Effstratios Patsouris

Diagnosing papillary lesions using vacuum-assisted breast biopsy: should conservative or surgical management follow?

Background: This study evaluates the underestimation rate of papilloma lesions diagnosed with vacuum-assisted breast biopsy (VABB), taking into consideration the greater volume excised. Patients and Methods: 56 women with a diagnosis of a papilloma lesion after VABB (Mammotest; Fischer Imaging, Denver, CO, USA) were evaluated. At least 24 cores were excised in all cases (mean 74, range 24–96 cores) and a preoperative diagnosis was established. Subsequently, open surgery using hook-wire localization followed. A second, postoperative diagnosis was independently and blindly made. The association between the pathological types and Breast Imaging Report and Data System (BI-RADS) classification, as well as the discrepancy between preoperative and postoperative diagnoses, was evaluated. Results: The underestimation rate of papillary lesions was 3.6%. When the papillary lesions did not coexist preoperatively with any other precursor breast lesions, the underestimation rate was 0%. The underestimation rate did not differ with age, BI-RADS category or type of lesion. Conclusion: Conservative management of patients with a papillary lesion diagnosis may follow when the extended VABB protocol is adopted and a great tissue volume is excised. However, when diagnosing a coexisting papillary lesion with a precursor breast lesion, open surgery should follow, given the high probability of a postoperative cancer diagnosis.

Hsp90 in the continuum of breast ductal carcinogenesis: Evaluation in precursors, preinvasive and ductal carcinoma lesions

BackgroundHsp90 (heat shock protein90) is a chaperone protein essential for preserving and regulating the function of various cellular proteins. Elevated Hsp90 expression seems to be a trait of breast cancer and may be an integral part of the coping mechanisms that cancer cells exhibit vis-à-vis stress. This manuscript tries to examine the immunohistochemical expression of Hsp90 all along the continuum of breast ductal lesions encompassing ductal hyperplasia without atypia (DHWithoutA), atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC).MethodsTissue specimens were taken from 30 patients with DHWithoutA, 31 patients with ADH, 51 with DCIS and 51 with IDC. Immunohistochemical assessment of Hsp90 was performed both in the lesion and the adjacent normal breast ducts and lobules; the latter serving as control. Concerning Hsp90 assessment the percentage of positive cells and the intensity were separately analyzed. Subsequently, the Allred score was calculated. Post hoc analysis on the correlations between Hsp90 Allred score and possible predictors (grade, nodal status, tumor size, ER Allred score, PR Allred score, c-erbB-2 status and triple negative status) was conducted in IDC.ResultsHsp90 exhibited mainly cytoplasmic immunoreactivity. Hsp90 Allred score exhibited an increasing trend along the continuum of breast ductal lesions (Spearmans rho = 0.169, p = 0.031). Compared to the adjacent normal ducts and lobules, no statistically significant differences were noted in DHwithoutA, ADH and DCIS. Hsp90 expression (intensity, positive cells, Allred score) was higher in IDC, compared to the adjacent normal tissue. Higher Hsp90 expression was observed in grade 2/3 IDCs (borderline association) and tumors of larger size. At the univariable analysis, higher Hsp90 expression was associated with higher ER Allred score, PR Allred score and c-erbB-2 positivity in IDC. Triple-negative IDCs exhibited significantly lower Hsp90 expression. The multivariable logistic regression model revealed that between the three markers, solely ER Allred score and c-erbB-2 positivity were independently associated with higher Hsp90 expression in IDC.ConclusionThe above point to significant variability in Hsp90 expression with significant implications upon the effectiveness and limitations of anti-Hsp90 drugs.

Decreased Hsp90 expression in infiltrative lobular carcinoma: an immunohistochemical study

BackgroundElevated Hsp90 expression has been documented in breast ductal carcinomas, whereas decreased Hsp90 expression has been reported in precursor lobular lesions. This study aims to assess Hsp90 expression in infiltrative lobular carcinomas of the breast.MethodsTissue specimens were taken from 32 patients with infiltrative lobular carcinoma. Immunohistochemical assessment of Hsp90 was performed both in the lesion and the adjacent normal breast ducts and lobules; the latter serving as control. Concerning Hsp90 assessment: i) the percentage of positive cells and ii) the intensity were separately analyzed. Subsequently, the Allred score was adopted and calculated. The intensity was treated as an ordinal variable-score (0: negative, low: 1, moderate: 2, high: 3). Statistical analysis followed.ResultsAll infiltrative lobular carcinoma foci mainly presented with a positive cytoplasmic immunoreaction for Hsp90. Compared to the adjacent normal ducts and lobules, infiltrative lobular carcinoma exhibited a statistically significant decrease in Hsp90 expression, both in terms of Hsp90 positive cells (%) and Allred score (74.2 ± 11.2 vs. 59.1 ± 14.2 p = 0.0001; 7.00 ± 0.95 vs. 6.22 ± 1.01, p = 0.007, Wilcoxon matched-pairs signed-ranks test). Concerning the intensity of Hsp90 immunostaining only a marginal decrease was noted (2.16 ± 0.68 vs. 1.84 ± 0.63, p = 0.087, Wilcoxon matched-pairs signed-ranks test).ConclusionILC lesions seem to exhibit decreased Hsp90 expression, a finding contrary to what might have been expected, given that high Hsp90 expression is a trait of invasive ductal carcinomas.

Ductal endoscopy of the breast: more painful at the luteal phase?

Purpose:  To assess the putative predictors that may influence the pain experienced during ductal endoscopy of the breast.

Lesions of “Uncertain Malignant Potential” Diagnosed by Vacuum-Assisted Breast Biopsy: An Unclear Management?

Dear Editor, The malignancy rate of breast lesions categorized as lesions of ‘‘uncertain malignant potential’’ (B3, according to the UK breast screening program) after excision is crucial in terms of optimal management in daily clinical practice. Dillon et al. have provided an important insight into the topic in a comprehensive study based on a large number of patients and the entire spectrum of B3 and B4 lesions. However, they mainly conducted their study based on automated rather than vacuumassisted biopsy (VABB) devices, as the latter have only recently been introduced into practice. Our research team estimated the malignancy rate of B3 lesions diagnosed by VABB (11G). Independently, our research team has evaluated putative ways of minimizing underestimation rate in preinvasive breast lesions. This letter summarizes our results on B3 lesions and compares them with the results of Dillon et al. In our sample more cores were excised than internationally recommended, ranging from 24 to 96. Cases where two or more lesions coexisted were classified as a higher relative risk. A total of 131 patients with B3 lesions were diagnosed in a 3-year period; in 11 lesions the predominant diagnosis was that of radial scars, in 47 lesions papilloma, in 33 lesions atypical intraductal epithelial proliferation (AIEP), in 32 lesions lobular neoplasia (LN), and in 8 lesions phyllodes tumor. In all cases, open surgery followed and a postoperative diagnosis was established. A second pathologist blind to the preoperative diagnosis examined the tissue removed. The overall rate of malignancy in our material was 5/131 (3.8%, 95% CI: 1.3%–8.7%): 1/47 (2.1%, 95% CI: 0.1%–11.3%) in papilloma, 2/33 (6.1%, 95% CI: 0.7%–20.2%) in AIEP, and 2/32 (6.3%, 95% CI: 0.8%–20.8%) in LN; no underestimation rate was observed in radial scars (0%, one-sided, 97.5% CI: 0%–28.5%) and phyllode tumors (0%, one-sided, 97.5% CI: 0%–36.9%). The underestimation rate in our sample is lower than that reported by Dillon et al. (5/131 versus 37/177 for patients subsequently undergoing open biopsy; p\ 0.001, Pearson’s chisquare test); similarly the same p value is obtained when comparing our results to the total of the sample by Dillon et al. This discrepancy can possibly be attributed to the use of VABB device as well as to the number of cores excised during the procedure. The minimization of the underestimation rate in VABB (excising more cores) is of special interest since this observation may lead to a modified way of managing B3 lesions diagnosed by VABB. In conclusion, it can be said that our results confirm and possibly reinforce the observations of Dillon et al. viz: (1) patients with predominant RS could be monitored, (2) not all LN lesions need surgical excision, and (3) lesions with atypia are more likely to be underestimated. However, patients with a papilloma diagnosis, without other coexisting B3 lesions, could potentially be managed conservatively. Published online April 19, 2008. Address correspondence and reprint requests to: George Zografos, PhD, FACS; E-mail: gzografo@med.uoa.gr