breast MRI would affect primary surgical management, reduce reexcision/reoperation procedures, and influence the choice of neoadjuvant treatment in patients with newly diagnosed breast cancer.

Methods

This prospective, randomized, multicenter study included 440 breast cancer patients younger than aged 56 years from three, Swedish, large-volume breast units. Patients were randomly allocated on a 1:1 basis to either preoperative staging with breast MRI (n = 220) or no breast MRI (n = 220) (control group). Treatment planning of all patients was discussed at multidisciplinary team conferences.

Results

In patients randomized to the MRI group, who had an observed higher percentage of planned breast-conserving surgery (BCS) compared with the control group, a change from suggested breast conservation to mastectomy occurred in 23 of 153 (15 %) patients. Breast MRI provided additional information in 83 of 220 (38 %) patients, which caused a change in treatment plan in 40 (18 %). The breast reoperation rate was significantly lower in the MRI group: 11 of 220 (5 %) versus 33 of 220 (15 %) in the control group (p < 0.001). The number of mastectomies, axillary reoperations, and the number of patients receiving neoadjuvant chemotherapy after definitive treatment did not differ significantly between the groups.

Conclusions

Preoperative staging with breast MRI in women younger than age 56 years altered the treatment plan in 18 % of the patients. Although a higher MRI-related conversion rate from breast conservation to mastectomy was found, the final numbers of mastectomies did not differ between the two groups. The breast reoperation rate in the MRI group was significantly reduced.