False Negative Rate of Sentinel Lymph Node Biopsy in Multicentric and Multifocal Breast Cancers May be Higher in Cases with Large Additive Tumor Burden

Abstract:  We aimed to evaluate the feasibility of sentinel lymph node biopsy (SLNB) in multicentric/ multifocal breast cancer. In this prospective study, 23 women with multicentric/multifocal breast cancer underwent SLNB at our institution from April 2002 to February 2006. Presence of preoperative axillary metastases was confirmed by FNA. Patients underwent sub-areolar radiopharmaceutical injection ± isosulfan blue to perform SLNB, then completion ALND. The false-negative (FN) rate of SLNB was determined based upon final pathology. Twenty women with multicentric and three with multifocal invasive carcinoma were enrolled. The SLN identification rate was 100%. The overall FN rate of SLNB was 15% (95% CI 0.0466, 0.4281). Both cases with FN SLNB had multicentric disease, pathologic stage III breast cancer and a larger tumor burden compared with the study population. SLNB using sub-areolar injection is feasible for patients with multicentric/multifocal breast cancer yet may be associated with a higher FN rate in patients with large additive tumor burden.     

Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer

BACKGROUND:

Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes.

METHODS:

A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local‐regional recurrence, distant disease‐free survival (DDFS), and overall survival were evaluated.

RESULTS:

We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow‐up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03‐2.6; P = .04) but not local‐regional recurrence or overall survival.

CONCLUSIONS:

IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy. Cancer 2012. © 2012 American Cancer Society.     

External qigong therapy for women with breast cancer prior to surgery

The majority of patients with cancer use some form of complementary or alternative medicine. External qigong treatment (EQT), classified as a bioenergy therapy, is one such approach that patients combine with conventional medicine or, in some cases, use in place of conventional medicine. This study aimed to determine whether EQT could shrink breast cancer tumors and improve quality of life (QOL) in women with pathologically confirmed breast cancer awaiting surgery. A total of 9 women with pathologically confirmed breast cancer were recruited from large cancer centers in the United States (n = 5) and China (n = 4). A single-arm pre/post design was used. Each patient underwent 5 consecutive days of EQT, with each treatment lasting from 2 to 5 minutes. All treatments were performed by the same qigong master. Tumor measurements were made before and after the EQT sessions. Tumor assessments were conducted prior to study initiation and following the last EQT. Patients underwent both an ultrasound and mammogram (United States) or an ultrasound and magnetic resonance imaging (China). All patients also underwent physical breast examinations (PBEs) and completed QOL questionnaires before and after the last EQT. No clinical changes in tumor measurements from pre- to post-EQT were noted. There was also no suggestion of change in tumor size by PBE or change in QOL. Using the current STUDY DESIGN: EQT also does not appear to have any effect on patient QOL. Because of the small sample size and working with only one qigong practitioner, to definitively determine the efficacy or lack of efficacy of EQT, a larger study with multiple qigong practitioners would need to be conducted.     

Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer

OBJECTIVE: To determine the effect of preoperative chemotherapy on the volume of tissue excised and the number of breast operations in patients undergoing breast-conserving therapy (BCT). SUMMARY BACKGROUND DATA: Preoperative chemotherapy is increasingly being used for breast cancer and increases rates of BCT. Its impact on the extent of surgery and the number of surgical procedures in BCT has never been fully defined. The extent of surgery in BCT directly affects cosmesis. METHODS: We reviewed the records of 509 consecutive patients with T1-T3, N0-N2 breast cancer who were treated in prospective randomized clinical trials of chemotherapy between 1998 and 2005. We analyzed the final surgical procedure (BCT or mastectomy), the number of operations, and, in patients who underwent BCT, re-excision rates, and the total volume of breast tissue excised [4Pi/3(width/2 x length/2 x height/2)]. RESULTS: A total of 241 patients underwent BCT, and 268 patients underwent mastectomy. Among BCT patients who had initial tumor size >2.0 cm, patients who received preoperative chemotherapy had significantly smaller volumes of breast tissue excised compared with patients who received postoperative chemotherapy (113 cm vs. 213 cm, P = 0.004). The re-excision rate and total number of breast operations did not significantly differ between the groups. Among BCT patients who had initial tumor size < or = 2 cm, preoperative chemotherapy had no impact on volume of breast tissue excised, re-excision rate, or number of breast operations (P > 0.05). CONCLUSIONS: Among patients treated with BCT for larger breast tumors, patients treated with preoperative chemotherapy have less extensive resection, with no change in rates of re-excision.     

Paget’s Disease of the Breast: There Is a Role for Breast-Conserving Therapy

Background The optimal surgical management of Pagets disease of the breast remains to be defined. Mastectomy has been the standard of care, but several institutions have recently advocated breast-conserving surgery, particularly for patients with minimal disease. In an effort to develop rational treatment guidelines, we examined our institutional experience with Pagets disease of the breast.Methods Patients with Pagets disease of the breast who had surgical therapy at our institution between 1949 and 1993 were reviewed. In addition to patient and tumor characteristics, charts were reviewed for treatment modalities, locoregional recurrence patterns, and survival. Subgroups were compared for differences in survival in both univariate and multivariate analyses.Results A total of 104 patients met the study criteria. The most common presenting symptoms were nipple discharge and eczematous changes of the nipple/areola complex. Ninety-seven patients (93.2%) had an underlying invasive or noninvasive cancer associated with Pagets disease. Ninety-two patients (88.5%) underwent mastectomy, and 12 (11.5%) had a breast-conserving procedure. On univariate analysis, patients with age <60 years at diagnosis, stage II disease, positive lymph nodes, invasive disease, or a palpable mass had significantly lower 10-year disease-specific and recurrence-free survival. There were four locoregional recurrences (three after mastectomy and one after breast conservation). There were no significant differences in overall, disease-specific, or recurrence-free survival according to the type of surgery.Conclusions Pagets disease of the breast is almost always associated with an underlying breast cancer. Breast-conserving approaches result in local control and survival rates similar to those achieved with mastectomy.Presented in part at the 26th Annual San Antonio Breast Cancer Symposium, San Antonio, Texas, December 2-6, 2003.Published by Springer Science+Business Media, Inc. © 2005 The Society of Surgical Oncology, Inc.     

Potential applicability of balloon catheter-based accelerated partial breast irradiation after conservative surgery for breast carcinoma

BACKGROUND: Balloon catheter-based accelerated partial breast irradiation (APBI) is an alternative to whole-breast external-beam irradiation during breast-conserving therapy (BCT) for breast carcinoma, but it is limited by the size of the segmental mastectomy cavity. There are scant data on the average or optimal volume of resection (VR) in BCT. The objective of the current study was to evaluate the percentage of patients who would be eligible for balloon catheter-based APBI based on the selection criteria of the American Society of Breast Surgeons and the surgical VR. METHODS: The authors reviewed the medical records of 443 patients with ductal carcinoma in situ (DCIS) or invasive carcinoma treated with BCT. Patient treatment and pathologic data were analyzed to assess VR and eligibility for APBI. RESULTS: BCT was performed for 178 patients with DCIS and 267 patients with invasive breast carcinoma. The majority of invasive carcinomas (63.3%) were infiltrating ductal carcinomas. The median overall lumpectomy volume was 67.61 cm3, with no significant difference between DCIS and invasive carcinoma (P>0.05). Although the majority (62.9-82.0%) of patients met the individual selection criteria for APBI, only 27.4% of the cohort was found to be eligible for any type of APBI when the selection criteria were considered together. Based on VR, only approximately one-half of the patients initially eligible for APBI would be candidates for immediate balloon catheter-based APBI using the 70 cm3 balloon device (13.3%). However, with the new, larger 125 cm3 balloon device, approximately three-fourths of patients initially eligible for APBI would be eligible for balloon catheter-based APBI at the time of the initial surgical procedure (20.7%). Although not evaluated in the current study, shrinkage of the lumpectomy cavity with time may increase the number of patients eligible based strictly on VR criteria. Patients with a very large VR (> or =125 cm3) were more likely to have invasive carcinoma (P=0.02; hazard ratio [HR], 7.4) and tumors > or =5 cm on final pathology (P<0.01; HR, 22.0). CONCLUSIONS: Approximately one-fifth to one-fourth of patients presenting for BCT may be eligible for balloon catheter-based APBI according to accepted national guidelines and VR. VR must be considered when selecting patients for balloon catheter-based APBI, because a minority of patients will have a lumpectomy cavity that exceeds the size limit of the current balloon device.     

Contralateral prophylactic mastectomy. Predictors of significant histologic findings

BACKGROUND: Women with unilateral breast carcinoma are at increased risk for developing contralateral breast carcinoma (CBC). The authors sought to identify predictors of malignant or moderate to high-risk histologic findings in contralateral prophylactic mastectomy (CPM) specimens, and to determine the efficacy of CPM. METHODS: The authors performed a retrospective review of 239 patients with unilateral early-stage breast carcinoma who underwent CPM. The number of CBCs expected if the contralateral breast had been left intact was calculated based on CBC rates observed in the Surveillance, Epidemiology, and End Results (SEER) database and on life-table analysis by family history. RESULTS: In the current study, 11 patients (4.6%) had occult contralateral malignancies (4 invasive carcinomas and 7 ductal carcinomas in situ) and 44 (18.4%) patients had moderate to high-risk pathology (8 lobular carcinoma in situ, 11 atypical lobular hyperplasia, 25 atypical ductal hyperplasia). At 1846 patient-years of follow-up, only 1 patient (0.4%) developed a new CBC compared with 11 expected cancers based on SEER data. One CBC was observed among 140 patients with a family history of breast carcinoma, compared with 16 expected cancers based on life-table analysis adjusted for adjuvant therapy. The determinants of significant findings at CPM were invasive lobular histology, estrogen and progesterone receptor positivity, additional ipsilateral moderate to high-risk pathology, and age > 40 years at cancer diagnosis. CONCLUSIONS: CPM was associated with a low risk of subsequent development of breast carcinoma. Evaluation of histologic findings in the ipsilateral breast may help to predict the likelihood of significant disease in the contralateral breast and assist in risk stratification.     

Small (< or = 2-cm) breast cancer treated with US-guided radiofrequency ablation: feasibility study

PURPOSE: To determine the feasibility and safety of ultrasonographically (US) guided percutaneous radiofrequency (RF) ablation in the local treatment of invasive breast carcinomas 2 cm or less in greatest diameter. MATERIALS AND METHODS: RF ablation of 21 malignant lesions was performed in 20 patients immediately before their scheduled lumpectomy or mastectomy. A 15-gauge needle electrode was placed in the lesions, and the prongs of the needle electrode were deployed with real-time US guidance. A temperature of approximately 95 degrees C was maintained for 15 minutes at the tips of the prongs. Histopathologic examination of the resected specimens included use of nicotinamide adenine dinucleotide in its reduced form-diaphorase stain, which is specifically used to confirm thermal cell injury and lack of viability. The desired outcome of the procedure was ablation of the tumor and of an adequate margin around it, as confirmed by the absence of viable tissue in the surgical specimen. RESULTS: In all 21 cases, complete ablation of the target lesion was visualized at US. In one patient, who had undergone preoperative chemotherapy for a mass that was initially judged to be a T2 tumor but who was found to have a small residual tumor at mammography and US performed at the time of ablation, the target lesion was ablated but residual in situ mammographically and US occult invasive carcinoma was found at histopathologic examination. There were no adverse effects. CONCLUSION: US-guided percutaneous ablation of small invasive breast carcinomas is feasible and safe.     

Selective use of sentinel lymph node surgery during prophylactic mastectomy

BACKGROUND: Patients with invasive cancer identified at the time of prophylactic mastectomy (PM) will require axillary lymph node dissection for staging; therefore, many surgeons advocate sentinel lymph node (SLN) surgery at the time of PM. The current study investigates the invasive cancer rate in PM and evaluates factors associated with invasive cancer to guide SLN surgery use. METHODS: Patients undergoing PM at the M. D. Anderson Cancer Center between January 2000 and July 2005 were identified from a prospective database. Clinical, radiographic, and pathologic data were collected. RESULTS: A total of 409 patients (436 PM cases) were identified; 382 underwent contralateral PM (CPM) and 27 underwent bilateral PM (BPM). Cancer was identified in 22 of 436 PM cases (5%). Of these, 14 patients (64%) had ductal carcinoma in situ (DCIS). Only 8 patients (1.8%) had invasive cancer, with a mean tumor size of 5 mm (range, 2-9 mm). There was no difference in the occult cancer rate between CPM and BPM. No cases of invasive cancer were identified in the 23 patients with BRCA mutations. Significantly increased risk of invasive cancer in the PM breast was seen in postmenopausal patients (3.7%; P = .007), patients age >60 years (7.5%; P = .008), and patients with history of invasive lobular carcinoma (9.7%; P = .0002) or lobular carcinoma in situ (LCIS) (7.7%; P = .008). CONCLUSIONS: The frequency of cancer in PM is very low and the majority represents DCIS. Therefore, routine use of SLN surgery in all patients undergoing PM is not warranted. However, patients at higher risk for whom SLN surgery should be considered include older women and patients with a history of lobular cancer or LCIS.