Germana Lissidini

The indocyanine green method is equivalent to the 99mTc-labeled radiotracer method for identifying the sentinel node in breast cancer: A concordance and validation study

AIMS The aim of this study was to assess concordance between the indocyanine green (ICG) method and (99m)Tc-radiotracer method to identify the sentinel node (SN) in breast cancer. Evidence supports the feasibility and efficacy of the ICG to identify the SN, however this method has not been prospectively compared with the gold-standard radiotracer method in terms of SN detection rate. METHODS Between June 2011 and January 2013, 134 women with clinically node-negative early breast cancer received subdermal/peritumoral injection of (99m)Tc-labeled tracer for lymphoscintigraphy, followed by intraoperative injection of ICG for fluorescence detection of SNs using an exciting light source combined with a camera. In all patients, SNs were first identified by the fluorescence method (ICG-positive) and removed. A gamma ray-detecting probe was then used to determine whether ICG-positive SNs were hot ((99m)Tc-positive) and to identify and remove any (99m)Tc-positive (ICG-negative) SNs remaining in the axilla. The study was powered to perform an equivalence analysis. RESULTS The 134 patients provided 246 SNs, detected by one or both methods. 1, 2 and 3 SNs, respectively, were detected, removed and examined in 70 (52.2%), 39 (29.1%) and 17 (12.7%) patients; 4-10 SNs were detected and examined in the remaining 8 patients. The two methods were concordant for 230/246 (93.5%) SNs and discordant for 16 (6.5%) SNs. The ICG method detected 99.6% of all SNs. CONCLUSIONS Fluorescent lymphangiography with ICG allows easy identification of axillary SNs, at a frequency not inferior to that of radiotracer, and can be used alone to reliably identify SNs.

Immediate breast reconstruction after mastectomy

AIMS There is a general agreement for immediate breast reconstruction in case of in situ tumors, while the reconstruction is often still delayed in cases of invasive cancers or not performed in the elderly cohort. Aim of this review is to investigate the safety of immediate postmastectomy reconstruction for invasive cancers and in the elderly population. METHODS AND RESULTS We reviewed our series and the recent literature on this topic. While there is a general consensus that advanced age is not a contraindication to immediate reconstruction and breast reconstruction can be successfully performed on well-selected elderly patients, many oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating the risk of delay of the medical adjuvant treatment in case of complications due to the reconstructive procedure. Our experience and a lot of studies suggest that immediate breast reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if postmastectomy irradiation is necessary on the basis of the final pathological finding, this is associated with a high rate of surgical complications and implant loss among patients who underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. CONCLUSIONS Immediate breast reconstruction after mastectomy is an integral part of the complete management of breast cancer. Determining the risk of postmastectomy irradiation prior to definitive resection and reconstructive operations may reduce complications and improve aesthetic outcomes by guiding surgical decision making.

The clinical relevance of micropapillary carcinoma of the breast: a case–control study

To ascertain the prognostic relevance of micropapillary carcinoma, a specific type of breast tumour.

Are all patients with ductal carcinoma in situ of the breast candidates for radiotherapy after breast conservative treatment? Institute of European Oncology Guidelines.

To the Editor: At present, we know that adjuvant radiotherapy (RT) after breast-conserving surgery (BCS) reduces local recurrence (LR) rates by about 50% in patients with ductal carcinoma in situ (DCIS) of the breast, with no benefits on survival. Comparable reductions were seen for the rise of both invasive and noninvasive LR. Also, nonsignificant long-term toxicity from RT was found (1). This has been demonstrated by wellknown randomized trials as NSABP B-17 (2), UK-ANZ (3), EORTC 10853 (4), SweDCIS (5), and recently confirmed by an update of the same studies (6). But do all DCIS patients have to undergo RT after BCS? This question was answered with opposing opinions by Buchholz (positively) (7) and Silverstein (negatively) (8). The answer offered by the 2011 St Gallen Consensus Conference (9) was in the negative: most panelists considered that RT could be avoided in elderly women or in patients with low-grade DCIS and clearly negative margins. On this last point, there is no agreement about the limits of safety related to the width of surgical margins (10) that vary from 10 mm to 1 mm, with intermediate measures of 3 mm, 2–3 mm and 2 mm. On the other hand, DCIS patients with G3 disease and necrosis are generally considered suitable for adjuvant RT, as both of them are associated with higher risk of recurrence (11). Major controversies are related to the need for RT in lower grade disease. Two prospective studies showed contradictory results: in the Dana-Faber Cancer Institute trial the omission of RT resulted in a cumulative LR rate of 12% at 5-year (12). Conversely, the EORTC 10850 trial showed a reduced risk of LR rate in the G1 subgroup after surgery alone, less than 10%, but at a doubled follow-up time, 10 years (4). Advances in molecular profiling analysis (13) along with the well-known clinical and pathologic parameters might help to improve risk stratification and decision-making. Several studies have investigated the prognostic significance of biomarkers, such as estrogen receptor status, HER2/neu expression, Ki-67-expression (14), but their validation is complex and needs to be tested prospectively in large cohorts of patients. These previous data justify the still open debate regarding the practice of RT in patients with DCIS. The lack of shared opinions is confirmed if we examine the published surveys on the indications and utilization of RT after BCS. In the UK, patients were significantly more likely to have RT planned (and administered) if they had large (>15 mm), intermediate or high-grade tumors or if central comedo-type necrosis was present (15). In North America, there were strong correlations between the grade of DCIS and margin status and the use of RT (16). Recommendations are in favor of RT as grade increased (more than 97% in G3) and margin width decreased (more than 95% with <10 mm). There were substantial differences in opinion between North America and Europe, as well as in Europe itself, especially regarding low-grade and wide margin lesions, for which Europeans offered observations more often than Americans (56.9% versus 41.2%). Substantial differences by surgeons in surgical treatment, receipt of RT and margin status found by Dick et al. (17) emphasize the importance of the physicians in the quality of care of DCIS. The heterogeneity of the disease accounts for the heterogeneity of treatment and makes the perception of risk and the treatment choices challenging (18). At the European Institute of Oncology (IEO), in Milan, for more than a decade RT was only administered to DCIS patients with G3, or G2 with comedo-type Address correspondence and reprint requests to: Gabriel Farante, European Institute of Oncology, Via Ripamonti 435, Milan 20141, Italy, or e-mail: gabriel.farante@ieo.it

Could radiotherapy play a major role in misidentification of sentinel lymph node in breast cancer recurrence

Misidentification of sentinel lymph node via lymphoscintigraphy for breast cancer is an infrequent event. We analysed 35.022 consecutive procedures from a single institution and tried to find a correlation between failures of sentinel node identification and previous oncologic treatments received by the patients.

Intra‐operative radiotherapy management for breast cancer treatment in patients with pseudoxanthoma elasticum: A case report

Pseudoxanthoma elasticum is a systemic metabolic disease presenting calcifications and progressive fragmentation of elastic fibers. Actually, no targeted therapies are available for the treatment; only prevention of complications is possible. Classically, pseudoxanthoma elasticum is a “benign” disease, without cancer association. Herein, we reported a singular association of pseudoxanthoma elasticum with breast carcinoma, describing the clinical management, in particular intra‐operative treatment, focusing on intra‐operative radiotherapy since no specific guidelines are available in literature.

Granular cell tumor of the breast: Molecular pathology and clinical management

Granular cell tumor is a rare condition that occasionally affects breast parenchyma: approximately, 5%‐15% of all granular cell tumors represent 1:1000 of breast tumors. In this study, we reported a consecutive series of 12 patients with primary granular cell tumor of the breast observed at our institute, focusing attention on preoperative management, surgical approach, and long‐term follow‐up. Eight cases (8/12; 66.78%) presented with left‐breast tumors; in the majority of patients (11/12; 91.7%), the lesion was identified in one of the upper quadrants. Specifically, upper intern quadrants (10 cases) were more affected. Surgical excision was performed in all patients. Mean diameter at pathologic section was 11.4 mm (range: 5‐22). Tumor relapse was reported only in one case (8.3%). Mean follow‐up was 98.1 months (range: 1‐192). We proposed a model to explain the molecular mechanism of granular cell tumorigenesis associating to the high level of S100 protein. Management of primary granular cell tumor of the breast requires a correct initial diagnosis using breast imaging associated with core biopsy. Surgical procedure with wide resection or quadrantectomy requires a careful evaluation of breast margins.

S25 Immediate breast reconstruction after mastectomy

Aims: We present a brief overview of the current state of postmastectomy immediate reconstruction, which is actually an integral part of breast cancer treatment with positive aesthetic and psychosocial effects. The preservation of the inframammary fold and the conservation of the skin envelope and nipple areola complex has led to improved cosmetic results following both autologous and implant-based reconstruction. There is a general agreement for immediate breast reconstruction in case of in situ tumors, while the reconstruction is often delayed in cases of invasive cancers or contraindicate in the elderly cohort. Second endpoint of this review is to investigate the safety of immediate postmastectomy reconstruction for invasive cancers and in the elderly population. Methods and results: We reviewed our series and the recent literature on this topic. While there is a general consensus that advanced age is not a contraindication to immediate reconstruction and breast reconstruction can be successfully performed on well-selected elderly patients, most oncologists in Europe do not prefer immediate reconstruction for invasive carcinoma, advocating the risk of delay of the medical adjuvant treatment in case of complications due to the reconstructive procedure. Our experience and a lot of studies suggest that immediate breast reconstruction is a safe and reliable treatment option in case of invasive cancers. However, if postmastectomy irradiation is necessary on the basis of the final pathological finding, this is associated with a high rate of surgical complications and implant loss among patients who underwent immediate reconstruction with prostheses. Moreover, current evidence suggests that postmastectomy radiation therapy also adversely affects autologous tissue reconstruction. Conclusions: Immediate breast reconstruction after mastectomy is an integral part of the complete management of breast cancer. Determining the risk of postmastectomy irradiation prior to definitive resection and reconstructive operations may reduce complications and improve aesthetic outcomes by guiding surgical decision making.