Beyza Ozcinar

Breast cancer risk factors in Turkish women – a University Hospital based nested case control study

BackgroundBreast cancer has been increased in developing countries, but there are limited data for breast cancer risk factors in these countries. To clarify the risk for breast cancer among the Turkish women, an university hospital based nested case-control study was conducted.MethodsBetween January 2000 and December 2006, a survey was prospectively conducted among women admitted to clinics of Istanbul Medical Faculty for examination and/or treatment by using a questionnaire. Therefore, characteristics of patients diagnosed with breast cancer (n = 1492) were compared with control cases (n = 2167) admitted to hospital for non-neoplastic, non-hormone related diseases.ResultsBreast cancer risk was found to be increased in women with age (≥ 50) [95% confidence interval (CI) 2.42–3.18], induced abortion (95% CI 1.13–1.53), age at first birth (≥ 35) (95% CI 1.62–5.77), body mass index (BMI ≥ 25) (95% CI 1.27–1.68), and a positive family history (95% CI 1.11–1.92). However, decreased breast cancer risk was associated with the duration of education (≥ 13 years) (95% CI 0.62–0.81), presence of spontaneous abortion (95% CI 0.60–0.85), smoking (95% CI 0.61–0.85), breast feeding (95% CI 0.11–0.27), nulliparity (95% CI 0.92–0.98), hormone replacement therapy (HRT) (95% CI 0.26–0.47), and oral contraceptive use (95% CI 0.50–0.69). On multivariable logistic regression analysis, age (≥ 50) years (OR 2.61, 95% CI 2.20–3.11), induced abortion (OR 1.66, 95% CI 1.38–1.99), and oral contraceptive use (OR 0.60, 95% CI 0.48–0.74) were found to be associated with breast cancer risk as statistically significant independent factors.ConclusionThese findings suggest that age and induced abortion were found to be significantly associated with increased breast cancer risk whereas oral contraceptive use was observed to be associated with decreased breast cancer risk among Turkish women in Istanbul.

Axillary sentinel node biopsy after neoadjuvant chemotherapy

INTRODUCTION The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear. PATIENTS AND METHODS Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively. RESULTS SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus <or=2 cm; p=0.004), positive extra-sentinel lymph node extension (versus negative; p=0.002) were more likely to have metastatic non-SLN(s). CONCLUSIONS SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.

Breast cancer related lymphedema in patients with different loco-regional treatments

INTRODUCTION Lymphedema, a sequela of breast cancer and breast cancer therapy, changes functional abilities and may affect a patients psychosocial adjustment and overall quality of life. Aim of this prospective observational study was to determine the rate of mid-term and late time period lymphedema in breast cancer patients with different loco-regional treatments, and factors associated with lymphedema. MATERIALS AND METHODS Patients surgically treated for early-stage breast cancer were prospectively enrolled in the study. Demographic, clinical, pathological, and loco-regional treatments data of patients and lymphedema rates were recorded. Patients were divided into six groups regarding different loco-regional treatments. Pre- and postoperative (12 months, and median 64 months after surgery) circumferences of arms were recorded. RESULTS 218 patients, all female with a median age of 48 (19-82) years, were included in the study. The numbers of patients in breast conservation surgery group (BCS) (N=104), mastectomy group (N=114), sentinel lymph node biopsy group (SLNB) (N=80), axillary lymph node dissection group (ALND) (N=138), group with radiotherapy (RT) (N=88) and group without radiotherapy (N=130). Incidence of lymphedema after surgery in mid-term period was 24.8%. The rate of lymphedema at 64 months median follow-up time was 7.3%. (BCS: 11.1%, 4.2% and 0.5%; Mastectomy: 15.0%, 3.2% and 1.4%; SLNB: 8.0%, 1.9% and 0.5%; ALND: 18.0%, 5.3% and 1.4%; RT: 14.7%, 6.3% and 1.4%; without RT: 11.4%, 2.1% and 0.5%). When we excluded patients with both mid-term and late term lymphedema, only four patients developed lymphedema at late time, then re-calculated late term lypmhedema rate was 1.8%. The factors affecting the lymphedema was ALND and radiotherapy (RT) and no lymphedema was detected in patients underwent breast conserving surgery and SLNB. Age and body mass index were not related to lymphedema at any time. CONCLUSION The incidence of lymphedema gradually increased in time and a quarter of patients experienced the complication at the end of year. The rate of lymphedema in patients with ALND was significantly higher than patients with SLNB alone. If RT added to SLNB the lymphedema rate was getting higher than SLNB alone. In all patients lymphedema rate was decreased one year after the surgery and further decreased at median 64 months follow-up time period.

Comparison of Intermittent Pneumatic Compression with Manual Lymphatic Drainage for Treatment of Breast Cancer-Related Lymphedema

BACKGROUND The aim of this prospective controlled study was to assess the efficacy of two different combination treatment modalities of lymphedema (LE). Manual lymphatic drainage (MLD) and compression bandage combination (complex decongestive therapy) have been compared with intermittent pneumatic compression (IPC) plus self-lymphatic drainage (SLD). METHODS AND RESULTS Both MLD with compression bandage (complex decongestive therapy) group (Group I, n=15) and IPC with SLD group (Group II, n=15) received treatment for LE 3 days in a week and every other day for 6 weeks. Arm circumferences were measured before and the 1st, 3rd, and 6th weeks of the treatment. EORTC-QLQ and ASES-tests were performed to assess the quality of life before and after 6 week-treatment. Patients in both groups had similar demographic and clinical characteristics. Even though both treatment modalities resulted in significant decrease in the total arm volume (12.2% decrease in Group II and 14.9% decrease in Group I) (p<0.001), no significant difference (p=0.582) was found between those two groups. Similarly, ASES scores were significantly (p=0.001) improved in both Group I and II without any significant difference between the groups. While emotional functioning, fatigue, and pain scores were significantly improved in both groups, global health status, functional and cognitive functioning scores appeared to be improved only in patients of group I. CONCLUSIONS Different treatment modalities consisting of MLD and compression bandage(complex decongestive therapy) or IPC and SLD appear to be effective in the treatment of LE with similar therapeutic efficacy in patients with breast cancer. However, combination modalities including IPC and SLD may be the preferred choices for their applicability at home.

Positive or close margins in breast conserving surgery: Is re-excision always necessary?

BACKGROUND More than half of re-excision specimens after breast conserving surgery (BCS) are found to be free of residual tumor at definitive histology. The aim of this study was to identify clinicopathological factors along with intrinsic subtypes of the tumor (luminal A, luminal B, HER2-overexpressing, triple-negative) associated with residual tumor in re-excision or mastectomy specimen. METHODS Two hundred forty-eight patients with initial BCS, who underwent one or more re-excisions or mastectomy because of close or positive margins were reviewed. RESULTS Residual cancer was found in 50% of re-excision(s) or mastectomy specimens. Patients with multifocality (vs unifocality; OR = 5.2; 95% CI, 2.6-10.4) or positive nodes (vs negative nodes; OR = 2.5; 95% CI, 1.4-4.4), or positive margins (vs close margins; OR = 1.7; 95% CI = 1.0-2.9) were more likely to have residual tumor in re-excision or mastectomy specimen compared to others. CONCLUSION Our results suggest that further surgery is often indicated in patients with node positive or multifocal cancers or positive margins after BCS since residual disease cannot be ruled out. Re-excision or mastectomy could be omitted in patients with close margins with favorable factors such unifocal tumor or node negative disease.

Factors predicting microinvasion in Ductal Carcinoma in situ.

BACKGROUND Whether sentinel lymph node biopsy (SLNB) should be performed in patients with pure ductal carcinoma in situ (DCIS) of the breast has been a question of debate over the last decade. The aim of this study was to identify factors associated with microinvasive disease and determine the criteria for performing SLNB in patients with DCIS. MATERIALS AND METHODS 125 patients with DCIS who underwent surgery between January 2000 and December 2008 were reviewed to identify factors associated with DCIS and DCIS with microinvasion (DCISM). RESULTS 88 patients (70.4%) had pure DCIS and 37 (29.6%) had DCISM. Among 33 DCIS patients who underwent SLNB, one patient (3.3%) was found to have isolated tumor cells in her biopsy, whereas 1 of 14 (37.8%) patients with DCISM had micrometastasis (7.1%). Similarly, of 16 patients (18.2%) with pure DCIS and axillary lymph node dissection (ALND) without SLNB, none had lymph node metastasis. Furthermore, of 20 patients with DCISM and ALND, only one (5%) had metastasis. In multivariate analysis, the presence of comedo necrosis [relative risk (RR)=4.1, 95% confidence interval (CI)=1.6-10.6, P=0.004], and hormone receptor (ER or PR) negativity (RR=4.0, 95%CI=1.5-11, P=0.007), were found to be significantly associated with microinvasion. CONCLUSIONS Our findings suggest patients presenting with a preoperative diagnosis of DCIS associated with comedo necrosis or hormone receptor negativity are more likely to have a microinvasive component in definitive pathology following surgery, and should be considered for SLNB procedure along with patients who will undergo mastectomy due to DCIS.

The effect of internal mammary lymph node biopsy on the therapeutic decision and survival of patients with breast cancer

BACKGROUND The role of internal mammary lymph node biopsy (IMLNB) is still being discussed in breast cancer treatment. The aim of this study was to investigate the role of IMLNB on adjuvant therapy and survival of patients with breast cancer. PATEINTS AND METHODS The data of 72 patients with clinically negative axilla and IMLNB were evaluated. IMLNB was performed either through a small separate intercostal incision or from the same incision for tumor resection or mastectomy by using both blue dye and radioisotope. Pathological analysis was performed on formalin-fixed paraffin-embedded tissues. RESULTS Ten of the patients (14%) were IMLNB-positive. The axillary sentinel lymph node and IMLN were negative in most of the patients (52.8%). In one patient (1.4%), the axilla was negative but the IMLNB was positive. IMLNB changed the pathologic stage in eight patients (11%). Adjuvant internal mammary radiotherapy was added to the treatment protocol for 10 patients due to IMLNB positivity and adjuvant chemotherapy was added in for only one patient with negative axilla. The factors found to be related with IMLN positivity were SLN positivity (p = 0.033), mastectomy (p = 0.022), and the number of resected IMLN ≥2 (p = 0.040). The median follow-up time was 115.5 months (range, 30-162 months). The ten-year overall survival (OS) rate was 86%. Systemic metastasis (p = 0.007), SLNB positivity (p < 0.001), and IMLNB positivity (p = 0.005) were statistically related to overall survival. CONCLUSION IMLNB positivity in patients with breast cancer changed the pathologic stage and adjuvant treatment modalities of patients and also adversely affected the overall survival.

Successful First Round Results of a Turkish Breast Cancer Screening Program with Mammography in Bahcesehir, Istanbul

BACKGROUND The Bahcesehir Breast Cancer Screening Project is the first organized population based breast cancer mammographic screening project in Turkey. The objective of this prospective observational study was to demonstrate the feasibility of a screening program in a developing country and to determine the appropriate age (40 or 50 years old) to start with screening in Turkish women. MATERIALS AND METHODS Between January 2009 to December 2010, a total of 3,758 women aged 40-69 years were recruited in this prospective study. Screening was conducted biannually, and five rounds were planned. After clinical breast examination (CBE), two-view mammograms were obtained. True positivity, false positivity, positive predictive values (PPV) according to ACR, cancer detection rate, minimal cancer detection rate, axillary node positivity and recall rate were calculated. Breast ultrasound and biopsy were performed in suspicious cases. RESULTS Breast biopsy was performed in 55 patients, and 18 cancers were detected in the first round. The overall cancer detection rate was 4.8 per 1,000 women. Most of the screened women (54%) and detected cancers (56%) were in women aged 40- 49. Ductal carcinoma in situ (DCIS) and stage I cancer and axillary node positivity rates were 22%, 61%, and 16.6%, respectively. The positive predictivity for biopsy was 32.7%, whereas the overall recall rate was 18.4 %. CONCLUSIONS Preliminary results of the study suggest that population based organized screening are feasible and age of onset of mammographic screening should be 40 years in Turkey.

Factors That Affect the False-Negative Outcomes of Fine-Needle Aspiration Biopsy in Thyroid Nodules

Background. The purpose of this study was to assess the factors that affect the false-negative outcomes of fine-needle aspiration biopsies (FNABs) in thyroid nodules. Methods. Thyroid nodules that underwent FNAB and surgery between August 2005 and January 2012 were analyzed. FNABs were taken from the suspicious nodules regardless of nodule size. Results. Nodules were analyzed in 2 different groups: Group 1 was the false-negatives (n = 81) and Group 2 was the remaining true-positives, true-negatives, and false-positives (n = 649). A cytopathologist attended in 559 (77%) of FNAB procedures. There was a positive correlation between the nodule size and false-negative rates, and the absence of an interpreting cytopathologist for the examination of the FNAB procedure was the most significant parameter with a 76-fold increased risk of false-negative results. Conclusion. The contribution of cytopathologists extends the time of the procedure, and this could be a difficult practice in centres with high patient turnovers. We currently request the contribution of a cytopathologist for selected patients whom should be followed up without surgery.

Multiple gastrointestinal stromal tumors and pheochromocytoma in a patient with von Recklinghausen's disease

INTRODUCTION Neurofibromatosis type 1 is a genetic disease characterized by neoplastic and non neoplastic disorders involving tissues of neuroectodermal and mesenchymal origin. Herein, we present a case with von Recklinghausens disease, right adrenal heochromocytoma and multiple gastrointestinal stromal tumors. PRESENTATION OF CASE A forty-eight year old male patient was admitted to our Emergency Department with melena. His physical examination revealed multiple neurofibromas all over the skin, kyphosis, multiple cafe au lait spots and Lisch nodules on the eye and, melena on digital rectal examination. Abdominal computerized tomography scan showed a mass on right adrenal gland and multiple soft tissue mass lesions between distal part of pancreas and small bowel. Adrenal mass was determined as a pheochromocytoma and small bowel lesions were verified as stromal tumors. DISCUSSION In patients with NF1, pheochromocytomas and GISTs are well known neoplasms seen with increased incidence than the general population. CONCLUSION In patients with NF1, any symptoms with other systems should be managed carefully for underlying malignity.