What about the other breast? A review of a series of bilateral breast carcinomas

The BreastScreen Queensland Brisbane Southside BreastScreen Service reports on a study of 10 cases of bilateral breast carcinomas from a total cancer population of 217 cases. All cases were patients of screening examinations that were recalled for a suspicious lesion in one breast. Two cases were mammographically suspicious of bilateral tumours. In eight cases, tumours were ultrasonically visible in both breasts and in two further cases, the suspicion of bilateral malignancy was raised by the presence of bilateral microcalcification. It is not the purpose of this paper to provide a statistical analysis of the occurrence of bilateral breast cancer. This is a radiological paper from a breast screening service reporting on findings that conventional wisdom may find unusual. The incidence of bilateral breast malignancy in the study was found to be somewhat higher than expected. These cases have been diagnosed by the utilization of a particularly high standard of ultrasound and mammography, performed and interpreted by diagnosticians possessing an elevated level of suspicion of the possible presence of a second primary lesion. It is therefore proposed that an increased rate of diagnosis of bilateral tumours is possible with an evolution of assessment protocols, combined with quality ultrasound and mammography.     

Detection of metachronous breast carcinoma: the role of follow-up?

Second primary (metachronous) breast carcinoma occurs at a rate of approximately 1% per year. Early detection of metachronous carcinomas will optimise the chances of curative treatment. The aim of this study was to identify the method of detection of metachronous carcinomas, so that efforts to detect these tumours can be made more focused. Thirteen patients presented twice to a surgical department in a 7-year period with second primary breast carcinomas. The means of detection of the second primary carcinoma was identified in each case. Eleven of the patients presented with new symptoms which they had noticed themselves. The remaining two carcinomas were detected mammographically, and their presence was confirmed on clinical examination. In no case was the second primary carcinoma detected by clinical examination alone. Metachronous carcinoma is unlikely to be detected by routine clinical examination, but rapid assessment of new symptoms should be facilitated. Follow-up mammography at regular intervals should also improve early detection of metachronous breast carcinoma.     

Can breast surgeons read mammograms of symptomatic patients in the one-stop breast clinic?

AIM: To establish how accurate surgeons were when compared to the radiologists in interpreting symptomatic mammograms in one-stop clinics. METHODS: The surgeons were asked to write their opinion on the mammograms which was compared with the radiologists' report. 144 patients were involved in the study and the data were analysed by McNemara's test for paired categorical data. RESULTS AND CONCLUSIONS: Surgeons were accurate in interpreting most of the mammographic findings. However, they underestimated the presence of benign calcification which was statistically significant. Surgeons can, therefore, be involved in double reading of mammograms in symptomatic breast disease patients and improve the sensitivity which has been the case in double reading by radiologists in the breast screening programme.     

Are the imaging features of the pleomorphic variant of invasive lobular carcinoma different from classic ILC of the breast?

The aim of this study was to evaluate whether pleomorphic invasive lobular carcinoma (PILC) is different from classic invasive lobular carcinoma (CILC) in terms of radiologic and clinicopathologic features.We compared the radiologic and clinicopathologic features of 22 surgically confirmed PILCs in 21 patients from 2004 to 2009 and 47 CILCs from 47 consecutive patients. For all cases, we reviewed the imaging findings, medical records and pathological results.PILC had a higher T stage, N stage, nuclear and histologic grade compared to CILC. PILC was more commonly negative for estrogen receptors and positive for HER2 than CILC (all p < 0.05). However, there were no significant differences in age, symptoms, tumor size, extensive intraductal component, lymphovascular invasion, triple negative profile, or multiplicity between the two groups. PILC was not detected on mammography in 1 (4.5%) of 22 cases, whereas CILC was not detected on mammography in 7 (14.9%) of 47 cases and on MRI in 2 (5.0%) of 40 (p = 0.42 and p = 1.000, respectively). MRI identified more frequent multiplicity than mammography for both PILC and CILC (p < 0.001), but was similar to US (p = 0.066). Most lesions showed a spiculated mass or architectural distortion with or without calcifications on mammography and ultrasound. No differences in mass and/or non-mass lesions or kinetics on MRI were observed between the two groups.PILC shows more pathologically aggressive features, but cannot be differentiated from CILC based on imaging findings.     

Does the addition of cement improve the rate of local recurrence after curettage of giant cell tumours in bone?

We retrospectively compared the outcome after the treatment of giant cell tumours of bone either with curettage alone or with adjuvant cementation. Between 1975 and 2008, 330?patients with a giant cell tumour were treated primarily by intralesional curettage, with 84 (25%) receiving adjuvant bone cement in the cavity. The local recurrence rate for curettage alone was 29.7% (73 of 246) compared with 14.3% (12 of 84) for curettage and cementation (p = 0.001). On multivariate analysis both the stage of disease and use of cement were independent significant factors associated with local recurrence. The use of cement was associated with a higher risk of the subsequent need for joint replacement. In patients without local recurrence, 18.1% (13 of 72) of those with cement needed a subsequent joint replacement compared to 2.3% (4 of 173) of those without cement (p?=?0.001). In patients who developed local recurrence, 75.0% (9 of 12) of those with previous cementation required a joint replacement, compared with 45.2% (33 of 73) of those without cement (p = 0.044).     

The surgical management of angiosarcoma of the breast—a single institution experience

Background

Angiosarcoma of the breast is a rare and aggressive tumour of the vascular endothelium. It may arise spontaneously or secondary to radiation. We present our experience of managing breast angiosarcoma, the largest single institution case series from the UK to date along with a summary of the relevant literature.

Methods

Data on all patients with breast angiosarcoma treated in our unit were prospectively recorded (2002–2014). Demographics, surgical details and outcomes were analysed.

Results

Eighteen female patients presented with breast angiosarcoma. Sixteen patients previously underwent adjuvant radiotherapy following surgery for breast carcinoma; the mean duration between radiotherapy and angiosarcoma development was 8.4 years (range 3–21). Resections were as follows: radical mastectomy (n?=?14), simple mastectomy (n?=?1) and wide local excision (n?=?3). Reconstruction was undertaken as follows: pedicled lattisimus dorsi (LD) musculocutaneous flap (n?=?5), pedicled LD muscle flap and split skin graft (n?=?7), free deep inferior epigastric perforator (DIEP) flap (n?=?1), pedicled vertical rectus abdominus muscle (VRAM) flap and split skin graft (n?=?1), pedicled LD muscle and pedicled VRAM muscle flaps and split skin graft (n?=?1), pedicled LD muscle and pedicled (contralateral) pectoralis major muscle flaps and split skin graft (n?=?1) and direct closure (n?=?2). Three patients developed local recurrence; mean duration from resection to recurrence was 12 months (range 9–19). Three patients developed metastasis. Seven patients (38.8 %) died; median survival from presentation was 19 months (range 2–55 months). The remaining eleven patients remain well with no disease recurrence; mean follow-up was 38 months (range 4–125). The estimated 5-year survival (Kaplan-Meier equation) in our cohort was 49 %.

Conclusions

Breast angiosarcomas are rare and challenging to manage. Successful outcomes can be achieved by early, aggressive resection and appropriate reconstruction. Level of Evidence: Level IV, therapeutic study.     

Genetic profile of primary mucinous cystadenocarcinoma of the breast—A case report

Primary mucinous cystadenocarcinoma of the breast is a rare neoplasm with few reports in the literature. Here, we report for the first time a comprehensive genetic profile of a primary mucinous cystadenocarcinoma of the breast, using next-generation sequencing 580 cancer-associated gene panel. Mutations in TP53, RB1, and BAP1 were identified. The findings suggest that this tumor is driven mostly by abnormalities in tumor suppressor genes, primarily involved in cell cycle control and chromatin remodeling. Molecular characterization of additional primary mucinous cystadenocarcinomas of the breast is warranted and might provide information related to its biology and behavior.     

New trends in breast cancer management: is the era of immediate breast reconstruction changing?

OBJECTIVE: Review of available literature on the topic of breast reconstruction and radiation is presented. Factors influencing the decision-making process in breast reconstruction are analyzed. New trends of immediate breast reconstruction are presented. SUMMARY BACKGROUND DATA: New indications for postmastectomy radiation have caused a dramatic increase in the number of radiated patients presenting for breast reconstruction. The major studies and their impact on breast cancer management practice are analyzed. Unsatisfactory results of conventional immediate reconstruction techniques followed by radiotherapy led to a new treatment algorithm for these patients. If the need for postoperative radiation therapy is known, a delayed reconstruction should be considered. When an immediate reconstruction is still desired despite the certainty of postoperative radiotherapy, reconstructive options should be based on tissue characteristics and blood supply. Autologous tissue reconstruction options should be given a priority in an order reflecting superiority of vascularity and resistance to radiation: latissimus dorsi flap, free TRAM or pedicled TRAM without any contralateral components of tissue, pedicled TRAM/midabdominal TRAM, and perforator flap. CONCLUSIONS: When the indications for postoperative radiotherapy are unknown, premastectomy sentinel node biopsy, delayed-immediate reconstruction, or delayed reconstruction is preferable.     

Columnar cell lesions of the breast: the missing link in breast cancer progression? A morphological and molecular analysis

Columnar cell lesions (CCLs) of the breast are a spectrum of lesions that have posed difficulties to pathologists for many years, prompting discussion concerning their biologic and clinical significance. We present a study of CCL in context with hyperplasia of usual type (HUT) and the more advanced lesions ductal carcinoma in situ (DCIS) and invasive ductal carcinoma. A total of 81 lesions from 18 patients were subjected to a comprehensive morphologic review based upon a modified version of Schnitt's classification system for CCL, immunophenotypic analysis (estrogen receptor [ER], progesterone receptor [PgR], Her2/neu, cytokeratin 5/6 [CK5/6], cytokeratin 14 [CK14], E-cadherin, p53) and for the first time, a whole genome molecular analysis by comparative genomic hybridization. Multiple CCLs from 3 patients were studied in particular detail, with topographic information and/or showing a morphologic spectrum of CCL within individual terminal duct lobular units. CCLs were ER and PgR positive, CK5/6 and CK14 negative, exhibit low numbers of genetic alterations and recurrent 16q loss, features that are similar to those of low grade in situ and invasive carcinoma. The molecular genetic profiles closely reflect the degree of proliferation and atypia in CCL, indicating some of these lesions represent both a morphologic and molecular continuum. In addition, overlapping chromosomal alterations between CCL and more advanced lesions within individual terminal duct lobular units suggest a commonality in molecular evolution. These data further support the hypothesis that CCLs are a nonobligate, intermediary step in the development of some forms of low grade in situ and invasive carcinoma.     

Does the use of pretreatment MRI change the management of patients with newly diagnosed breast cancer?

Breast MRI plays a critical role in the diagnosis and management of breast cancer. The purpose of this study is to evaluate the effect of preoperative breast MRI on the management of a large cohort of breast cancer patients at our institution. This study is a retrospective chart review of all newly diagnosed breast cancer patients who underwent preoperative breast MRI at our institution between January 1, 2004 and December 31, 2009. 1352 patients comprised the study population. 241 (17.8%) patients underwent a change in surgical management as a result of preoperative MRI. Patients with tumors in the lower inner quadrant and the central breast and those with pathology of invasive lobular carcinoma were significantly more likely to have their management changed by preoperative MRI. There was also a significant trend for larger tumors to be associated with a change in surgical management. No statistically significant association was found between breast density and change in management. This study supports the recommendation for the use of preoperative breast MRI in the majority of newly diagnosed breast cancer patients, especially those with larger tumors, pathology of invasive lobular carcinoma, and tumors in the lower inner quadrant. Preoperative breast MRI is a useful tool for the evaluation of additional disease that led to a change in the surgical management of 17.8% of patients.     

Can the addition of clonidine improve the analgesic efficacy of low dose intrathecal morphine? A randomised double-blind trial

OBJECTIVE: To evaluate the influence of intrathecal clonidine on spinal morphine analgesia and adverse effects after major orthopaedic surgery. METHODS: The study was approved by the local Ethics Committee.After written informed consent, 45 ASA I-III patients scheduled for hip or knee replacement were included. Patients were randomly allocated to receive either placebo, 0.1 mg morphine or 0.1 mg morphine+50 microg clonidine in addition to 15 mg bupivacaine intrathecally. The primary outcome parameter was the time to first opioid request. Statistical differences were calculated with U-test or Fisher's exact test. RESULTS: Clonidine did not result in a significant improvement of postoperative analgesia. The mean time until first opioid request was for placebo 10.3+/-7.9 h, for 0.1 mg morphine 23.0+/-3.9 h and for 0.1 mg morphine+ 50 microg clonidine 21+/-6.9 h, respectively. Clonidine significantly increased the rate of adverse effects. CONCLUSION: Our trial did not confirm an improved analgesia with the combination of intrathecal morphine and clonidine. Due to increased adverse effects the combination of intrathecal clonidine and morphine does not seem to be a reasonable alternative in the management of postoperative pain after orthopaedic surgery.     

Primary small cell neuroendocrine carcinoma of the breast – A case report and review of the literature

IntroductionPrimary small cell neuroendocrine carcinoma of the breast (SCNCB) is a very uncommon type of breast cancer. Histology and morphology are virtually indistinguishable from small cell neuroendocrine carcinomas of the lung (SCNCL), mandating a search for a primary site elsewhere in the body. There is no standard approach to treatment as there are only a limited number of cases reported in the literature. This report summarizes a case of primary SCNCB and presents a review of the literature.Presentation of caseA 65-year-old female presented to her gynecologist with a right breast mass. After biopsy, she was diagnosed with a primary SCNCB with regional lymph node involvement. She was treated with chemotherapy and radiation therapy with a good clinical response.DiscussionDue to the rare nature of this tumor, no standard treatment exits. Case reports have described breast conserving therapy combined with neoadjuvant or adjuvant chemotherapy as well as chemoradiation therapy alone for metastatic disease. Both chemotherapy regimens, those used to treat SCNCL and invasive breast cancer, have been described in these reports.ConclusionPrimary SCNCB is a very rare type of breast cancer with no standard treatment. Further research is needed to better understand the behavior of this rare tumor in order to develop a standard approach to treatment.     

Does a sector resection of the breast cure nodal mastopathy?

Results of the clinico-morphological investigation of 265 patients with localized mastopathy who were submitted to sectorial resection showed that in the margins of the operative wound there were morphological signs of mastopathy in 252 (95.1%) patients. The results obtained confirm the opinion that structural alterations of the tissues known to be the essential feature of fibroadenomatosis can not be local, they are of diffuse character. So, the sectorial resection performed for localized mastopathy can not be radical and is of no therapeutic significance. The indication to surgical intervention must be determined not so much by the necessary treatment as by the real risk of hypo-diagnosis of breast cancer. So, there is no need to fulfil the sectorial resection for localized mastopathy. It is enough to make operation of less volume (excision biopsy).     

Does immediate breast reconstruction compromise the delivery of adjuvant chemotherapy?

BackgroundImmediate breast reconstruction (IBR) provides psychological benefit to many early breast cancer patients however concerns persist regarding its potential impact on chemotherapy delivery. We investigated the association between IBR, complications and adjuvant chemotherapy delivery.MethodRetrospective analysis of patients in an academic breast service, who underwent mastectomy, with or without reconstruction, and received adjuvant chemotherapy.ResultsComparisons were made between 107 patients who received IBR and 113 who received mastectomy alone. Those receiving IBR were on average younger, with lower body mass index (BMI) and better prognoses. Overall complication rates were comparable (mastectomy alone: 45.1% versus IBR: 35.5%, p = 0.2). There was more return to surgery in the IBR group with 11.5% of tissue expanders requiring removal, whilst more seromas occurred in the mastectomy group. There was no significant difference in the median time to chemotherapy.ConclusionWe found no evidence that IBR compromised the delivery of adjuvant chemotherapy, although there was a significant incidence of implant infection.     

Should oncoplastic breast conserving surgery be used for the treatment of early stage breast cancer? Using the GRADE approach for development of clinical recommendations

IntroductionThe potential advantages of oncoplastic breast conserving surgery (BCS) have not been validated in robust studies that constitute high levels of evidence, despite oncoplastic techniques being widely adopted around the globe. There is hence the need to define the precise role of oncoplastic BCS in the treatment of early breast cancer, with consensual recommendations for clinical practice.MethodsA panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints and establish recommendations for the use of oncoplastic BCS as primary treatment of unifocal early stage breast cancers using the GRADE approach.ResultsAccording to the results of the systematic review of literature, the panelists were asked to comment on the recommendation for use of oncoplastic BCS for treatment of operable breast cancer that is suitable for breast conserving surgery, with the GRADE approach. Based on the voting outcome, the following recommendation emerged as a consensus statement: Oncoplastic breast conserving surgery should be recommended versus standard breast conserving surgery for the treatment of operable breast cancer in adult women who are suitable candidates for breast conserving surgery (with very low certainty of evidence).DiscussionThis review has revealed a low level of evidence for most of the important outcomes in oncoplastic surgery with lack of any randomized data and absence of standard tools for evaluation of clinical outcomes and especially patients’ values.Despite areas of controversy, about one-third (36%) of panel members expressed a strong recommendation in support of oncoplastic BCS. Presumably, this reflects a synthesis of views on the relative complexity of these techniques, associated complications, impact on quality of life and costs.     

Papillary lesions of the breast: To excise or observe?

Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long‐term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma (IDP) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia (ADH/ALH) and followed up for long‐term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH/ALH, surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long‐term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.