Helen Anne D'Alessandro

External Beam Accelerated Partial-Breast Irradiation Using 32 Gy in 8 Twice-Daily Fractions: 5-Year Results of a Prospective Study

PURPOSE External beam accelerated partial breast irradiation (APBI) is an increasingly popular technique for treatment of patients with early stage breast cancer following breast-conserving surgery. Here we present 5-year results of a prospective trial. METHODS AND MATERIALS From October 2003 through November 2005, 98 evaluable patients with stage I breast cancer were enrolled in the first dose step (32 Gy delivered in 8 twice-daily fractions) of a prospective, multi-institutional, dose escalation clinical trial of 3-dimensional conformal external beam APBI (3D-APBI). Median age was 61 years; median tumor size was 0.8 cm; 89% of tumors were estrogen receptor positive; 10% had a triple-negative phenotype; and 1% had a HER-2-positive subtype. Median follow-up was 71 months (range, 2-88 months; interquartile range, 64-75 months). RESULTS Five patients developed ipsilateral breast tumor recurrence (IBTR), for a 5-year actuarial IBTR rate of 5% (95% confidence interval [CI], 1%-10%). Three of these cases occurred in patients with triple-negative disease and 2 in non-triple-negative patients, for 5-year actuarial IBTR rates of 33% (95% CI, 0%-57%) and 2% (95% CI, 0%-6%; P<.0001), respectively. On multivariable analysis, triple-negative phenotype was the only predictor of IBTR, with borderline statistical significance after adjusting for tumor grade (P=.0537). CONCLUSIONS Overall outcomes were excellent, particularly for patients with estrogen receptor-positive disease. Patients in this study with triple-negative breast cancer had a significantly higher IBTR rate than patients with other receptor phenotypes when treated with 3D-APBI. Larger, prospective 3D-APBI clinical trials should continue to evaluate the effect of hormone receptor phenotype on IBTR rates.

The Mammary Hamartoma Appreciation of Additional Imaging Characteristics

Objective. To determine the mammographic and sonographic findings of hamartomas that were not classic on imaging, how pathologists distinguish the hamartoma from benign breast tissue on core samples, and reasons for discrepancies between core and surgical biopsy. Methods. A retrospective review of all image‐recommended core biopsies between 1993 and 2001 was performed. There were 41 cases of hamartomas found on either core or surgical biopsy. The mammographic, sonographic, and pathologic findings were reviewed. Results. Of 41 hamartomas in 38 patients, 18 went on to surgical biopsy. Of these 18 cases, 4 cases of hamartoma on core biopsy were fibroadenoma after excision; 2 cases of hamartoma on core biopsy were confirmed by surgery; and 12 cases of fibrocystic change after core biopsy were hamartoma after surgical biopsy. The 4 cases of fibroadenoma shown at final pathologic examination were excluded from imaging review, leaving 37 cases. In the 20 patients who underwent only core sampling, 23 hamartomas were diagnosed. Seventeen masses were visible on mammography, and 82% were homogeneously dense. Of 36 masses shown on sonography, 86% were uniformly hypoechoic. At histologic examination, only 16% contained fat within the mass. Conclusions. Hamartomas may appear as homogeneously dense, well‐circumscribed masses, varying in appearance from the classically described encapsulated mixed fatty‐fibroglandular mass. Pathologists can make the diagnosis of hamartoma without the presence of adipose tissue but may have difficulty in distinguishing the hamartoma from fibrocystic change. However, if there is radiologic‐pathologic concordance, further surgical excision is not warranted.

Detecting Nonpalpable Recurrent Breast Cancer: The Role of Routine Mammographic Screening of Transverse Rectus Abdominis Myocutaneous Flap Reconstructions

PURPOSE To perform a retrospective cohort study to determine the rates of recall and cancer detection and then to develop a decision analytic model to evaluate the effectiveness of routine screening of transverse rectus abdominis myocutaneous (TRAM) flap reconstructions. MATERIALS AND METHODS This study was approved by the institutional review board, and the methods comply with HIPAA regulations. A retrospective search of the institutional mammographic results database was done to identify bilateral screening mammographic examinations obtained from January 1, 1999, through July 15, 2005. The search included the term TRAM; the recall and cancer detetion rates were then detected. Subsequently, a decision analytic model was constructed to evaluate a hypothetical cohort of women with TRAM flap reconstructions. RESULTS Of 554 mammograms (265 TRAM flap reconstructions), 546 (98.6%) had negative results (Breast Imaging Reporting and Data System category 1 or 2). Eight (1.4%) had positive test results (Breast Imaging Reporting and Data System category 0, 3, 4, or 5). All suspicious lesions underwent biopsy and had benign pathologic results. No interval breast cancers were identified. The detection rate for nonpalpable recurrent breast cancer was 0% (exact 95% confidence interval: 0.0%, 1.4%). According to decision analysis, screening would help detect an estimated 12 additional recurrent cancers per 1000 women screened, providing an additional 1.6 days of life expectancy for the screened cohort. Under base-case conditions, screening of TRAM flap reconstructions is less effective than screening asymptomatic women in their 40s. Sensitivity analysis revealed that a benefit equivalent to that of screening asymptomatic women in their 40s was achievable under conditions related to estimates of screening effectiveness and cancer detection rate. CONCLUSION Routine screening mammography of TRAM flap reconstructions has a very low detection rate for nonpalpable recurrent breast cancer. Decision analysis indicates that screening such women is less effective than screening asymptomatic women in their 40s for primary breast cancer.

Case 15-2010: An 85-year-old woman with mammographically detected early breast cancer

From the Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill; and the Department of Medicine, University of North Carolina College of Medicine — both in Chapel Hill (H.B.M.); and the Departments of Radiology (H.A.D.) and Pathology (E.F.B.), Massachusetts General Hospital; and the Departments of Radiology (H.A.D.) and Pathology (E.F.B.), Harvard Medical School — both in Boston.

Case 15-2010

From the Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill; and the Department of Medicine, University of North Carolina College of Medicine — both in Chapel Hill (H.B.M.); and the Departments of Radiology (H.A.D.) and Pathology (E.F.B.), Massachusetts General Hospital; and the Departments of Radiology (H.A.D.) and Pathology (E.F.B.), Harvard Medical School — both in Boston.

Case records of the Massachusetts General Hospital. Case 25-2009. A 36-year-old woman with hormone-receptor-positive breast cancer.

From the Division of Medical Oncology, Dana–Farber Cancer Institute, and the Department of Medicine, Brigham and Women’s Hospital (H.J.B.); the Departments of Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Massachusetts General Hospital; and the Departments of Medicine (H.J.B.), Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Harvard Medical School ― all in Boston.

Case 25-2009: A 36-Year-Old Woman with Hormone-Receptor-Positive Breast Cancer

From the Division of Medical Oncology, Dana–Farber Cancer Institute, and the Department of Medicine, Brigham and Women’s Hospital (H.J.B.); the Departments of Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Massachusetts General Hospital; and the Departments of Medicine (H.J.B.), Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Harvard Medical School ― all in Boston.

Case 25-2009

From the Division of Medical Oncology, Dana–Farber Cancer Institute, and the Department of Medicine, Brigham and Women’s Hospital (H.J.B.); the Departments of Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Massachusetts General Hospital; and the Departments of Medicine (H.J.B.), Obstetrics, Gynecology, and Reproductive Biology (I.S.), Radiology (H.A.D.), and Pathology (D.C.S.), Harvard Medical School ― all in Boston.

Case 30-2008

From the Department of Medicine, Northwestern University, and the Feinberg School of Medicine (W.J.G.) — both in Chicago; and the Department of Radiation Oncology, Brigham and Women’s Hospital, and the Dana–Farber Cancer Institute ( J.R.B.); the Departments of Surgical Oncology (M.A.G.), Radiology (H.A.D.), and Pathology (K.B.), Massachusetts General Hospital; and the Departments of Radiation Oncology (J.R.B.), Surgery (M.A.G.), Radiology (H.A.D.), and Pathology (K.B.), Harvard Medical School — all in Boston.

Evaluation of a Nonradioactive Magnetic Marker Wireless Localization Program

OBJECTIVE The purpose of this study is to evaluate the feasibility and effectiveness of a nonradioactive magnetic marker wireless localization technique. MATERIALS AND METHODS A retrospective review was performed of consecutive patients who underwent image-guided needle localization with nonradioactive magnetic markers and subsequent surgical excision from March to August 2017. Indications for marker placement, lesion type, imaging guidance used for marker placement, postprocedure mammographic imaging and reports, surgical reports, and surgical margin status were reviewed. RESULTS A total of 188 patients (mean age, 59 years; range, 22-89 years) underwent image-guided localization with 213 magnetic markers and subsequent surgical excision. The indications for marker placement included invasive carcinoma (96 markers [45.1%]), ductal carcinoma in situ (41 markers [19.2%]), and high-risk lesions (71 markers [33.3%]). Localization markers were most commonly placed for masses (96 markers [45.1%]) and were deployed under mammographic guidance (160 markers [75.1%]) or sonographic guidance (53 markers [24.9%]). Technical success, which was defined as placement of the magnetic marker within 1 cm of the target, was achieved for 206 of 213 markers (96.7%). All 213 markers were successfully retrieved at surgery. Of 137 cases of in situ or invasive carcinoma, 30 (21.9%) had tumor-positive or close surgical margins that required reexcision. No major or minor complications were observed during marker placement, intraoperatively, or postoperatively. CONCLUSION Image-guided needle localization with magnetic markers is a safe, feasible, and effective method for localizing breast lesions. Magnetic marker localization has the potential to replace conventional wire needle localization and radioactive seed needle localization for lesions that require surgical excision.