Marguerite Bonaventura

The Importance of Detection of Subclinical Lymphedema for the Prevention of Breast Cancer-Related Clinical Lymphedema after Axillary Lymph Node Dissection; A Prospective Observational Study

PURPOSE Early detection and timely intervention have potential to reduce late-stage lymphedema (LE) in patients with breast cancer undergoing axillary lymph node dissection (ALND). This study aims to determine if detection and early treatment of subclinical LE by using prospective monitoring with bioimpedance spectroscopy (BIS) can lead to reduced development of clinical LE. METHODS AND RESULTS Subclinical LE was prospectively detected using an L-Dex(®) U400 analyzer to measure BIS in 186 patients who underwent ALND between 2010 and 2013 through our LE monitoring program. Baseline measurements were obtained and at 3-6 month intervals for 5 years. Patients diagnosed with subclinical LE received short-term physical therapy, compression garments, and education about exercise, elevation, infection precautions, BMI, and hand usage. The control group had a preoperative baseline L-Dex(®) measurement, but had only clinical follow-ups with circumferential arm measurements. Mean age and BMI were 56 years and 28.3 kg/m(2), respectively. The majority of the women underwent mastectomy (61%) and received chemotherapy (89%) and radiotherapy (77%). Thirty-three percent patients who had repeated L-Dex measurements were diagnosed with subclinical LE and received early intervention. Progression to clinical lymphedema occurred in 4.4% over an average of 20 months follow-up. In the control group, the incidence of clinical LE was 36.4%. CONCLUSION Periodic monitoring of women at high risk for LE with BIS allows early detection and timely intervention for LE, which reduces the incidence of clinical LE from 36.4% to 4.4%. This may have implications for quality of life and health care costs.

Decision Making and Factors Influencing Long-term Satisfaction With Prophylactic Mastectomy in Women With Breast Cancer

Purpose:Studies demonstrate an increasing rate of contralateral prophylactic mastectomy (CPM). The purpose of this study is to evaluate decision making and factors influencing women’s long-term satisfaction with CPM. Descriptive analysis is used to analyze the results of our designed questionnaire approved by our Institutional Review Board. Methods:We searched our institutional cancer registry for patients diagnosed with breast cancer between 2000 and 2010. The studied time frame is of significance as this study is the first to measure response rate in questions examining patient satisfaction for >1 year after undergoing CPM. The questionnaire was mailed to all consented participants to examine factors contributing to the choice of CPM and postoperative satisfaction. Results:Of the 206 women included in the study, 147 were aged up to 50 years. Majority of women who underwent CPM in this cohort was with a bachelor’s degree or higher, married or partnered women, and women earning >

Rationale of excisional biopsy after the diagnosis of benign radial scar on core biopsy: a single institutional outcome analysis.

60,000/y. Almost all women were “happy with overall surgery” and would recommend CPM to other patients. Psychological factors, such as fear of recurrence, were more commonly associated with the decision for CPM in patients with invasive carcinoma. Opinions of partners, relatives, friends, and physicians further contributed to the decision to undergo surgery. The availability of reconstruction was also an influential factor in the overall decision. Conclusions:The majority of our study participants experienced long-term satisfaction with the surgical procedure of CPM. From our analysis, we can confidently say that fear of cancer recurrence and the opinions of others, among other factors, were influencing contributors toward the decision of undergoing CPM.

Models for predicting non‐sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system

Background:Radial scar (RS) is characterized by a fibroelastic core with entrapped ducts and lobules. Association with carcinoma is not uncommon. There is some dilemma as to the need for excisional biopsy or follow-up after RS diagnosis on core biopsy. Aim:To determine the necessity of excisional biopsy after the diagnosis of benign RS by core biopsy. Study Design:A total of 67 RS specimens associated with benign findings on core biopsy obtained between 2003 and 2008 were reviewed. They were grouped by their accompanying histopathologic features found upon subsequent surgical excision: benign, high-risk lesion (HRL), or carcinoma. Demographic features, radiologic findings, and needle gauge were compared within subgroups. Results:After surgical excision, 15 (22.4%) patients in the benign group were upgraded to a HRL, 4 (5.9%) patients were upgraded to carcinoma, and 48 (71.6%) remained benign. We found that malignancy is associated with RS more frequently if the patient is older and postmenopausal. Other variables such as symptoms at presentation, presence and type of abnormality on mammography (Breast Imaging Reporting and Data System score), breast density, size of biopsy needle used, and number of core samples retrieved did not help to predict the presence of carcinoma. Conclusions:The HRL and cancer upgrade rate of RS, requiring further intervention such as surgery or chemoprevention, is 28% in this study. However, we found that age and menopausal status may be taken into consideration when making the decision to follow up or excise the RS diagnosed on core biopsy. There is insufficient data to support the predictive value of any variables. Therefore, RS associated with benign findings on core biopsy should be excised.

Atypical hyperplasia on core biopsy: is further surgery needed?

Background:  Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non‐sentinel nodes and undergo a non‐therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision‐making about further treatment. To predict non‐SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created.

Predicting Likelihood of Having Four or More Positive Nodes in Patient With Sentinel Lymph Node-Positive Breast Cancer: A Nomogram Validation Study

Introduction: Percutaneous core needle biopsy (CNB) has been widely performed as a standard technique for initial histological diagnosis of suspicious breast lesions. There have been an increased number of atypical lesions diagnosed on CNB as a consequence of the advances in breast imaging techniques. The authors aim to identify if any of the radiological and histopathological criteria evaluated in this study can predict the presence of malignancy associated with atypical hyperplasia (AH) diagnosed on CNB. Methods: The authors retrospectively reviewed the medical records of 450 patients diagnosed with AH. Surgical excision was then performed and pathology revealed carcinoma or benign lesions. Patient age, imaging features, number of CNB samples taken, biopsy needle gauge, presence of additional proliferative diseases and calcification on CNB or excision were evaluated in both groups. Results: Fifty-one (11.3%) patients were found to have malignancy on surgical excision; 74.5% had ductal carcinoma in situ only and 25.6% had invasive cancer. In subgroup analysis, pure atypical ductal hyperplasia lesions were upgraded in 11.5%, pure atypical lobular hyperplasia lesions were upgraded in 8.1% and mixed lesions were upgraded in 17.6% (P > 0.05) of patients. The majority of the patients were older than 50 years, and calcification was the main reason for biopsy in both groups. The presence of additional proliferative lesions and needle gauge were not found to be statistically significant (P > 0.05). Conclusion: Upgrade rate to cancer after surgical excision was 11.3% of AH patients diagnosed on CNB. However, none of the variables are significant in determining the presence of malignancy associated with AH diagnosed by CNB.

The predicted probability of having positive non‐sentinel lymph nodes in patients who received neoadjuvant chemotherapy for large operable breast cancer

PURPOSE Katz suggested a nomogram for predicting having four or more positive nodes in sentinel lymph node (SLN)-positive breast cancer patients. The findings from this formula might influence adjuvant radiotherapy decisions. Our goal was to validate the accuracy of the Katz nomogram. METHODS AND MATERIALS We reviewed the records of 309 patients with breast cancer who had undergone completion axillary lymph node dissection. The factors associated with the likelihood of having four or more positive axillary nodes were evaluated in patients with one to three positive SLNs. The nomogram developed by Katz was applied to our data set. The area under the curve of the corresponding receiver operating characteristics curve was calculated for the nomogram. RESULTS Of the 309 patients, 80 (25.9%) had four or more positive axillary lymph nodes. On multivariate analysis, the number of positive SLNs (p < .0001), overall metastasis size (p = .019), primary tumor size (p = .0001), and extracapsular extension (p = .01) were significant factors predicting for four or more positive nodes. For patients with <5% probability, 90.3% had fewer than four positive nodes and 9.7% had four or more positive nodes. The negative predictive value was 91.7%, and sensitivity was 80%. The nomogram was accurate and discriminating (area under the curve, .801). CONCLUSION The probability of four or more involved nodes is significantly greater in patients who have an increased number of positive SLNs, increased overall metastasis size, increased tumor size, and extracapsular extension. The Katz nomogram was validated in our patients. This nomogram will be helpful to clinicians making adjuvant treatment recommendations to their patients.

Placement technique and the early complications of balloon breast brachytherapy: Magee-Womens Hospital experience.

The accuracy of the nomogram in women with positive sentinel nodes following neoadjuvant chemotherapy (NCT) is unknown. The aim of this study was to evaluate the accuracy of the nomogram in patients receiving NCT. Between December 1999 and December 2005, we identified 233 patients who had a positive sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection at Magee‐Womens Hospital of University of Pittsburgh Medical Center. Thirty‐two patients (14%) had presented with clinically N0 breast cancer (BC) for which NCT was administered. The computerised BC nomogram was used to calculate the probability of non‐sentinel node metastases utilising tumour size before NCT and after NCT for the same patient. The discrimination of the nomogram was assessed by calculating the area under (AUC) the receiver operating characteristic curve (ROC). The median patient age was 51.5 (range: 39–66) years in the NCT group of patients. Twelve patients (37%) had positive axillary non‐sentinel lymph nodes (NSLNs). The nomogram was first validated in our institution for 201 patients without NCT and the predicted accuracy of the nomogram by the AUC was 0.73. The area under the ROC was identical regardless of whether pre‐ or posttreatment tumour size was used to determine predicted probability of NSLN metastases (0.66). The predictive accuracy of the nomogram was found to have less power for patients receiving NCT (0.66) than the non‐NCT group of patients.

Association Between Serotonin Transport Polymorphisms and Postdischarge Nausea and Vomiting in Women Following Breast Cancer Surgery

Backgrounds and Objectives:Open (OT) and percutaneous closed (PCT) techniques have been described for placement of the MammoSite catheter to deliver accelerated partial breast brachytherapy. We report early complications of both techniques. Methods:A total of 125 patients underwent catheter placement for MammoSite high-dose rate brachytherapy, with 108 patients successfully completing treatment. The OT was used in 85 patients and PCT in 40 patients. The mean distance between the balloon surface and breast skin was 1.44 cm and 1.31 cm, respectively. Average skin dose was 278 cGy in the OT group and 295 cGy in the PCT group (P > 0.05). Average gross specimen size was 43.16 cm3 in the OT group and 62.19 cm3 in the PCT group. Median follow-up was 11 months for the OT group and 5 months for the PCT group. Results:In 17 cases, the catheter was subsequently removed without the patient completing treatment. Two of the patients in the OT group (3%) developed a delayed abscess. The overall incidence of persistent seroma (>6 months) was 20% with all occurring in the OT group, 30% of those patients. There were no acute skin toxicities higher than grade 2. The overall cosmesis is excellent or good in 95% of patients. Conclusion:Despite short follow-up and a small sample size in this study, it seems that the MammoSite brachytherapy was well tolerated by patients with early stage breast cancer when using either the OT or PCT.

Breast Tumor Resembling Tall Cell Variant of Papillary Thyroid CarcinomaA Solid Papillary Neoplasm With Characteristic Immunohistochemical Profile and Few Recurrent Mutations

PURPOSE/OBJECTIVES To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery. DESIGN A cross-sectional study. SETTING A comprehensive cancer center in Pittsburgh, PA. SAMPLE 80 post-menopausal women treated surgically for early-stage breast cancer. METHODS Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression. MAIN RESEARCH VARIABLES Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety. FINDINGS Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores. CONCLUSIONS Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications. IMPLICATIONS FOR NURSING Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.