Maíra Teixeira Dória

Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer.

INTRODUCTION In this prospective ex vivo study, we propose a new technique for the intraoperative examination of retroareolar tissue and describe both surgical excision and pathological methods. We performed a nipple-sparing mastectomy simulation in patients selected to total mastectomy, in order to evaluate the accuracy of these new technique. MATERIALS AND METHODS A total of 158 total mastectomy specimens from patients affected by ductal carcinoma in situ (n = 15) or invasive ductal carcinoma (stages I, II, or IIIA) (n = 143) were examined. To obtain the entire sample area, the terminal retroareolar milk duct bunch was isolated. Fragments approximately 1.5 cm in length were excised and sectioned in parallel at the base of the nipple using a cold bistoury. Three transverse histological sections (4 μm each) at 200 μm intervals that included the entire isolated fragments were subjected to frozen section examination. The sections were stained with hematoxylin-eosin and were evaluated. The remainder of each fragment was embedded in paraffin and 4 μm sections were subsequently stained with hematoxylin-eosin and examined. RESULTS There were two false-negative (1.3%) and five false-positive (3.1%) findings among the frozen and paraffin sections analyzed. A statistical analysis of the frozen section examinations showed a sensitivity of 92.0%, a specificity of 96.2%, a positive predictive value of 82.1%, a negative predictive value of 98.4%, and an accuracy of 95.4%. CONCLUSION The frozen section examination technique described here detected nipple involvement in breast cancer with greater accuracy than the frozen section usually performed by most surgeons.

Criteria for prediction of metastatic axillary lymph nodes in early-stage breast cancer.

PURPOSE To estimate the likelihood of axillary lymph node involvement for patients with early-stage breast cancer, based on a variety of clinical and pathological factors. METHODS A retrospective analysis was done in hospital databases from 1999 to 2007. Two hundred thirty-nine patients were diagnosed with early-stage breast cancer. Predictive factors, such as patient age, tumor size, lymphovascular invasion, histological grade and immunohistochemical subtype were analyzed to identify variables that may be associated with axillary lymph node metastasis. RESULTS Patients with tumors that are negative for estrogen receptor, progesterone receptor, and HER2 had approximately a 90% lower chance of developing lymph node metastasis than those with luminal A tumors (e.g., ER+ and/or PR+ and HER2-) - Odds Ratio: 0.11; 95% confidence interval: 0.01-0.88; p=0.01. Furthermore, the risk for lymph node metastasis of luminal A tumors seemed to decrease as patient age increased, and it was directly correlated with tumor size. CONCLUSION The molecular classification of early-stage breast cancer using immunohistochemistry may help predicting the probability of developing axillary lymph node metastasis. Further studies are needed to optimize predictions for nodal involvement, with the aim of aiding the decision-making process for breast cancer treatment.

Gastric metastasis as the first manifestation of an invasive lobular carcinoma of the breast

Gastrointestinal metastases from breast cancer are rare and generally occur several years after the diagnosis of the primary lesion. The diagnosis of gastric metastasis as the initial presentation of breast cancer is even rarer and can potentially mimic gastric carcinoma. We report the case of a 66-year-old female patient submitted to a total gastrectomy because of the histological diagnosis of undifferentiated gastric carcinoma. During the surgical procedure, biopsies of the peritoneum and the liver were performed, which were consistent with metastatic breast invasive lobular carcinoma (ILC). The primary lesion of the breast was detected during the post-operative period, when a 4-cm-long lesion was detected on physical examination and mammography. The revision of the gastric biopsy confirmed the diagnosis of ILC. The authors call attention to the rarity of gastrointestinal metastases as the initial presentation of breast ILC.

Development of a Model to Predict Invasiveness in Ductal Carcinoma In Situ Diagnosed by Percutaneous Biopsy—Original Study and Critical Evaluation of the Literature

Background Approximately 30% of ductal carcinoma in situ (DCIS) cases have an invasive component discovered on the final analysis that could affect surgical management. The aims of the present study were to determine the risk factors associated with the underestimation of DCIS and to develop a model to predict the probability of invasiveness. Materials and Methods A retrospective analysis was performed on the data for all patients with a diagnosis of DCIS found by percutaneous biopsy from January 2008 to February 2016. Thirteen potential predictors of invasiveness were examined. The statistical analysis of the present study was improved using Nagelkerke’s R2, the area under the receiving operating characteristic (AUC) curve, and the Hosmer‐Lemeshow goodness‐of‐fit test. Results Of 354 biopsy specimens deemed to be DCIS on initial biopsy, 100 (28.2%) were recategorized as invasive carcinoma after surgery. On multivariate analysis, the strongest predictors of invasiveness were comedonecrosis, size on mammography, suspected microinvasion, histologic grade, and younger patient age. The model had a good discriminative ability, with an AUC of 0.764. The overall performance of the model was fair, with a Nagelkerke’s R2 of 40.9%. A separate analysis performed on 274 specimens obtained through vacuum‐assisted biopsy revealed different variables were associated with underestimation; however, a similar AUC (0.743) and Nagelkerke’s R2 (45.7%) were obtained. Conclusion Our model had the best AUC for predicting DCIS invasiveness reported to date. However, further statistical analysis showed only a fair overall performance. The currently known clinical, radiographic, and pathologic features might be insufficient to identify which patients with DCIS have underestimated disease. Micro‐Abstract Our aim was to develop a model to predict invasiveness in patients with a diagnosis of ductal carcinoma in situ found at percutaneous biopsy. The calculated sample size was 296 patients. We used Nagelkerke’s R2 and Hosmer‐Lemeshow goodness‐of‐fit tests to improve statistical analysis. We evaluated 354 patients and developed 2 models that have the best discrimination reported to date.

Predictive factors for positive surgical margins in the treatment of breast ductal carcinoma in situ

CONTEXT Surgery is the main form of treatment for ductal carcinoma in situ (DCIS) of the breast. Among other factors, treatment success requires that the surgical margins are free of disease, to reduce the risk of recurrence. AIMS The purpose of this study was to analyze factors that might be associated with positive margins in patients diagnosed with DCIS. SETTINGS AND DESIGN A retrospective analysis was performed of hospital databases from the year 2006 to 2014, to identify patients with an initial diagnosis of DCIS made by percutaneous biopsy. SUBJECTS AND METHODS Age, the presence of disease symptoms, lesion size on mammogram, and the presence of estrogen receptors, and their relationship to the surgical margins were evaluated in 249 patients. STATISTICAL ANALYSIS USED Shapiro and Wilcoxon-Mann-Whitney tests were used to verify that the data were normally distributed. Chi-squared test was used to verify the independence of the variables. RESULTS Lesions measuring 1.55 cm or greater had a relative risk of positive margins after conservative surgery of 1.39 (95% confidence interval [95% CI]: 1.02-1.90). The presence of symptoms had a relative risk of positive margins after conservative surgery of 1.54 (95% CI: 1.17-2.02). CONCLUSION Lesions measuring 1.55 cm or greater and the presence of symptoms are risk factors for positive margins in the treatment of ductal carcinoma in situ. Therefore, these patients need a better surgical planning in order to reduce the risk of positive margins. There is a clear need for large prospective studies to validate our findings and define other factors that might contribute to the success of surgical resection for ductal carcinoma in situ.

Abstract P3-13-09: Improved frozen section examination of the retroareolar margin for prediction of nipple involvement in breast cancer

Introduction: Development of the nipple-sparing mastectomy (NSM) technique has constituted a significant advance in the surgical treatment of selected cases of breast cancer. The most important aspect of areolar complex preservation is the exclusion of carcinoma involving the nipple. The retroareolar surgical margin is usually sampled and subjected to an intraoperative evaluation by frozen section examination in order to avoid a second procedure. However, this method is not standardized resulting in variable rates of false-negative results.Here, a new technique is proposed for the intraoperative study of the retroareolar margin. This ex vivo study was conducted by performing a simulated NSM procedure for patients undergoing total mastectomy to assess the impact of these measures on the accuracy of retroareolar frozen section examination.

Abstract P4-02-04: Magnetic resonance imaging to predict nipple involvement in breast cancer patients

Introduction. The implementation of Nipple-Sparing Mastectomy (NSM) as a treatment option for selected cases of breast cancer has risen great interest among breast surgeons. The preservation of the nipple-areola complex (NAC) can lead to extremely favorable psychological effects in breast cancer patients treated with this type of procedure. However, to ensure the oncologic safety of this technique it is of utmost importance to evaluate the likelihood of NAC involvement pre-operatively. In this study we evaluate the contribution of Breast Magnetic Resonance Imaging (MRI) in predicting the involvement in the NAC in breast cancer patients. Materials and Methods: We studied 170 mastectomy specimens from 165 breast cancer patients (five patients had bilateral disease) affected by Ductal Carcinoma in situ (DCIS)(n=19) or Invasive Ductal Carcinoma (n=151), stages I, II or IIIA. Every patient was pre-operatively studied using a 1.5 Tesla, 4-channel in vivo dedicated surface breast coil MRI. The parameters we investigated were: type of index lesion enhancement pattern (nodular or non-nodular), size of the index lesion, enhancement between the index lesion and the NAC, enhancement of the nipple, thickening of the areola, nipple retraction and size of the nipple in comparison with the contra-lateral nipple. The retro-areolar area and papilla were evaluated in histological sections of 4μm to identify DCIS and Invasive Ductal or Lobular carcinomas. One radiologist, blinded to the result of the histological evaluation of the papillae, performed the evaluation of the MRIs. Results. In univariate analysis, type of lesion enhancement in MRI, enhancement between index lesion and the papilla, distance between the index lesion and the papilla, enhancement of the papilla and nipple retraction had a statistically significant correlation with neoplastic involvement of the NAC (p Conclusion. We can conclude that the probability of the NAC being cancer-free is around 90% when there is no enhancement between the index lesion and the nipple, and there is no retraction of the nipple in the pre-operative MRI study of the breast. Citation Format: Piato JR, Chala LF, Alves-Jales RD, Doria MT, Mota BS, Messias AP, Goncalves R, Mano MS, Soares JM, de Barros N, Filassi JR, Baracat EC. Magnetic resonance imaging to predict nipple involvement in breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-02-04.