Lorenzo Ferguson

Review of Third and Fourth Re-Excision for Narrow or Positive Margins of Invasive and Intraductal Carcinoma

The trend in breast surgery has shifted toward breast conservation. We reviewed our third and fourth breast re-excision cases, with an analysis of various factors used in making this decision. A retrospective analysis identified 585 patients who underwent re-excision surgery for positive or close margins of invasive carcinoma or ductal carcinoma in situ (DCIS). Of these patients 75 (13%) and 17 (3%) underwent third and fourth re-excisions, respectively. The indication for a third re-excision was the presence of positive and/or close (< or = 1 mm) margins for invasive carcinoma or DCIS in 72/75 patients. A third re-excision was done 31 days (range 8-123 days) after the second re-excision. Re-excision of margins was done in 45 (60%) patients, whereas 30 (40%) patients underwent mastectomy. Residual tumor mandated a fourth re-excision in 17 patients, which was done 45 days (range 14-87 days) after the third surgery. Re-excision of margins was done in 6 patients, whereas 11 patients underwent mastectomy. Involved or close margins with DCIS were the most common indication for re-excision, accounting for 61/75 (82%) of third and 16/17 (94%) of fourth re-excisions. Histopathology revealed that 28/75 (37%) of third and 7/17 (41%) of fourth re-excision patients had no residual tumor. In conclusion, the majority of re-excisions was done for margins < 1 mm. Lower rates of re-excision were noted in well-differentiated invasive carcinomas. A close or involved DCIS margin was more likely to lead to a third and even a fourth re-excision. The absence of residual tumors in 40% of patients undergoing third and fourth re-excisions calls for a review of margin guidelines for breast re-excision.

Receptor changes in metachronous breast tumors—our experience of 10 years

INTRODUCTION Patients with primary breast cancer (PBC) are at 2 to 6 times higher risk for developing synchronous and metachronous breast cancer (MBC). The pathology and behavior of MBC still remains unclear. METHODS We reviewed the charts of 108 women with MBC at our hospital over the past 10 years. Profile patterns of the estrogen receptor (ER), the progesterone receptor (PR), and Her2/neu receptors were explored. RESULTS Of 33 patients with ER(+)/PR(+) in the primary tumor, 23 (70%) retained the status in MBC. Forty-five (92%) of 49 patients with ER(-)/PR(-) in the primary tumor remained the same in MBC. Most Her2(-) tumors (22/31, 71%) remained negative, but 50% (8/16) of Her2(+) tumors became negative. CONCLUSIONS Most MBC retained the ER/PR expression patterns irrespective of the treatment for the primary tumor, thus suggesting a common origin. Because MBCs tend to be triple negative and thus more aggressive, early detection and close surveillance techniques must be devised.

Enlarging Breast Mass in a 55-Year-Old Woman

A 55-year-old woman presented to the clinic with a mass in her left breast that had been enlarging over the previous 3 months. The patient denied any antecedent trauma or infection. Her medical history was significant for hypertension and left breast invasive ductal carcinoma in 2007 treated with lumpectomy and adjuvant radiation as well as synchronous rectal cancer after neoadjuvant chemoradiation and abdominoperineal resection. As part of her treatment course, the patient received a total dose of 50.5 Gy pelvic irradiation and 60 Gy irradiation to the left breast and axillary basin. The patient was followed up with yearly computed tomography of the abdomen and pelvis in addition to yearly digital mammography. Her last mammogram, 5 months prior to presentation, was unremarkable. On physical examination, she had a hard, well-circumscribed, fixed mass in the upper, outer quadrant of her left breast. The lesion was not tender to palpation nor was there any associated axillary or supraclavicular lymphadenopathy. Examination of the nipple as well as the contralateral breast and axilla was unremarkable. Computed tomography of the thorax revealed a 6.7 × 4 cm mass arising from the left chest wall distinct from the left breast with extent to the pleural surface of the left thorax (Figure, A). Positron emission tomography revealed metabolic activity within the mass but did not reveal any distant disease. Core needle biopsy confirmed the diagnosis and the patient was offered resection with reconstruction. The patient underwent a left radical mastectomy including resection of the pectoralis major and minor and resection of the adjacent chest wall resulting in a chest wall defect spanning ribs 2 through 4 (Figure, B). The patient underwent immediate reconstruction of the chest wall with 2-mm-thick expanded polytetrafluoroethylene and latissimus dorsi pedicle flap reconstruction of the soft tissue defect and breast mound. A B