Gianluca Franceschini

Characterization of Solid Breast Masses Use of the Sonographic Breast Imaging Reporting and Data System Lexicon

Objective. The purpose of this study was to determine the reliability of sonographic American College of Radiology Breast Imaging Reporting And Data System (BI‐RADS) classification in differentiating benign from malignant breast masses. Methods. One hundred seventy‐eight breast masses studied by sonography with a known diagnosis were reviewed. All lesions were classified according to the sonographic BI‐RADS lexicon. Pathologic results were compared with sonographic features. Sensitivity, specificity, accuracy, and positive predictive value (PPV) and negative predictive value (NPV) for the sonographic BI‐RADS lexicon were calculated. Results. Twenty‐six cases were assigned to class 3, 73 to class 4, and 79 to class 5. Pathologic results revealed 105 malignant and 73 benign lesions. The sonographic BI‐RADS lexicon showed 71.3% accuracy, 98.1% sensitivity, 32.9% specificity, 67.8% PPV, and 92.3% NPV. The NPV for class 3 was 92.3%. The PPVs for classes 4 and 5 were 46.6% and 87.3%. Typical signs of malignancy were irregular shape, antiparallel orientation, noncircumscribed margin, echogenic halo, and decreased sound transmission. Typical signs of benignity were oval shape and circumscribed margin. Conclusions. The sonographic BI‐RADS lexicon is an important system for describing and classifying breast lesions.

Oncoplastic techniques in the conservative surgical treatment of breast cancer: an overview.

Abstract:  Conservative surgery has become a well‐established alternative to mastectomy in the treatment of breast cancer. However, in case of larger lesions or small‐size breasts, the removal of adequate volumes of breast tissue to achieve tumor‐free margins and reduce the risk of local relapse may compromise the cosmetic outcome, causing unpleasant results. In order to address this issue, new surgical techniques, so‐called oncoplastic techniques, have been introduced in recent years to optimize the efficacy of conservative surgery both in terms of local control and cosmetic results. This article discusses the indications, advantages, and limitations of these techniques and their results in terms of local recurrence and overall survival. 

Solid breast mass characterisation: use of the sonographic BI-RADS classification

PurposeThe aim of this study was to assess the reliability of the sonographic Breast Imaging Reporting and Data System (BI-RADS) classification in differentiating benign from malignant breast masses.Materials and methodsA total of 292 female patients with breast masses undergoing biopsy between November 2004 and March 2006 in our department were included in this study. All lesions were classified according to the sonographic BI-RADS lexicon. Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) for the sonographic BI-RADS lexicon and PPV and NPV for each lesion category and each sonographic descriptor were calculated. The χ2 test and the Fischer exact test were used to evaluate our results.ResultsUnivariate analysis showed a significant difference between malignant and benign groups with regard to morphology (p<0.001), horizontal-vertical diameter ratio<1 (p<0.002), orientation (p<0.001), noncircumscribed margins (p<0.001), echogenic halo (p<0.001), hypoechoic pattern (p=0.035), shadowing (p<0.001) and surrounding tissue alterations (p=0.001). The cumulative risk for malignancy was 64 and 10 times higher, respectively, in categories 5 and 4 than in category 3.ConclusionsThe sonographic BI-RADS lexicon is an important system for describing and classifying breast lesions.RiassuntoObiettivoValutare l’attendibilità della classificazione BI-RADS nella caratterizzazione ecografica delle lesioni solide della mammella.Materiali e metodiSono state studiate 292 pazienti con nodulo mammario sottoposto a biopsia nel nostro Dipartimento dal novembre 2004 al marzo 2006. Ogni lesione è stata studiata ecograficamente e classificata secondo i criteri BI-RADS. Sono stati calcolati specificità, sensibilità, accuratezza, valore predittivo positivo e negativo (VPP e VPN) del sistema BI-RADS, VPP e VPN per ogni classe e per ogni descrittore ecografico. Sono stati adottati il test del χ2 e il test esatto di Fischer per valutare la significatività dei nostri risultati.RisultatiDall’analisi univariata sono emerse differenze statisticamente significative tra il gruppo lesioni maligne e quello lesioni benigne rispetto alle seguenti variabili: forma (p<0,001), rapporto dei diametri inferiori a 1 (p<0,002), orientamento (p<0,001), margini non circoscritti (p<0,001), alone iperecogeno (p<0,001), ipoecogenecità (p=0,035), sbarramento (p<0,001), presenza di alterazioni del parenchima circostante (p=0,001). Dall’analisi multivariata è risultato che il rischio di avere una lesione maligna è in classe V e IV, rispettivamente 64 e 10 volte maggiore rispetto alla classe III.ConclusioniIl nostro studio conferma che la classificazione ecografica BI-RADS costituisce un accurato sistema per la descrizione e il management delle lesioni mammarie.

Role of the Apparent Diffusion Coefficient in the Prediction of Response to Neoadjuvant Chemotherapy in Patients With Locally Advanced Breast Cancer

BACKGROUND We evaluated the diagnostic performance of the baseline diffusion weighted imaging (DWI) and the apparent diffusion coefficient (ADC) in the prediction of a complete pathologic response (pCR) to neoadjuvant chemotherapy (NAC) in patients with breast cancer stratified according to the tumor phenotype. PATIENTS AND METHODS We retrospectively studied 225 patients with stage II, III, and IV breast cancer who had undergone contrast-enhanced magnetic resonance imaging (MRI) and DWI before and after NAC, followed by breast surgery. RESULTS The tumor phenotypes were luminal (n = 143; 63.6%), triple-negative (TN) (n = 37; 16.4%), human epidermal growth factor receptor 2 (HER2)-enriched (n = 17; 7.6%), and hybrid (hormone receptor-positive/HER2(+); n = 28; 12.4%). After NAC, a pCR was observed in 39 patients (17.3%). No statistically significant difference was observed in the mean ADC value between a pCR and no pCR in the general population (1.132 ± 0.191 × 10(-3) mm(2)/s vs. 1.092 ± 0.189 × 10(-3) mm(2)/s, respectively; P = .23). The optimal ADC cutoff value in the general population was 0.975 × 10(-3) mm(2)/s (receiver operating characteristic [ROC] area under the curve [AUC], 0.587 for the prediction of a pCR). After splitting the population into subgroups according to tumor phenotype, we observed a significant or nearly significant difference in the mean ADC value among the responders versus the nonresponders in the TN (P = .06) and HER2(+) subgroups (P = .05). No meaningful difference was seen in the luminal and hybrid subgroups (P = .59 and P = .53, respectively). In contrast, in the TN and HER2(+) subgroups (cutoff value, 0.995 × 10(-3) mm(2)/s and 0.971 × 10(-3) mm(2)/s, respectively), we observed adequate ROC AUCs (0.766 and 0.813, respectively). CONCLUSION The pretreatment ADC value is not capable of predicting the pCR in the overall population of patients with locally advanced breast cancer. Nonetheless, an ameliorated diagnostic performance was observed in specific phenotype subgroups (ie, TN and HER2(+) tumors).

Effect of breast cancer phenotype on diagnostic performance of MRI in the prediction to response to neoadjuvant treatment.

AIM The estimation of response to neoadjuvant chemotherapy (NAC) is useful in the surgical decision in breast cancer. We addressed the diagnostic reliability of conventional MRI, of diffusion weighted imaging (DWI) and of a merged criterion coupling morphological MRI and DWI. Diagnostic performance was analysed separately in different tumor subtypes, including HER2+ (human epidermal growth factor receptor 2)/HR+ (hormone receptor) (hybrid phenotype). MATERIALS AND METHODS Two-hundred and twenty-five patients underwent MRI before and after NAC. The response to treatment was defined according to the RECIST classification and the evaluation of DWI with apparent diffusion coefficient (ADC). The complete pathological response - pCR was assessed (Mandard classification). RESULTS Tumor phenotypes were Luminal (63.6%), Triple Negative (16.4%), HER2+ (7.6%) or Hybrid (12.4%). After NAC, pCR was observed in 17.3% of cases. Average ADC was statistically higher after NAC (p<0.001) among patients showing pCR vs. those who had not pCR. The RECIST classification showed adequate performance in predicting the pCR in Triple Negative (area under the receiver operating characteristic curve, ROC AUC=0.9) and in the HER2+ subgroup (AUC=0.826). Lower performance was found in the Luminal and Hybrid subgroups (AUC 0.693 and 0.611, respectively), where the ADC criterion yielded an improved performance (AUC=0.787 and 0.722). The coupling of morphological and DWI criteria yielded maximally improved performance in the Luminal and Hybrid subgroups (AUC=0.797 and 0.761). CONCLUSION The diagnostic reliability of MRI in predicting the pCR to NAC depends on the tumor phenotype, particularly in the Luminal and Hybrid subgroups. In these cases, the coupling of morphological MRI evaluation and DWI assessment may facilitate the diagnosis.

Synchronous Bilateral Paget's Disease of the Nipple Associated with Bilateral Breast Carcinoma

T he presence of bilateral Paget’s disease with the coexistence of two synchronous and morphologically different bilateral breast cancers is extremely rare. A 73-year-old woman presented with bilateral, red, oozing crusted lesions of the nipple-areola complex. On physical examination, bleeding and crust formation were observed to involve both nipples; the left nipple was retracted and deformed (Fig. 1). The patient had normal mammogram and ultrasound examinations. Exfoliative cytology obtained by scraping of the nipples showed bilateral Paget’s disease. The patient underwent bilateral central quadrantectomy with complete excision of the nippleareolar complex including the underlying breast tissue. Microscopically the epidermis of both nipples showed characteristic features of Paget’s disease. The epidermis contained large round cells with abundant pale cytoplasm. The nuclei had fine chromatin and identifiable nucleoli (Fig. 2). Histologic examination of the right breast parenchyma showed a high-grade intraductal carcinoma with comedo necrosis in the lactiferous ducts with a focal Pagetoid growth pattern and a single focus of stromal microinvasion (Fig. 3a). Histologic examination of the left breast parenchyma showed a 0.8 cm retroareolar micropapillary invasive carcinoma in the nipple dermis with a morular cluster of neoplastic cuboidal cells surrounded by empty space and simulating lymphatic tumor emboli (Fig. 3b). The immunohistochemical evaluation of estrogen and progesterone receptor status was positive in the left lesion. Left axillary lymph node dissection was subsequently performed and histologic examination showed that the invasive micropapillary carcinoma had metastasized to 1 of 14 axillary lymph nodes. The patient was then treated with bilateral radiotherapy and Tamoxifen.

A feasibility study of neo-adjuvant low-dose fractionated radiotherapy with two different concurrent anthracycline-docetaxel schedules in stage IIA/B-IIIA breast cancer

AIMS AND BACKGROUND The aim of the study was to evaluate the feasibility of neoadjuvant low-dose fractionated radiotherapy, in combination with two anthracycline-docetaxel regimens, in breast cancer treatment. MATERIALS AND METHODS Women with stage IIA/B-IIIA breast cancer were assigned to receive the treatment of low-dose fractionated radiotherapy (0.4 Gy/per fraction, 2 fractions per day, for 2 days, every 21 days for 8-6 cycles) with concomitant neoadjuvant chemotherapy with non-pegylated liposomal doxorubicin and docetaxel. Two chemotherapy schedules were planned to be combined with low-dose fractionated radiotherapy. The first schedule consisted of four cycles of non-pegylated liposomal doxorubicin sequentially followed by four cycles of docetaxel, and the second schedule consisted of six cycles of non-pegylated liposomal doxorubicin plus concomitant docetaxel. Acute toxicity was evaluated according to the Radiation Therapy Oncology Group score system. Pathological response was evaluated by the Mandard score and expressed as tumor regression grade. RESULTS Between March 2008 and February 2009, 10 patients underwent low-dose fractionated radiotherapy and concomitant chemotherapy. No grade 3-4 breast toxicity was observed. Five patients had a clinical complete response. Seven patients underwent conservative surgery. Overall, tumor regression grade 1 (absence of residual cancer) was achieved in one patient (10%) and grade 2 (residual isolated cells scattered through the fibrosis) in 4 patients (40%). The pathologic major response rate (tumor regression grade 1 + 2) was 20% in patients receiving low-dose fractionated radiotherapy and sequential non-pegylated liposomal doxorubicin and docetaxel and 80% in the group receiving low-dose fractionated radiotherapy and concurrent non-pegylated liposomal doxorubicin and docetaxel treatment. CONCLUSIONS Concomitant low-dose fractionated radiotherapy combined with anthracycline and docetaxel is feasible. The toxicity profile of radio-chemotherapy was similar to that of chemotherapy alone: there was no acute skin or cardiac toxicity. The concurrent application of liposomal doxorubicin and docetaxel with low-dose fractionated radiation led to higher histological response rates compared to the sequential application of the same two drugs.

Gastro-intestinal symptoms as clinical manifestation of peritoneal and retroperitoneal spread of an invasive lobular breast cancer: report of a case and review of the literature

BackgroundDistant spread from breast cancer is commonly found in bones, lungs, liver and central nervous system. Metastatic involvement of peritoneum and retroperitoneum is unusual and unexpected.Case presentationWe report the case of a 67 year-old-woman who presented with gastrointestinal symptoms which revealed to be the clinical manifestations of peritoneal and retroperitoneal metastatic spread of an invasive lobular breast cancer diagnosed 15 years before.ConclusionTo the best of our knowledge, the case presented is the third one reported in literature showing a wide peritoneal and extraperitoneal diffusion of an invasive lobular breast cancer. The long and complex diagnostic work up which led us to the diagnosis is illustrated, with particular emphasis on the multidisciplinary approach, which is mandatory to obtain such a result in these cases. Awareness of such a condition by clinicians is mandatory in order to make an early diagnosis and start a prompt and correct therapeutic approach.

Contralateral Breast Symmetrisation in Immediate Prosthetic Breast Reconstruction after Unilateral Nipple-Sparing Mastectomy: The Tailored Reduction/Augmentation Mammaplasty

Background In the literature on nipple-sparing mastectomy (NSM) with one-stage immediate implant reconstruction, contralateral symmetrisation has drawn little attention, with many surgeons still performing standard cosmetic mammaplasty procedures. However, standard implant-based mammaplasty usually does not result in proper symmetry with the mastectomy side, especially regarding breast projection, overall shape, and volume distribution. Methods We retrospectively reviewed 19 consecutive patients undergoing unilateral NSM with immediate prosthetic reconstruction and contralateral simultaneous symmetrisation by using the tailored reduction/augmentation mammaplasty technique between June 2012 and August 2013. Results The average follow-up time was 13 months (range, 10-24 months). No major complications, such as infection, haematoma, and nipple-areola complex necrosis, were experienced. Conclusions Our experience suggests that simultaneous contralateral symmetrisation with tailored reduction/augmentation mammaplasty after unilateral immediate implant reconstruction after NSM facilitates durable and pleasant symmetric outcomes.

Oncoplastic Breast Surgery with Oxidized Regenerated Cellulose: Appraisals Based on Five-year Experience

To the Editor: We have read with great interest the article by Tanaka et al. reporting improved cosmetic outcomes after breast conserving surgery with the use of oxidized regenerated cellulose (ORC) (1) in 94 breast cancer patients treated at the Osaka Medical College Hospital (Osaka, Japan). Evaluation of cosmetic outcomes, performed by three staff surgeons at least 2 months after surgery using the scoring system (0–12 points) of the Japanese Breast Cancer Society, documented very positive results, with a mean score of 9.5 (3–12 points) and 71 patients (75.5%) categorized as “Excellent” (≥11 points) or “Good” (8–10 points), and only one patient (1.1%) as “Poor” (≤4 points). We have previously reported our 5-year experience with the use of ORC at the Catholic Breast Unit of Rome and agree with the Authors that the use of this biomaterial can improve the cosmetic results (Fig. 1) in patients undergoing an oncoplastic procedures for breast cancer (2). However, as ORC is being increasingly utilized in breast conserving surgery (1–3), we think that it is important to properly inform the patients not only about the potential cosmetic advantages but also about possible postoperative complications of this technique. Tanaka et al. report a 18% rate of allergic reaction with the use of ORC, mainly presenting as acute dermatitis and eczema, and one case of exudation followed by wound dehiscence. In our series, we noted a 10% rate of allergic skin reactions with irritation, redness, itching, swelling, rash, and hives in the mammary region, successfully managed with steroids and antihistamine medications. In addition, we experienced a significant seroma in the site of ORC placement in 45% of our patients. This