Lobular histology and response to neoadjuvant chemotherapy in invasive breast cancer

Invasive lobular carcinoma (ILC) has been reported to be less responsive to neoadjuvant chemotherapy (NAC) than invasive ductal carcinoma (IDC). We sought to determine whether ILC histology indeed predicts poor response to NAC by analyzing tumor characteristics such as protein expression, gene expression, and imaging features, and by comparing NAC response rates to those seen in IDC after adjustment for these factors. We combined datasets from two large prospective NAC trials, including in total 676 patients, of which 75 were of lobular histology. Eligible patients had tumors ??3?cm in diameter or pathologic documentation of positive nodes, and underwent serial biopsies, expression microarray analysis, and MRI imaging. We compared pathologic complete response (pCR) rates and breast conservation surgery (BCS) rates between ILC and IDC, adjusted for clinicopathologic factors. On univariate analysis, ILCs were significantly less likely to have a pCR after NAC than IDCs (11 vs. 25?%, p?=?0.01). However, the known differences in tumor characteristics between the two histologic types, including hormone receptor (HR) status, HER2 status, histological grade, and p53 expression, accounted for this difference with the lowest pCR rates among HR+/HER2? tumors in both ILC and IDC (7 and 5?%, respectively). ILC which were HR? and/or HER2+ had a pCR rate of 25?%. Expression subtyping, particularly the NKI 70-gene signature, was correlated with pCR, although the small numbers of ILC in each group precluded significant associations. BCS rate did not differ between IDC and ILC after adjusting for molecular characteristics. We conclude that ILC represents a heterogeneous group of tumors which are less responsive to NAC than IDC. However, this difference is explained by differences in molecular characteristics, particularly HR and HER2, and independent of lobular histology.     

The Role of MRI in Invasive Lobular Carcinoma

PURPOSE: To determine the value of MR imaging in the detection and measurement of tumor size in patients with invasive lobular carcinoma (ILC) compared to mammography and ultrasound. MATERIALS AND METHODS: From 36 cases of ILC in 34 patients who were surgically treated, the pre-operative imaging measurements, being mammography, ultrasound and contrast enhanced MR, were retrospectively re-evaluated for tumor detection and size. Findings were compared with pathology. Two radiologists were used for evaluation of the mammograms, the other imaging modalities were only evaluated by one radiologist. The Pearsons correlation test was used to determine the correlation between histopathological and imaging measurements for each imaging modality. RESULTS: For mammography, ultrasound and MRI the false negative scores were respectively 14%, 3% and 0%. The percentage for underestimated, correctly estimated and overestimated measurements on imaging were 56%, 33% and 11% for radiologist 1 and 50%, 33% and 17% for radiologist 2 on mammography. For ultrasound and MRI these percentages were respectively 53%, 47%, 0% and 14%, 75%, 11%. The correlation coefficients for mammography were respectively r = 0.34 (p < 0.05) and r = 0.27 (p > 0.05) for both radiologists, for Ultrasound r = 0.24 (p > 0.05) and for MRI r = 0.81 (p < 0.01). CONCLUSION: Of the three imaging modalities contrast enhanced MR has the lowest false negative rate in detecting ILC and has the highest accuracy in measuring the size of the ILC. MR could play a key role in the pre-operative work-up for accurate tumor size determination.     

Preoperative MRI for Evaluation of Extent of Disease in IDC Compared to ILC

ObjectivesThe purpose of this study was to assess the incremental value of preoperative breast MRI over mammography and US in depicting the accurate extent of disease in invasive duct carcinoma (IDC) compared to invasive lobular carcinoma (ILC).Patients and MethodsRetrospective analysis of pre-operative mammography, US and MRI was performed in 239 patients with either IDC (n = 193) or ILC (n = 46). Images were evaluated for solitary, multifocal or multi centric disease and compared for concordance with postsurgical pathology. Discordance was documented as either overestimation or underestimation. Two tailed paired T and Fischer's exact tests were used for analysis.ResultsMultifocality was present on pathology in 35% and 61% of patients with IDC and ILC (P < .05) and multicentricity in 23% and 41% respectively (P = .84). In ILC, MRI demonstrated better concordance with pathology compared to mammography and US (89%, 44%, 49% for multifocality [P < .05] and 80.5%, 63%, 71% for multicentricity [P = .3]). For IDC, concordance with pathology for all modalities was similar (65%-76%). Among discordant cases, underestimation was significantly more common for mammography and US, while MRI more frequently overestimated disease extent. MRI very rarely overestimated multifocal disease in ILC (2%).ConclusionMRI demonstrates an 80% to 90% concordance rate with pathology for ILC, superior to mammography and US. The addition of MRI in IDC patients may decrease underestimation of disease extent and potentially contribute to a reduction in post-operative residual disease.     

Accuracy of contrast-enhanced computed tomography in the prediction of residual breast cancer after neoadjuvant chemotherapy

Determination of the extent of residual disease after neoadjuvant chemotherapy is sometimes inaccurate by conventional diagnostic methods. The purpose of this study was to evaluate the accuracy of contrast-enhanced computed tomography (CE-CT) in depicting the extent of residual carcinomas. Fifty-seven patients with breast carcinomas of 3 cm diameter or more received neoadjuvant chemotherapy with four cycles of AT (doxorubicin and docetaxel). Before surgery, the patients underwent clinical examination, mammogram (MMG), ultrasonography (US), and CE-CT. Thirteen patients were not evaluated by CE-CT before surgery. Enhancement patterns on CE-CT were classified into multiple spots, tumor and spots, solid tumor type, and no enhancement. When all types of cancers were included in the analysis, clinical examination showed the best correlation with the pathology of the extent of residual carcinomas. However, except in invasive lobular carcinoma (ILC) and inflammatory breast carcinoma (IBC), CE-CT showed the best correlation (R insertion mark2 = 0.537). More than half of the residual microcalcifications on MMG after neoadjuvant chemotherapy suggested residual viable tumor. In conclusion, CE-CT is the most accurate noninvasive technique for identifying the extent of the residual carcinoma after neoadjuvant chemotherapy if cases of IBC and ILC are excluded.     

超声及钼靶对乳腺癌新辅助化疗后腋窝淋巴结状态的诊断价值评估

目的:评估乳腺癌新辅助化疗(neoadjuvant chemotherapy,NAC)后腋窝淋巴结的变化,探讨超声及钼靶在NAC疗效评价中的应用价值。方法:对我院176例经穿刺病理证实为腋窝淋巴结转移的乳腺癌患者行NAC,所有患者NAC前后均行彩超与钼靶检查,对比两种检查的灵敏度、特异度及准确率。评价NAC后腋窝淋巴结的状态,并评估临床缓解与病理完全缓解（pathological complete response,pCR）的相关性。结果:NAC后超声、钼靶及两者联合评估的灵敏度分别为:79.4%、76.6%、86.5%;特异度分别为:68.6%、51.4%、71.4%;准确率分别为:77.3%、71.6%、83.5%;较NAC前超声、钼靶及两者联合评估的灵敏度、特异度及准确率明显下降,阳性预测价值最高的为两者联合检查（92.4%）。NAC后超声图像评估44例达到临床完全缓解,其中25（25/44,56.8%）例患者经病理证实达到pCR,NAC后超声检查评估pCR的灵敏度为71.4%,特异度为86.5%,准确率为83.5%。结论:超声诊断NAC后腋窝淋巴结转移较钼靶诊断灵敏度、特异度及准确率高,具有重要的临床诊断价值,但尚存局限性,对手术及术后治疗的指导性仍需进一步研究。     

A new method to optimize resection area using a radiation treatment planning system and deformable image registration for breast-conserving surgery after neoadjuvant chemotherapy

BackgroundWe devised a breast-conserving surgery (BCS) utilizing a new image-processing and projection technique using a radiation treatment planning system (RTPS) and deformable image registration (DIR) for patients with breast cancer after neoadjuvant chemotherapy (NAC). RTPSs and DIR are commonly used in planning radiation treatment. The purpose of this pilot study was to evaluate the feasibility of our procedure.Patients and methodsTwenty-six patients diagnosed with breast cancer underwent NAC and BCS between November 2014 and May 2020. Multidetector-row computed tomography was performed in the same position used for surgery before and after NAC. In the DIR, CT before NAC was fused to CT after NAC. The RTPS simulated the design of tumor excision, and excision area was projected onto the breast skin utilizing an irradiation device.ResultsIn 26 patients with breast cancer after NAC, BCS was performed using the processing and projection technique of the RTPS with DIR. Only 1 of 26 patients showed carcinoma present in the surgical margins, and subsequently developed ipsilateral breast tumor recurrence. Mean excised volume was 33.5 cm³ (range, 12.8–62.8 cm³), and percent breast volume excised was 6.8% (range, 2.5–15.7%).ConclusionsThis pilot study confirmed the simplicity and utility of our procedure for minimally invasive BCS in patients with breast cancer after NAC. We will keep evaluating the safety and efficacy of our procedure in more patients.     

Synchronous lobular carcinoma in situ and invasive lobular cancer: Marker or precursor for invasive lobular carcinoma

Aim

Lobular carcinoma in situ (LCIS) is a known risk factor for invasive breast carcinoma, but there is increasing data indicating a possible precursor relationship. This study investigates the incidence of lobular carcinoma in situ that occurs with invasive lobular carcinoma (ILC).

Methods

Women diagnosed with ILC or LCIS from 2000 to 2010 were retrospectively identified and reviewed after institutional review board approval. This group was divided into two cohorts: ILC alone, and LCIS and ILC (ILC/LCIS). Patient demographics, disease characteristics, and treatment modalities were captured. p < 0.05 is considered significant.

Results

A total of 148 patients with ILC or LCIS were identified. Forty-four (54%) patients with only ILC, and 37 (46%) patients with ILC/LCIS were identified. Median age at diagnosis was 62 for ILC and 64 years for ILC/LCIS (p = 0.8). In patients with ILC, total mastectomy was the predominant treatment modality in 28 of 44 (64%) patients, while 18 of 37 (49%) patients with ILC/LCIS underwent breast conservation therapy (p = 0.3). Median largest tumor diameter was 35 mm (range 1–110) for ILC, and 15 mm (range 5–85) for ILC/LCIS (p = 0.03). Nodal status was positive in 17 of 39 (44%) ILC and 13 of 34 (38%) ILC/LCIS (p = 0.6).

Conclusions

The 46% incidence of LCIS associated with ILC in our cohort study is similar to that reported for ductal carcinoma in situ identified with invasive ductal carcinoma at ∼40%. The association of pre-invasive and invasive lobular lesions should be further studied in a large scale prospective study to assess for a precursor relationship.     

Diagnosis of breast cancer: MDCT versus MRI

In Japan, helical CT has been applied to breast cancers for the accurate determination of cancer extent before surgery. In recent years, multidetector CT (MDCT) has become commercially available. Compared with mammography and ultrasonography, MDCT of the breast is thought to be useful for preoperative assessment of breast-conserving surgery. In contrast, magnetic resonance imaging (MRI) is extremely accurate in the diagnosis of intraductal carcinoma and multicentricity of breast cancer. A real problem related to the use of CT is X-ray exposure. Therefore, it is controversial whether the use of CT for the patients with breast cancer is appropriate or not. Recent studies that compared the use of MDCT and MRI in the same patients concluded that MRI was more accurate for the detection and evaluation of the extent of intraductal carcinoma. We should consider the pitfalls and limitations of CT for assessing the breast cancer extent.     

Imaging and Clinicopathologic Features Associated With Pathologic Complete Response in HER2-positive Breast Cancer Receiving Neoadjuvant Chemotherapy With Dual HER2 Blockade

BackgroundIn human epidermal growth factor receptor 2-positive (HER2⁺) breast cancer, the incorporation of a dual HER2 blockade into neoadjuvant chemotherapy (NAC) has been shown to induce a higher rate of pathologic complete response (pCR). The purpose of this study was to investigate whether pretreatment imaging and clinicopathologic features show any association with pCR in HER2⁺ breast cancer receiving NAC plus dual blockade.Materials and MethodsThis retrospective study evaluated 94 consecutive patients (mean age, 49.8 ± 9.9 years) with HER2⁺ breast cancer who underwent NAC plus dual blockade with trastuzumab and pertuzumab between April 2016 and June 2018. All patients underwent mammography, ultrasound, and magnetic resonance imaging prior to NAC. Clinicopathologic and imaging features acquired before NAC were evaluated for their ability to predict the pathologic response after surgery. Multivariate analysis was used to identify independent predictors of pCR.ResultsFifty patients (53.2%) showed pCR and 44 (46.8%) did not. According to a univariate analysis, fine pleomorphic/fine linear or linear-branching calcification morphology on mammography, parallel orientation on ultrasound, intratumoral high signal intensity on T2-weighted magnetic resonance imaging, progesterone receptor negativity, and high levels of tumor-infiltrating lymphocytes were associated with pCR. On multivariate analysis, fine pleomorphic/fine linear or linear-branching calcification morphology on mammography (odds ratio [OR], 7.23), progesterone receptor negativity (OR, 6.76), and a high tumor-infiltrating lymphocyte level (OR, 5.92) remained significant independent factors associated with pCR.ConclusionSeveral pretreatment imaging and clinicopathologic features were shown to be independent variables predicting pCR in patients with HER2⁺ breast cancer receiving NAC with dual blockade.     

Value Added of Preoperative Contrast-Enhanced Digital Mammography in Patients With Invasive Lobular Carcinoma of the Breast

Background

Invasive lobular carcinoma (ILC) is the second most frequently diagnosed breast cancer, accounting for 5% to 15% of all invasive breast cancers, yet it remains radiologically elusive in many cases. The goal of this study was to compare the ability to accurately assess disease extent with contrast-enhanced digital mammography (CEDM) and full-field digital mammography (FFDM) in patients with biopsy-proven ILC.

The impact of preoperative breast MRI on the re-excision rate in invasive lobular carcinoma of the breast

Re-excision rates after breast conserving surgery (BCS) of invasive lobular carcinoma (ILC) are high. Preoperative breast MRI has the potential to reduce re-excision rates, but may lead to an increased rate of mastectomies. Hence, we assessed the influence of preoperative breast MRI on the re-excision rate and the rate of mastectomies. We performed a retrospective cohort study of a consecutive series of patients with ILC who presented in one of two dedicated tertiary cancer centers between 1993 and 2005. We assessed the initial type of surgery (BCS or mastectomy), the re-excision rate and the final type of surgery. Patients were stratified into two groups: those who received preoperative MRI (MR+ group) and those who did not (MR− group). In the MR− group, 27% of the patients underwent a re-excision after initial BCS. In the MR+ group, this rate was significantly lower at 9%. The odds ratio was 3.64 (95% CI: 1.30–10.20, P = 0.010). There was a trend towards a lower final mastectomy rate in the MR+ group compared to the MR− group (48 vs. 59%, P = 0.098). In conclusion, preoperative MRI in patients with ILC can reduce re-excision rates without increasing the rate of mastectomies.     

Lobular breast cancer series: imaging

The limitations of mammography in the detection and evaluation of invasive lobular carcinoma (ILC) have long been recognized, presenting real clinical challenges in treatment planning for these tumors. However, advances in mammography, ultrasound, and magnetic resonance imaging present opportunities to improve the diagnosis and preoperative assessment of ILC. The evidence supporting the performance of each imaging modality will be reviewed, specifically as it relates to the pathology of ILC and its subtypes. Further, we will discuss emerging technologies that may be employed to enhance the detection rate and ultimately result in more effective screening and staging of ILC.     

乳腺癌新辅助化疗疗效评价方法的比较

目的 比较查体、超声和钼靶在乳腺癌新辅助化疗(NAC)疗效评价中的差异.方法 通过查体、超声和钼靶分别测量、记录141例NAC患者肿瘤状况,分析治疗前后原发灶、淋巴结的变化.结果 全组中晚期患者居多,Ⅰ期仅占8.5%.化疗前查体的乳腺肿块较超声检查明显偏大(P＜0.01).评价疗效时,原发灶查体误判完全缓解(CR)率高达46.8%(22/47),而超声误判残留率为84.0%(21/25).43例行钼靶检查患者中,有23例(53.5%)患者困难以测量肿块大小而无法评价疗效;5例有钙化的患者,虽化疗后肿块缩小,但钙化范围无变化.在治疗中,25例有效患者行原发灶空芯针穿刺,在9例穿刺病理阴性者中,仅有3例达pCR;16例穿刺阳性者均未达pCR.超声检查怀疑腋窝淋巴结转移的患者,通过空芯针穿刺的病理阳性率为88.3%(53/60),超声检查不怀疑者仍有20.0%(1/5)为阳性.24例超声未探及腋窝肿大淋巴结患者中,有9例(37.5%)前哨淋巴结活检阳性.化疗前淋巴结病理阳性患者64例,化疗后转阴36例(56.3%).全组原发灶及淋巴结均达病理完全缓解(pCR)者21例,占14.9%(21/141).结论 乳腺癌患者化疗前对腋窝淋巴结进行空芯针穿刺或前哨淋巴结活检明确病理状态非常重要,查体、超声及铜靶检查对原发灶肿瘤大小的判断都有相当的误差,可采用病灶穿刺来评价NAC的疗效,但对结果 的判断还需综合分析.     

A retrospective study comparing the individual modalities of triple assessment in the pre-operative diagnosis of invasive lobular breast carcinoma.

AIMS: Early invasive lobular breast carcinoma (ILC) is associated with few symptoms and signs. The individual sensitivity of clinical examination, mammography, ultrasonography, cytology and core biopsy have each been reported to be of limited value. The aim of this study was to evaluate the accuracy of triple assessment in the pre-operative detection of patients identified to have ILC from their surgical pathology. METHODS: Pure ILC was defined as tumours containing at least 90% lobular features. The triple assessment of 273 patients diagnosed primarily at our institution were reviewed. RESULTS: 87.5% of women were symptomatic and 12.5% were screen detected. The mean patient age was 59 (range 30-81) years and the median tumour size was 26 (range 5-110) mm. The main mammographic abnormalities were a spiculated lesion (33.3%), an ill-defined mass (33.3%) or architectural distortion (23.5%). The sensitivities for detecting ILC of each modality were: clinical examination (76.6%), mammography (79.8%), ultrasound examination (93.9%), fine-needle aspiration cytology (FNAC) (60.5%) and core biopsy (90.8%). Combining the three modalities of clinical examination, imaging and cyto/pathology increased the pre-operative detection rate of ILC. CONCLUSION: Triple assessment is useful in the diagnosis of ILC. As the features of ILC may be subtle, a high index of suspicion is required to facilitate early diagnosis.     

Effectiveness of multi-detector row computed tomography in detection of the presence and extent of ductal carcinoma in situ

Background

As ductal carcinoma in situ (DCIS) lesions can spread widely in the ductal-lobular segment, often without palpable tumor, complete resection of the lesion in breast-conserving surgery requires establishment of the precise location and extent of the lesion during preoperative imaging studies. We investigated the potential of multi-detector row computed tomography (MDCT) in detecting and delineating DCIS lesions.

Methods

Overall, 74 patients with 75 DCIS lesions underwent breast MDCT. The size of the DCIS lesion in each patient was measured in the volume rendering images and compared to the size obtained by pathological mapping. The differences between the actual tumor size and that obtained from MDCT (L-Path and L-CT) were calculated, and the relationships between these differences and tumor characteristics were investigated.

Results

DCIS was detected fully or partially in 64 (84.9 %) of 75 lesions, whereas the detection rate of magnetic resonance imaging (MRI) was 90 %. The detection rate was not influenced by comedo/non-comedo status, but the detection rate of higher nuclear grade DCIS lesions tended to be higher than that of low grade lesions (p = 0.089), while the estimated size was also more accurate in the former (p = 0.046). Hormone receptor and Her2 status did not affect MDCT findings.

Conclusion

MDCT is highly effective for detecting DCIS, especially the more aggressive types of DCIS. Moreover, the patient’s position during MDCT imaging is more similar to that during surgery than that during MRI, making MDCT a highly useful presurgical imaging technique for the assessment of DCIS.     

Enhancement of the nipple-areolar-complex on contrast-enhanced MR imaging of the breast

Objective  To evaluate patterns of enhancement in the nipple-areolarcomplex (NAC) on contrast-enhanced MRI. Methods  We reviewed the MR images of 37 patients in which enhancement of the NAC was demonstrated on gadolinium-enhanced dynamic fast radiofrequency spoiled gradient recalled echo (fast-SPGR) images. Time intensity profiles derived from signal intensity values were constructed, and findings correlated with histological results. Results  Three types of curve were observed. In the first type seen in adenoma of the nipple, rapid initial increase in signal intensity with an early peak (1 min) occurred followed by gradual washout. In the second type seen in direct invasion from carcinoma, subareolar intracystic papilloma, or Paget’s disease, rapid initial increase in signal intensity followed by a more gradual increase or plateau was seen. In the third type seen in carcinoma without nipple invasion, fibrocystic disease and fibroadenoma, a gradual increase in signal intensity was observed throughout the examination period. Conclusion  Early and prominent enhancement of the NAC on contrast-enhanced MRI may indicate the presence of a primary lesion in the NAC or secondary involvement by a primary tumor elsewhere in the breast.     

动态增强MRI监测乳腺癌新辅助化疗疗效的应用价值

目的 探讨动态增强MRI监测乳腺癌新辅助化疗疗效及评估化疗后残留病灶的价值.方法 对43例患者的44个浸润性导管癌病灶行术前新辅助化疗,分别于化疗前、1个疗程化疗后和化疗结束时行动态增强MRI扫描,比较化疗有效与无效患者的肿瘤组织形态学变化、肿瘤体积变化和血流动力学变化特点.以手术病理为对照,评价术前MRI判断病灶残留情况的效果.结果 44个乳腺癌病灶中,治疗有效36个病灶,无效8个病灶.治疗有效组经1个疗程化疗后,肿瘤体积缩小不明显,化疗结束后肿瘤体积较治疗前明显缩小(P<0.01),缩小中位数为18.5 cm3.治疗有效组病灶呈向心型缩小29个,树枝型缩小7个.新辅助化疗前,有效组与无效组的早期强化率(E1)、峰值强化率(Emax)和达峰时间(Tmax)差异均有统计学意义(均P<0.05).化疗1个疗程后,有效组的E1和Emax降低,而Tmax升高,与化疗前比较,差异均有统计学意义(均P<0.01);而无效组的E1、Emax和Tmax未发生明显变化.新辅助化疗前,有效组的时间信号强度曲线以廓清型、平台型为主(占86.1%);化疗后,强化峰值明显下降,时间-信号强度曲线转为以持续强化型为主;化疗结束时,持续强化型占63.9%.无效组的时间-信号强度曲线化疗前后变化不大.新辅助化疗后动态增强MRI监测乳腺癌残留病灶与手术病理结果高度相关(r=0.866,P<0.01).结论 动态增强MRI可在乳腺癌新辅助化疗疗程中监测瘤体变化,评价、预测新辅助化疗疗效,并可用于术前评估化疗后病灶的残留情况.     

Nipple-sparing mastectomy in association with intra operative radiotherapy (ELIOT): a new type of mastectomy for breast cancer treatment

Summary Background Breast-conserving surgery has become the standard approach for about 80% of patients treated for primary breast cancer in most centres. However, mastectomy is still required in case of multicentric and/or large tumours or where recurrences occur after conservative treatment. When a total mastectomy is performed, the removal of the nipple areola complex (NAC) is a strongly debated issue. In fact, although removal of the NAC greatly increases the patient’s sensation of mutilation, and the risk of tumor involvement of the areola is reported as a very variable percentage, NAC excision still remains the standard treatment. Patients and methods From March 2002 to September 2003, 106 nipple sparing mastectomies (NSM) were peformed in 102 patients, 63% of whom had invasive carcinoma and 37% of whom had in situ carcinoma. Four patients underwent bilateral surgery. In all cases, a large or multicentric tumour and/or diffuse microcalcifications, clinically distant from the NAC, were present. During surgery, the tissue under the areola was routinely sampled to exclude the presence of tumor. If disease-free at the frozen sections, the NAC was spared and a NSM was performed. Additionally, a total dose of 16 Gy of radiotherapy (ELIOT) was delivered intraoperatively in the region of the NAC. All the patients underwent an immediate plastic breast reconstruction. Results In eleven patients (10.4%), the breast tissue under the areola resulted infiltrated at the definitive histological examination: in 10 cases a single or multiple foci of in situ carcinoma and in one case an invasive component were present. Eleven patients (10.4%) developed a superficial skin areolar slough followed by spontaneous healing, and 5 patients (4.7%) lost their NAC due to total necrosis. Among these, one patient had a poor cosmetic result on the NAC with asymmetrical location and required further surgical removal and reconstruction with tattoo and local flap in a better position. When rating the results from 0 (bad) to 10 (excellent), on average, the colour of the areola was rated 9/10, the sensitivity of nipple 3/10, the overall aesthetic result was rated 8/10 by both the surgeon and the patients. Early radiodystrophy (pigmentation) was observed in eight cases (7.5%). After an average follow up of 13 months, one local recurrence, located under the clavicula, far from the NAC, was observed. The preliminary results of the psychological study show a very high satisfaction with the preservation of the nipple (97.6 %), with younger women expressing a higher satisfaction than older counterparts. Conclusions In selected cases, NSM with ELIOT of NAC has so far permitted good local control of the disease and satisfactory cosmetic results. Wider surgical experience is required to minimise the risk of leaving tumor cells in the region of the spared NAC and a longer follow up is necessary to evaluate the long term tumor recurrence rate at the NAC.     

Resection margin status in lumpectomy specimens of infiltrating lobular carcinoma

Aims.To study the status of resection margins in specimens from patients with infiltrating lobular carcinoma (ILC) treated with lumpectomy. Materials and methods.Sixty-six consecutive cases of ILC were compared with the same number of consecutive cases of infiltrating ductal carcinoma (IDC). All cases were treated with lumpectomy. Results.ILCs were divided into 42 cases of typical ILC, 15 variants of ILC (alveolar or solid types) and 9 cases of mixed ILC and IDC. These groups were associated with positive or close resection margins in 22 (52%), 5 (33%) and 3 (33%) cases, respectively. For the group of IDC with partial mastectomies, matched for patient's age and tumor size, positive or close resection margins were observed in 26%. ILCs, measuring less than 2 cm in greatest diameter and having low nuclear grade, had rates of positive or close margins comparable with those of IDC. Typical ILCs, measuring more than 2 cm in diameter, had rates of positive or close margins of 70%. All cases with a positive extensive intraductal component had positive margins. Furthermore, in all types of ILC, tumors with a high nuclear grade tended to be associated with a high rate of positive margins. Conclusions.The status of resection margins in lumpectomy specimens for infiltrating lobular carcinoma is related to the extensive intraductal component status, tumor size and grade, and the presence of variants of ILC or mixed ILC and IDC. Most of these factors can be determined preoperatively by mammography and histopathological evaluation of breast core biopsies, therefore, aiding in planning the surgical strategy of mastectomy.     

Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older

BACKGROUND: Reduction in breast carcinoma mortality is a major benefit of screening mammography and has been demonstrated in multiple randomized clinical trials and service screening programs. Another benefit from screening is that it allows the patient a wider choice of treatment options, particularly the possibility of conservation surgery. The current study analyzed the impact of mammography in the staging and treatment of breast carcinoma. METHODS: A total of 1591 women aged > or = 40 years were treated for breast carcinoma between July 1995 and October 2001. Three subgroups were defined and compared. Group 1 had 192 patients with no previous mammography, Group 2 was comprised of 695 patients who underwent mammography on average less often than once yearly, and Group 3 was comprised of 704 patients who on average underwent mammography once yearly or more often. RESULTS: The difference in tumor stage was found to be statistically significant between the groups (P < 0.0001). In Group 1, 15% of the patients had ductal carcinoma in situ (DCIS) compared with 21% of patients in Group 2 and 26% of patients in Group 3. In addition, 32% of patients in Group 1 had T1 tumors, whereas 50% of patients in Group 2 and 56% of patients in Group 3 had T1 tumors. The tumor size was < or = 1 cm in 8% of the patients in Group 1 compared with 20-23% of patients in Groups 2 and 3 (P = 0.0092). Breast conservation was an option for 41% of the patients in Group 1 but mastectomy was recommended in another 41% of patients. However, in Groups 2 and 3, 61% of patients were offered breast conservation and mastectomy was recommended to 28% (P < 0.0001). CONCLUSIONS: In the current study, women age > or = 40 years with breast carcinoma who underwent mammography at least once yearly were diagnosed with DCIS more often compared with patients who underwent mammography less frequently or those who had no prior mammography. Women who underwent mammographic screening were found to have smaller tumors, which resulted in a majority of these patients being able to consider breast conservation as an alternative to mastectomy.