Christine Desbiens

Factors associated with upgrading to malignancy at surgery of atypical ductal hyperplasia diagnosed on core biopsy

Previous studies have shown that 4-54% of breast lesions reported on core biopsies as atypical ductal hyperplasia (ADH) are upgraded on further excision to ductal carcinoma in situ (DCIS) or invasive carcinoma. We evaluated the rate of upgrading ADH to carcinoma at surgery for ADH diagnosed by percutaneous biopsy, and examined characteristics associated with malignancy. We identified 13,488 consecutive biopsies conducted at one center over a nine-year period. A total of 422 biopsies with ADH in 415 patients were included. DCIS or invasive carcinoma was found in 132 cases (31.3% upgrading). Multivariate model revealed that ipsilateral breast symptoms, mammographic lesion other than microcalcifications alone, 14G core needle biopsy, papilloma co-diagnosis, severe ADH and pathologists with lower volume of ADH diagnosis were factors statistically associated with malignancy. However, no subgroups were identified for safe clinical-only follow-up. Surgery is recommended in all cases of ADH diagnosed by percutaneous breast biopsy.

The Choosing Wisely Canada cancer initiative.

5 Background: Choosing Wisely Canada is a campaign modelled after Choosing Wisely in the USA and aims, through a pan-Canadian cancer physician-based consensus process, to identify a list of low value or harmful cancer services/practices frequently used in Canada. The following describes the approach taken for this work related to cancer in Canada. METHODS A Task Force approach was used, facilitated by the Canadian Partnership Against Cancer (CPAC), and included representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: (1) identify potentially relevant items and a framework for their subsequent selection; (2) develop a long list; (3) refine and reduce the long list to a short list; and (4) select and endorse a final list of low value or harmful cancer practices. Phases 2-4 followed a framework-driven consensus process and used a series of electronic surveys and voting processes. RESULTS For Phase 1, 66 cancer relevant practices were initially identified. The framework for subsequent selection included: (1) the size of population to which the practice is relevant; (2) frequency of use in Canada; (3) cost; (4) evidence of low value/harm; and (5) potential for change in use of the practice. The long list (41 practices) was refined and reduced to a short list of 19 practices and a final list including 10 practices. Of these, 5 are completely new, and 3 are revisions/adaptations practices from USA Choosing Wisely. Of the 10 practices, 6 are involve multiple disease sites, while 4 practices are disease-site specific. One practice relates to diagnosis, 6 are treatment- focussed, 2 target surveillance/survivorship, while one practice spans the cancer continuum from diagnosis through survivorship. CONCLUSIONS Through CPAC facilitation, the collective input and work of three professional oncology societies informed this initiative. The content of the final list will be officially released through Choosing Wisely Canada in October 2014, and will be fully revealed at the ASCO Quality Care Symposium.

Primary Breast Angiosarcoma: Avoiding a Common Trap

Background. Primary breast angiosarcoma is a rare entity. Case. Initial diagnosis was a benign hemangioma at core biopsy. Wide local excision was performed, with positive margins. Pathology after surgery reported a moderately differentiated angiosarcoma. Tumor was finally treated using mastectomy and radiations. She developed a second angiosarcoma in contralateral breast, with an initial diagnosis on core biopsy of an atypical vascular lesion and was again treated using mastectomy and radiations. She developed bones and lung metastases. Conclusion. Primary breast angiosarcoma is a rare entity often difficult to diagnose on core biopsy, and a benign differential diagnosis is frequent. A highly vascular breast mass should always be considered malignant until proven otherwise. Surgical treatment seems to be the best course of action. There is a lack of data proving efficacy of adjuvant chemotherapy and radiation therapy.

Metastatic pattern of invasive lobular carcinoma of the breast-Emphasis on gastric metastases.

Breast invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC) have different metastatic patterns, but the exact pattern of metastases from ILC is poorly known. This study aimed to determine the frequency of ILC metastases in atypical locations, with an emphasis on gastric metastases.

Low Frequency of Cancer Occurrence in Same Breast Quadrant Diagnosed with Lobular Neoplasia at Percutaneous Needle Biopsy

PURPOSE To determine the type of mammographic abnormality leading to needle biopsy of lobular neoplasia (LN) and define the clinical evolution of low-risk LN lesions diagnosed at needle biopsy but not surgically removed. MATERIALS AND METHODS This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. Among 16 945 needle biopsies performed between April 1998 and August 2008, LN was determined to be the most suspicious lesion in 352 samples (2.1%) (pleomorphic and necrotic forms were excluded). Among 299 pure LN lesions that were not surgically removed, follow-up was available for 276 lesions in 275 women. RESULTS Needle biopsy was performed because of mammographic calcifications in 215 of the 276 lesions (77.9%) and because of mammographic masses in 35 (12.7%). The mean follow-up was 5.0 years ± 2.4 (range, 0.6-12.2 years). All 275 women underwent one mammographic follow-up, 205 (74.5%) underwent a second mammographic follow-up, and 147 (53.5%) underwent a third mammographic follow-up. Cancer was diagnosed in 27 of the 275 cases (9.8%) after a mean of 3.9 years ± 2.6 (range, 1.2-10.8 years). Only three cancers (1.1%) occurred in the same breast quadrant as the one originally diagnosed with LN at needle biopsy. CONCLUSION Lumpectomy of pure LN lesions may not prevent malignancy in most cases. Consequently, women with pure LN of a low-risk type diagnosed at needle biopsy are strongly encouraged to undergo a yearly breast clinical examination and yearly mammographic follow-up to detect an eventual cancer in its early stages.

Choosing Wisely Canada cancer list: ten low-value or harmful practices that should be avoided in cancer care.

PURPOSE Choosing Wisely Canada, modeled after Choosing Wisely in the United States, is intended to identify low-value or potentially harmful practices relevant to the Canadian health care environment. Our objective was to use multidisciplinary, pan-Canadian, physician-based consensus to identify a list of low-value or harmful cancer practices frequently used in Canada. METHODS A Task Force convened by the Canadian Partnership Against Cancer included physician representation from the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology, and an expert advisor. The methodology included four phases: identify potentially relevant items, develop a long list, refine and reduce the long list to a short list, and select and endorse a final list. A framework-driven consensus process and a series of electronic surveys and voting processes were used to capture consensus. RESULTS Sixty-six potentially relevant cancer-related practices were identified. The long list (41 practices) was reduced to a short list of 19 practices. Of the 10 practices on the final list, five are completely new, and five are revisions or adaptations of practices from previous US society lists. Six of the 10 involve multiple disease sites, and four are disease-site specific. One relates to diagnosis, six relate to treatment, two relate to surveillance/survivorship, and one practice spans the cancer care continuum. CONCLUSION The cancer list was developed in partnership with the Canadian Society of Surgical Oncology, Canadian Association of Medical Oncologists, and Canadian Association of Radiation Oncology. Using knowledge translation and exchange efforts, this list should empower patients with cancer and physicians to assist in a targeted conversation about the appropriateness and quality of individual patient care.

Comparison of Serious Adverse Events Between the Original and a Generic Docetaxel in Breast Cancer Patients

Background: Generic formulations are not necessarily identical to the original in terms of efficacy and adverse events. Generic docetaxel has been available in Canada since 2011. Objective: To compare the occurrence of grade III to IV adverse events between original docetaxel and a generic formulation in breast cancer patients. Methods: A consecutive series of 400 patients were assessed retrospectively: 200 who received the original docetaxel and 200 who received a generic formulation. Patients who received both formulations or received their chemotherapy outside our center were excluded. The primary outcome was the occurrence of grade III to IV adverse events related to docetaxel (febrile neutropenia, hand and foot syndrome, intestinal perforation, thrombotic event, and death). Results: Three hundred-sixty-four patients were available for analysis (182/group). The use of a granulocyte colony-stimulating factor (G-CSF) was more frequent in the generic group (44.5% vs 28.8%), as well as treatment discontinuation (26.4% vs 14.8%). The occurrence of grade III to IV febrile neutropenia, hand and foot syndrome, intestinal perforation, thrombotic event, and docetaxel-related deaths were similar between the 2 formulations. However, grade IV febrile neutropenia was more frequent with the generic formulation (78.8% vs 56.3%). Limitations were the retrospective nature of the study and the variety of chemotherapy regimens. Conclusion: Adverse events occurrence was similar between the 2 formulations. However, febrile neutropenia was more serious with generic docetaxel, despite increased G-CSF use. Results suggest that the studied generic formulation may be safe, but more caution during treatments might be warranted, especially concerning febrile neutropenia events.

How Wide Should Margins Be for Phyllodes Tumors of the Breast

The surgical management of phyllodes tumors (PTs) is still controversial. Some studies have suggested surgical margins ≥1 cm, but recent studies suggested that negative margins could be appropriate regardless of their width. To evaluate recurrence rates of PTs following surgery according to margins. Retrospective study of women who attended a tertiary breast cancer reference center between 1998 and 2010: 142 patients with a PT diagnosis, either at minimally invasive breast biopsy or at surgery, were identified. Clinical, pathologic and follow‐up characteristics were assessed. Among 140 patients who underwent surgery, 64.3% of biopsies accurately predicted the final PT diagnosis at surgery. Forty‐two (42/87, 48.3%) PTs had positive margins. Twenty‐one (21/42, 50.0%) patients had a surgical revision of margins. Only one (1/42, 2.4%) had margins greater or equal to 1 cm. After a median follow‐up of 1.29 years in benign PTs, 4.99 years in borderline PTs, and 5.42 years in malignant PTs, there were five local recurrences, three in originally benign PTs and two in borderline PTs. All were managed with surgery. Four had initial margins ≤1 mm. One patient with borderline PT had a local recurrence and later progressed to regional recurrence and metastasis. Free surgical margins are necessary to treat PT, and margins of at least 1 mm might be sufficient to prevent recurrence. Core needle biopsy might not be the best diagnostic tool for PTs.

Is there an Upgrading to Malignancy at Surgery of Mucocele-Like Lesions Diagnosed on Percutaneous Breast Biopsy?

Management of pure mucocele‐like lesion (MLL) diagnosed on percutaneous breast biopsy (PBB) is controversial. To assess surgical upgrade rate and clinical outcome of pure MLL obtained as sole diagnosis on PBB. Patients diagnosed with a MLL as the most advanced lesion on PBB from April 1997 to December 2010 were reviewed for radiologic presentation, biopsy technique, and pathologic and clinical outcomes. Of the 21,340 image‐guided PBB performed during the study period, 50 women with 51 MLL (0.24%) were identified. Mean age was 53.1 ± 7.7 years. Radiologic findings were mostly microcalcifications (n = 47, 92.2%). Stereotactic PBB was performed for 49 lesions (96.1%). Surgery was performed shortly after biopsy in 35 women, with benign final pathology in 33, and upgrade to ductal carcinoma in situ (DCIS) in two patients (2/35, 5.7%). Mean follow‐up was 4.2 ± 2.5 years (3.7 ± 2.1 years for surgical patients; 5.9 ± 2.9 years for follow‐up only patients); three women were lost to follow‐up (3/50). Three invasive cancers (3/47, 6.4%) were diagnosed 1.2, 1.2, and 2.8 years after biopsy: two in surgical patients, and one in a follow‐up only patient. No cancer occurred at the same site as the original MLL. Pure MLL lesion of the breast is a rare entity and is mostly associated with a benign outcome. We observed an upgrade to DCIS slightly superior to 5%, but no invasive cancer. It is therefore unclear if these lesions should be excised or clinically and radiologically followed up when such lesions are found at PBB.

Characteristics and long-term survival of patients diagnosed with pure tubular carcinoma of the breast

Pure tubular carcinomas (TC) of the breast are generally considered to have an excellent prognosis. This study aimed to analyze the characteristics and survival of patients with TC.