Angrit Stachs

Differentiating between malignant and benign breast masses: factors limiting sonoelastographic strain ratio.

PURPOSE We compared strain ratio vs. qualitative elastography for the further differentiation of focal breast lesions, with special focus on limiting factors. MATERIALS AND METHODS 215 patients with 224 histologically proven breast masses (116 malignant, 108 benign) were prospectively examined using a high-end ultrasound system (Philips iU22) with serial elastography function. B-mode scans and available mammograms were reviewed according to the BIRADS classification, raw elastogram data was analyzed qualitatively using the Tsukuba score and semiquantitatively by calculating the strain ratio (fat to lesion ratio). For diagnostic performance, Receiver Operating Characteristic (ROC) curve analysis was obtained. A sub-group analysis regarding breast density, lesion size, lesion depth and histological subtypes was performed. RESULTS Mean strain ratio values were 3.04 ± 0.9 for malignant and 1.91 ± 0.75 for benign lesions (p < 0,001). The areas under the ROC curve values were 0.832 (95 % CI 0.777; 0.888) for strain ratio, 0.869 (95 % CI 0.822; 0.917) for Tsukuba score, 0.822 (95 % CI 0.768; 0.876) for B-mode ultrasound and 0.853 (95 % CI 0.799; 0.907) for mammography. Sensitivity, specificity, positive predictive value and negative predictive value of the strain ratio were 90.7 %, 58.2 %, 70.3 % and 85.1 %, when a cutoff point of 2.0 was used. Only lesion depth ≤ 4 mm was associated with diagnostic failure in the multivariate analysis of factors influencing accuracy, whereas no significant correlation between breast density and lesion size and the accuracy of the strain ratio could be found. CONCLUSION The addition of strain ratio to B-mode ultrasound increases specificity without loss of sensitivity in differentiating between malignant and benign breast tumors. Strain ratio measurements should not be carried out on tumors with a lesion depth ≤ 4 mm.

Pathologic Nipple Discharge: Surgery Is Imperative in Postmenopausal Women

BackgroundA total of 10% to 15% of pathologic nipple discharge in women is due to malignant lesions of the breast. The purpose of this study was to discover the rate of breast cancer in women who present with this symptom and undergo ductal excision, to evaluate the different diagnostic methods used before surgery, and to discover whether there are specific factors with regard to dignity.MethodsWe analyzed 118 ductal excisions in 116 patients performed at the women’s hospital of the University of Rostock, Germany, between 1995 and 2002. The discharging duct was identified by preoperative galactography.ResultsThe rate of cancer in these patients was 9.3% (n = 11). The most frequent benign lesion was intraductal papillomatous proliferation (36.4%; n = 43). Solitary papillomas were shown in 21.2% (n = 25), and other specific benign histologic findings were shown in 27.1% (n = 32). Women with malignancies were significantly older (P = .009) and were more often postmenopausal (P = .095) compared with patients with benign histology. Galactography was the method that reached the highest sensitivity (73%), and clinical examination showed the highest specificity (85%) in distinguishing between benign and malignant lesions.ConclusionsBecause 94.1% of all cases presented with specific histological findings causing pathologic nipple discharge, ductal excision combined with preoperative galactography was proven to be a sufficient method for diagnosis and therapy. This procedure should be performed in all postmenopausal women with this symptom because of a cancer rate of 12.7% among this age group and the unsatisfactory quality of other diagnostic methods.

Axillary lymph node dissection in early-stage invasive breast cancer: is it still standard today?

Evaluation of axillary lymph node status by sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection (ALND) are an inherent part of breast cancer treatment. Increased understanding of tumor biology has changed the prognostic and therapeutic impact of lymph node status. Non-invasive imaging techniques like axillary ultrasound, FDG-PET, or MRI revealed moderate sensitivity and high specificity in evaluation of lymph node status. Therefore, they are not sufficient for lymph node staging. Otherwise, the impact of remaining micrometastases and even macrometastases for prognosis and treatment decisions is overestimated. Considering tumor biology, the distinction of axillary metastases in isolated tumor cells (ITC, pN0(i+)); micrometastases (pN1mi), and macrometastases (pN1a) is not comprehensible. Increasing data support the thesis that remaining axillary metastases neither increase the axillary recurrence rate nor decrease overall survival. It is doubtful that axillary tumor cells are capable to complete the complex multistep metastatic process. If applied, axillary metastases are sensitive to systemic treatment and are targeted by postoperative tangential breast irradiation. Therefore, the controversy about the clinical relevance of tumor cell clusters or micrometastases in SLN is a sophisticated but not contemporary discussion. Currently, there is no indication for axillary surgery in elderly patients with favorable tumors and clinically tumor-free lymph nodes. Nonetheless, a rational and evidence-based approach to the management of clinically and sonographically N0 patients with planned breast-conserving surgery and limited tumor size is needed now.

Primary Metastatic Breast Cancer: The Impact of Locoregional Therapy

The impact of treatment for the primary tumor on distant metastases and survival in primary metastatic breast cancer patients is controversial. Previous retrospective studies and meta-analyses suggested a survival benefit for the removal of the primary tumor. Early follow-up data from 2 prospectively randomized trials presented at San Antonio Breast Cancer Symposium 2013 could not confirm this. Only a very small subgroup of patients with solitary bone metastases seemed to profit from surgery, while patients with multiple visceral metastases showed a worse prognosis with initial surgery. There are no studies available with the primary aim to investigate the impact of axillary lymph node surgery or locoregional radiotherapy on the survival of stage IV breast cancer patients. Based on current data, locoregional treatment in primary metastatic breast cancer should not be recommended in patients with asymptomatic primary tumor as a matter of routine. More solid conclusion of the impact of primary tumor treatment in stage IV breast cancer patients on their prognosis will be reached with the completion of the ongoing prospectively randomized trials. Until these studies are completed, locoregional therapy, which can provoke additional morbidity in a metastatic setting with limited live expectancy, is exclusively indicated for palliative reasons.

Ruptured Poly-Implant Protheses Breast Implant After Aesthetic Breast Augmentation: Diagnosis, Case Management, and Histologic Evaluation

AbstractSince the scandal of the poly-implant protheses (PIP) breast implants, all patients with PIP are advised to have their implants removed. With approximately 400,000 PIP implants sold worldwide breast, surgeons will be confronted with these patients. Histologic examination in the reported case showed silicone infiltration into fatty tissue and breast tissue without signs of malignancy. A general histologic analysis for the rare event of an anaplastic large T cell lymphoma is not advised. The malignant potential of PIP implants currently is uncertain, and further investigation is required. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The role of specimen radiography in breast-conserving therapy of ductal carcinoma in situ

BACKGROUND To assess the role of intraoperative specimen radiography (SR) and to define risk factors for positive margins in breast-conserving therapy (BCT) of ductal carcinoma in situ (DCIS). METHODS In a retrospective study in calcification-associated DCIS treated with BCT between January 2009 and December 2011, digital mammographs and SR were reviewed and radiological margin width was determined. Clinical, radiological, and histological data were correlated with surgical histological data, and a histologically free margin of at least 2 mm was taken as evidence of successful BCT. RESULTS 47/91 patients (51.6%) fulfilling the inclusion criteria had histologically involved surgical margins. Univariate analyses revealed DCIS size, mammographic extension of calcification, presence of comedo necrosis, negative progesterone receptor status, and a small radiological margin on SR to be risk factors for unsuccessful BCT. Receiver Operating Characteristic (ROC) analysis showed a radiological margin width of 4 mm to be optimal, with a sensitivity of 72.3% and specificity of 52.3%. The likelihood of surgical free margins was increased 2.9-fold with a radiological margin width ≥4 mm. On multivariate logistic regression analysis, only histological DCIS size >20 mm clearly emerged as an independent predictive factor for surgically involved margins (p < 0.001), while an SR margin <4 mm trended toward significance (p = 0.066). CONCLUSIONS SR is a reliable method for predicting free surgical margins in non-invasive breast cancer where a minimum radiological free margin of 4 Fmm is achieved. However, histological DCIS size remains the most important factor determining successful BCT.

Breast reconstruction with a latissimus dorsi flap in a patient who had had her axillary lymph nodes irradiated in childhood

We describe a 34-year-old woman who, at the age of 11 years, had had Hodgkin disease treated by irradiation of the axillary nodes. Twenty-two years later she developed a secondary breast carcinoma which was managed by skin-sparing mastectomy and immediate reconstruction with a pedicled latissimus dorsi flap.

Restricted Axillary Staging in Clinically and Sonographically Node-Negative Early Invasive Breast Cancer (c/iT1–2) in the Context of Breast Conserving Therapy: First Results Following Commencement of the Intergroup-Sentinel-Mamma (INSEMA) Trial

Axillary lymph node status remains an important prognostic factor in early breast cancer. It is regarded as an indicator for (neo)adjuvant systemic treatment and postoperative radiotherapy of the regional lymphatics. Commenced in September 2015, the INSEMA trial is investigating whether operative determination of nodal status as part of breast conserving therapy (BCT) for early stage breast cancer (c/iT1-2 c/iN0) can be avoided without reducing oncological safety. After inclusion of 1001 patients there was general acceptance of the complex study design by patients and study doctors so that recruitment for the first randomisation (axillary sentinel lymph node biopsy [SLNB]: yes or no) achieved predicted case numbers. The second randomisation however (SLNB alone versus complete axillary dissection when one or two macrometastases are present at SLNB) recruited fewer cases than expected for the following three reasons: a) the 13 % rate of one or two macrometastases after SLNB in the INSEMA trial collective was lower than expected; b) around 20 % of patients refused the second randomisation; c) there was delayed inclusion of the Austrian study centres, which only recruited for the second randomisation. Lack of knowledge of nodal status when SLNB is avoided represents a new challenge for the postoperative tumour board. In particular decisions on chemotherapy for luminal-like tumours and irradiation of the lymphatics (excluding axilla) must be guided by tumour biological parameters. The INSEMA trial does not provide answers to some important questions, e.g. it remains unclear whether patients without SLNB can be offered partial breast irradiation alone in low-risk situations and whether SLNB can also be avoided in patients with stage T1-2 tumours who have a mastectomy indication.

Adjuvante endokrine Therapie des Mammakarzinoms

ZusammenfassungBei Brustkrebspatientinnen mit Östrogen- und/oder Progesteronrezeptor-positiven Tumoren ist eine adjuvante endokrine Therapie indiziert. Neben Risikoprofil und Nebenwirkungen sollte für die Therapie der Menopausestatus der Betroffenen Beachtung finden.

Preservation of Fertility or Ovarian Function in Patients with Breast Cancer or Gynecologic and Internal Malignancies

Because of the efficacy of systemic therapies, neoplasias which occur in pediatric and adolescent patients and in young adults have high cure rates. This means that fulfilling their wish to have children has become a more pressing concern, particularly among young women with malignant tumors. Premature ovarian failure is also a not insignificant problem as it has a lasting detrimental effect on quality of life. Every oncology patient who may potentially wish to have children should be informed about their options for preserving fertility prior to starting treatment. The rates of patient who received detailed briefing on this point remain low. This review presents the effects of different chemotherapeutic drugs on gonadal function together with an overview of currently valid recommendations on fertility preservation. Risk groups are defined and the specific approaches for malignancies of various organ systems are described. Cryopreservation of oocytes, fertilized embryos and ovarian tissue are fertility-preserving options for girls/young women. The data on the benefits of administering GnRH analogs for ovarian protection prior to starting chemotherapy are not clear. In postpubertal boys or male cancer patients, the standard approach is to cryopreserve sperm before starting therapy. The cryopreservation of testicular tissue is possible for prepubertal boys, however in-vitro sperm maturation is still in its experimental stages. This review also presents existing drug options for the preservation of ovarian function in oncology patients prior to chemotherapy, particularly for patients with (hormone-sensitive) breast cancer, and looks at the special issues of fertility-preserving surgery and radiation therapy in patients with gynecologic malignancies.