Alan J. Stolier

A comparison of methylene blue and lymphazurin in breast cancer sentinel node mapping

BACKGROUND When lymphazurin became unavailable to our institution, we elected to employ methylene blue to perform sentinel node mapping for patients with breast cancer. The purpose of this study was to compare methylene blue and lymphazurin for performing sentinel node mapping for breast cancer. METHODS We evaluated our sentinel node mapping experience from April 1, 2001 to March 31, 2002. Patients were divided into two groups based on the dye used for lymphatic mapping. The two groups were compared to evaluate the results of the sentinel node mapping procedure. RESULTS During the study period a total of 199 patients were evaluated with sentinel node mapping, 87 with lymphazurin and 112 with methylene blue. The two groups were similar in demonstrating the success of the sentinel node procedure, nodes identified per case, and technique used for node identification (colloid or dye, or both). CONCLUSIONS In our initial experience, methylene blue appears to be equivalent to lymphazurin for sentinel node mapping in breast cancer.

A prospective study of seeding of the skin after core biopsy of the breast

BACKGROUND The number of core biopsies done for breast abnormalities is increasing. The risk of skin seeding resulting from core biopsy is unknown. METHODS Consecutive patients diagnosed with breast cancer were studied. The skin and subcutaneous fat surrounding the site of core needle penetration were excised and studied by routine histologic staining. Findings were correlated with other clinical variables. RESULTS Eighty-nine consecutive patients were studied. Thirty-one had stereotactic core biopsies, 23 had vacuum-assisted biopsy, 8 had multiple-puncture biopsy, and 58 had ultrasound-guided core biopsy. Two patients who were biopsied using multiple-puncture biopsy were found to have nests of cancer cells in the dermis. One of these patients had recurrence in the skin biopsy site at 34 months. CONCLUSION Skin seeding may be important in light of increasing use of image-directed biopsy, and particularly for cases in which the biopsy puncture site is outside the index quadrant and in which no radiation is anticipated.

Initial experience with surgical treatment planning in the newly diagnosed breast cancer patient at high risk for BRCA-1 or BRCA-2 mutation.

Abstract:  Despite an abundance of information available for dealing with patients with BRCA‐1 and BRCA‐2 mutations, little guidance is available to assist the surgeon in dealing with the genetically high‐risk patient recently diagnosed with breast cancer. A retrospective review was undertaken of 170 patients who underwent genetic counseling and testing over a 3‐year period from March 2000 to March 2003. Forty‐three of the 170 patients tested were diagnosed with breast cancer prior to genetic testing. Nine patients (20.9%) tested positive for a deleterious mutation. Fifty‐eight percent underwent genetic counseling prior to definitive cancer surgery. Five of the 25 patients who underwent lumpectomy tested positive for a deleterious mutation. Testing results became available during systemic therapy or radiation was delayed until results were known. After counseling, all five patients testing positive went on to bilateral prophylactic mastectomy and reconstruction. None had radiation therapy. Because of a strong family history, eight patients elected to undergo prophylactic mastectomy and reconstruction prior to obtaining genetic test results; and despite compelling histories, all eight tested negative for a mutation. Treatment algorithms are developed to manage patients that are first discovered to be at high risk for a BRCA‐1 or BRCA‐2 mutation at the time they are diagnosed with breast cancer. Patients diagnosed with breast cancer who are discovered to be at high risk for a genetic mutation should undergo counseling prior to definitive surgery. This maximizes the time that patients have to consider options for prophylaxis and monitoring should their test be positive. It also prevents women who would otherwise be candidates for breast preservation from undergoing unnecessary radiation therapy should they chose prophylactic mastectomy in the face of a positive test. 

Breast Conservation Therapy with Concomitant Breast Reduction in Large‐Breasted Women

Abstract: Cosmetic results from radiation following breast‐conserving surgery and radiation therapy are generally poorer in women with large or heavy breasts. Breast reduction carried out at the time of definitive surgery allows this group of women to undergo breast‐conserving surgery and radiation with excellent cosmetic results. Four cases are presented in which partial mastectomy was carried out in conjunction with immediate bilateral breast reduction. All patients had clear margins and all had excellent cosmetic results following radiation therapy. Immediate breast reduction should be considered in women with large or heavy breasts who otherwise qualify for breast‐conserving surgery. 

Nipple-Sparing Mastectomy and Immediate Free-Flap Reconstruction in the Large Ptotic Breast

AbstractBecause of increased risk for nipple necrosis, many surgeons believe large ptotic breasts to be a relative contraindication to nipple-sparing mastectomy (NSM). A retrospective review was performed on 85 consecutive patients who underwent NSM with 141 immediate perforator free-flap breast reconstructions. We analyzed the subset of patients with large ptotic breasts, defined as cup size C or greater, sternal notch to nipple distance greater than 24 cm and grade 2 or 3 breast ptosis. Of the 85 patients, 19 fit the inclusion criteria. Breast cup size ranged from 34C to 38DDD. There was 1 case of nipple necrosis in the patient with previous breast radiation (5%), 1 hematoma (5%), and no flap losses. Five (26%) patients underwent subsequent mastopexy or breast reduction, a mean of 6.6 months after the primary procedure. We demonstrate that NSM and free-flap breast reconstruction can be safely and reliably performed in selected patients.

Breast lymphatic mapping using blue dye and radiocolloid

I read Dr Kern’s article on the technique of subareolar blue dye injection with great interest. I was also interested in Dr Kern’s reply to the letter by Dr Ahmad Shatila. I was particularly intrigued by the comment made by Dr Kern that the sentinel lymphatic channels provide access to the same sentinel lymph nodes that receive lymph flow from peritumoral injections, and most importantly, that “we know this because of our 0% falsenegative rate achieved in our first study. . . .” I found Dr Kern’s first study compelling but hardly proof-positive that subareolar injections are 100% accurate as claimed. This study included only 40 patients, with 39 having successful mapping. Most importantly, only 15 patients harbored positive nodes. Because all patients with negative nodes will theoretically have a successful mapping, it is only these 15 patients from whom we can draw conclusions concerning the accuracy of the technique. As Dr Kern has demonstrated, the technique of subareolar injection is relatively easy and, most importantly, solves a number of troublesome logistical problems. Accurate injections in patients with deep-lying tiny clusters of microcalcifications and in those with multicentric disease are clearly problematic. Hopefully, further studies will confirm the utility and accuracy of this technique. Although the technique may in fact be highly accurate, I do not believe that we should rush to make sweeping statements based on the study of such small numbers.

The evolution in management of patients with subcentimeter, node-negative, triple-negative breast cancer.

BACKGROUND The aim of this study was to determine the evolution in treatment recommendations and outcomes for patients with subcentimeter, node-negative, triple-negative disease. METHODS Patients were divided into a remote (diagnosed from 1997 to 2003) and a recent (diagnosed from 2004 to 2011) group. Demographics, tumor size, surgical treatment, use of adjuvant chemotherapy, survival, and disease recurrence were evaluated. RESULTS Thirty patients were placed in the remote group and 31 in the recent group. Demographics, tumor sizes, and surgical treatment were similar between groups. The use of adjuvant chemotherapy increased from 7% to 42% in the recent group (P < .002). Disease-free survival and recurrence (7%) was not influenced by the use of chemotherapy. CONCLUSIONS This study demonstrates that adjuvant chemotherapy is increasingly used in patients with the triple-negative phenotype, regardless of other favorable prognostic variables. The value of adjuvant chemotherapy for the subgroup of patients in our study is unclear and mandates further investigation.