Antoni Pessarrodona

Use of Axillary Ultrasound, Ultrasound-Fine Needle Aspiration Biopsy and Magnetic Resonance Imaging in the Preoperative Triage of Breast Cancer Patients Considered for Sentinel Node Biopsy

We assessed the diagnostic yield of axillary ultrasound, alone or in combination with fine-needle aspiration axillary biopsy and magnetic resonance imaging in patients with invasive breast carcinoma compared with final axillary histology by sentinel node biopsy or by axillary lymph node dissection. From January 2003 to March 2009, 520 axillary ultrasound examinations and 105 axillary magnetic resonance imaging studies were included. Compared with final axillary histology, ultrasound fine-needle aspiration showed positive predictive value of 87%, negative predictive value of 82%, sensitivity of 53% and specificity of 100%. In cases of negative ultrasound, the rate of positive nodes was 17% (micro-metastases excluded). Ultrasound examination of the axilla, combined with fine-needle aspiration as appropriate must be included in the preoperative work-up of patients considered for sentinel node biopsy to definitively establish such an indication while minimizing the risk of false-negative sentinel node. Axillary magnetic resonance imaging did not improve the preoperative work-up.

Survival and clinicopathological characteristics of breast cancer patient according to different tumour subtypes as determined by hormone receptor and Her2 immunohistochemistry. A single institution survey spanning 1998 to 2010

As far as recent breast cancer molecular subtype classification is concerned, much work has dealt with clinical outcomes for triple negative and Her2 patients. Less is known about the course of patients in the remaining subtypes. Molecular classification based on immunohistochemistry is widely available and correlates well with genetic microarray assessment, but at a lower cost. The aim of our investigation was to correlate immunohistochemical subtypes of breast cancer with clinical characteristics and patient outcomes. Since 1998, 1167 patients operated for 1191 invasive breast tumours were included in our database. Patients were regularly followed up until March 2010. Disease-free survival, overall mortality, and breast cancer-specific mortality at 5 years were calculated for the cohort. 72% of tumours were ER+PR±HER2- group, 13% triple negative (ER-PR-HER2-), 10% ER+PR±HER2+ group, and 5% Her2 (ER-PR-HER2+). Cancer-specific survival was 94.2% for the ER+PR+HER2- subtype, 84.8% for the Her2 subtype, 83.3% for the ER+PR-HER2- subtype, and 78.6% for triple negatives. Distant metastases prevalence ranged from 7% to 22% across subtypes, increasing stepwise from ER+PR+HER2-, ER+PR+HER2+, ER+PR-HER2-, ER+PR-HER2+, ER-PR-HER2+ through triple negative. Small, low-grade tumours with low axillary burden were more likely to belong to the ER+PR±HER2- group. Conversely, larger high-grade tumours with significant axillary burden were more likely to belong to Her2 or triple negative groups. ER+PR±HER2- group patients with negative PR receptors performed more like Her2 or triple negative than like the rest of ER+PR±HER2± groups patients. Molecular classification of breast tumours based only on immunohistochemistry is quite useful on practical clinical grounds, as expected. ER+PR±HER2- group patients with negative PR receptors seem to be at high risk and deserve further consideration.

Introital ultrasonography : a comparison of women with stress incontinence due to urethral hypermobility and continent women

To determine if there is a variable on introital ultrasonography (IUS) that can be used to distinguish between women with stress urinary incontinence (SUI) due to urethral hypermobility (UH) and continent women.

Comparative Long-term Study of a Large Series of Patients with Invasive Ductal Carcinoma and Invasive Lobular Carcinoma. Loco-Regional Recurrence, Metastasis, and Survival

Our aim was to compare histologic and immunohistochemical features, surgical treatment and clinical course, including disease recurrence, distant metastases, and mortality between patients with invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC). We included 1,745 patients operated for 1,789 breast tumors, with 1,639 IDC (1,600 patients) and 145 patients with ILC and 150 breast tumors. The median follow‐up was 76 months. ILC was significantly more likely to be associated with a favorable phenotype. Prevalence of contralateral breast cancer was slightly higher for ILC patients than for IDC patients (4.0% versus 3.2%; p = n.s). ILC was more likely multifocal, estrogen receptor positive, Human Epidermal Growth Factor Receptor‐2 (HER2) negative, and with lower proliferative index compared to IDC. Considering conservative surgery, ILC patients required more frequently re‐excision and/or mastectomy. Prevalence of stage IIB and III stages were significantly more frequent in ILC patients than in IDC patients (37.4% versus 25.3%, p = 0.006). Positive nodes were significantly more frequent in the ILC patients (44.6% versus 37.0%, p = 0.04). After adjustment for tumor size and nodal status, frequencies of recurrence/metastasis, disease‐free and specific survival were similar among patients with IDC and patients with ILC. In conclusion, women with ILC do not have worse clinical outcomes than their counterparts with IDC. Management decisions should be based on individual patient and tumor biologic characteristics rather than on lobular versus ductal histology.

Does episiotomy protect against injury of the levator ani muscle in normal vaginal delivery

To investigate whether episiotomy is associated with avulsion of the levator ani in its pubic insertion after normal vaginal delivery.

Positive versus negative sentinel nodes in early breast cancer patients: Axillary or loco-regional relapse and survival. A study spanning 2000–2012

Sentinel Node Biopsy (SNB) is a minimally invasive alternative to elective axillary lymph node dissection (ALND) for nodal staging in early breast cancer. The present study was conducted to evaluate prognostic implications of a negative sentinel node (SN) versus a positive SN (followed by completion ALND) in a closely followed-up sample of early breast cancer patients. We studied 889 consecutive breast cancer patients operated for 908 primaries. Patients received adjuvant therapy with chemotherapy, hormone therapy and eventually trastuzumab. Radiation therapy was based on tangential radiation fields that usually included axillary level I. Median follow-up was 47 months. Axillary recurrence was seen in 1.2% (2/162) of positive SN patients, and 0.8% (5/625) of negative SN patients (p = n.s.). There was an overall 3.2% loco-regional failure rate (29/908). Incidence of distant recurrence was 3.3% (23/693) for negative SN patients, and 4.6% (9/196) for positive SN patients (p = n.s.). Overall mortality rate was 4% (8/198) for positive SN patients, while the corresponding specific mortality rate was 2.5% (5/198). For patients with negative SNs, overall mortality was 4.9% (34/693), and the specific mortality was 1.4% (19/693) (p = n.s.). We did not find significant differences in axillary/loco-regional relapse, distant metastases, disease-free interval or mortality between SN negative and SN positive patients, with a follow-up over 4 years.

Role of axillary ultrasound, magnetic resonance imaging, and ultrasound-guided fine-needle aspiration biopsy in the preoperative triage of breast cancer patients.

PurposeRoughly two-thirds of early breast cancer cases are associated with negative axillary nodes and do not benefit from axillary surgery at all. Accordingly, there is an ongoing search for non-surgical staging procedures to avoid lymph-node dissection or sentinel node biopsy (SNB). Non-invasive imaging techniques with very high sensitivity (Se) and negative predictive value (NPV) could eventually replace SNB. We aimed to establish the role of axillary US and MRI, alone or in combination, associated with ultrasound-guided fine-needle aspiration biopsy (US-FNAB) in the prediction of axillary node involvement.Methods/patientsBetween January 2003 and September 2015, we included 1505 of the 1538 breast cancer patients attending our centres. All patients had been referred from a single geographical area. Axillary US, magnetic resonance imaging and ultrasound-guided fine-needle aspiration biopsy (US-FNAB) were performed if required.Results1533 axillary US examinations and 1351 axillary MRI studies were analyzed. For axillary US, Se, Specificity (Sp), Positive Predictive Value (PPV), and NPV were 47.5, 93.6, 82.5, and 73.8%, respectively. For axillary MRI, corresponding values were 29.8, 96.6, 84.9, and 68.4%. When both tests were combined, Sp and PPV slightly improved over individual tests alone. US-FNAB showed a 100% Sp and PPV, with a Se of 80%.ConclusionWe may confidently state that axillary US and US-FNAB have to be included in the preoperative work-up of breast cancer patients.

Magnetic resonance imaging in the preoperative setting for breast cancer patients with undetected additional disease.

OBJECTIVE The last few years have witnessed a significant increase in the preoperative use of Magnetic Resonance Imaging (MRI) for staging purposes in breast cancer (BC) patients. Many studies have confirmed the improvement that MRI can provide in terms of diagnostic assessment, especially with regard to additional disease foci. In the present study, we address the advantages and disadvantages of MRI in the preoperative setting for BC patients. PATIENTS AND METHODS There were 1513 consecutive breast MRI studies performed in patients with either primary or recurrent BC, who were scheduled for surgery. RESULTS Beyond the primary lesion, 10.4% of our cases had additional disease at the final histological assessment. MRI overall sensitivity, when considering tumour size and additional foci together, was 74.3%, and 80.3% when considering additional foci exclusively. MRI specificity for additional disease was 95.3%, positive predictive value was 77.4%, and negative predictive value was 94.6%. Nevertheless, 5% of cases had additional tumours that were missed by MRI or, conversely, had additional foci on MRI that were not confirmed by histology. Age (p=0.020) and lobular carcinomas (p=0.030) showed significance in the multivariate analysis by logistic regression, using the presence of additional foci diagnosed by MRI as a dependent variable. CONCLUSION Preoperative MRI seems to have a role in preoperative tumour staging for breast cancer patients, as it discloses additional disease foci in some patients, including contralateral involvement. However, given the lack of absolute accuracy, core-needle biopsy cannot be neglected in the diagnosis of such additional malignant foci, which could result in a change in surgical treatment.

Comparison of Screened and Nonscreened Breast Cancer Patients in Relation to Age: A 2-Institution Study

INTRODUCTION Screening programs for breast cancer aim to allow early diagnosis, and thus reduce mortality. The aim of this study was to assess the effect of a population screening program in a sample of women aged between 50 and 69 years in terms of recurrence, metastasis, biological profiles, and survival, and to compare their results with those of women of a wider age range who did not participate on the screening program. PATIENTS AND METHODS A prospective multicenter study in which 1821 patients with 1873 breast tumors who received surgery between 1999 and 2014 at MútuaTerrassa University Hospital and the Hospital of Terrassa in Barcelona were analyzed. A comparison was performed in the 50- to 69-year-old age group between those who participated on the screening program and those who did not. RESULTS The mean age of patients was 58 years. The mean follow-up was 72 months, and median follow-up 59 months. The screened group showed significantly better results in all prognostic factors and in specific mortality than all nonscreened groups. The specific mortality rate in the screened patients was 2.4% (12/496), local recurrence 2.8% (14/496), and metastasis at 10 years 3.6% (18/496). In the nonscreened group, younger women presented a higher rate of metastasis (16.4% [81/493]) and a shorter disease-free period (77.1% [380/493]). The age group older than 70 years had the highest number of T4 tumors (7.5% [30/403]) and the highest proportion of radical surgery (50.4% [203/403]). CONCLUSION Patients in the screening program presented improved survival. We speculate that extending breast cancer screening programs to women younger than 50 and older than 70 years could bring about mortality benefits.

Using microbubble sonographic contrast agent to enhance the effect of high intensity focused ultrasound for the treatment of uterine fibroids.

OBJECTIVE To evaluate the effects of the ultrasound contrast agent SonoVue in enhancing the ablative effects of Ultrasound-Guided high-intensity focused ultrasound (HIFU) on different sub-types of uterine fibroids. MATERIALS AND METHODS In this study, 390 fibroids from 319 patients were retrospectively evaluated, among which 155 were treated with SonoVue and 235 were without SonoVue during HIFU ablation. The efficacy of HIFU was evaluated using magnetic resonance scanning (MRI) in all patients. RESULTS The total ablation time to achieve the same non-perfused volume was significantly shortened with SonoVue. The average energy used and the acoustic energy for treating 1 mm(3) (EEF) was less when SonoVue is used as enhancing agent. The non-perfused volume (NPV) was measured by post-HIFU MRI and the mean fractional ablation was calculated. Mean NPV was 74% (range: 15%-100%) in the HIFU-only group and 75% (range: 17%-100%) in the HIFU+ SonoVue group. However, for T2 MRI low intensity signal fibroids, NPV in the SonoVue group reached 83% (range: 20%-100%) that was significantly higher than in the HIFU-only group, which was 76% (range: 15%-100%). No differences in adverse events were observed between the two groups. CONCLUSIONS Our observations demonstrate that the use of therapeutic SonoVue during the HIFU procedure can significantly decrease the ablation time and the energy requirement for the treatment of the same fibroid volume in all types of fibroids.