Mary Gardner

Clinical patterns of metastasis.

In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis.Different patens of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.

Radioactive seed localization breast biopsy and lumpectomy: can specimen radiographs be eliminated?

AbstractBackground: Wire localization (WL) is the current standard for surgical diagnosis of nonpalpable breast lesions. Many disadvantages inherent to WL are solved with radioactive seed localization (RSL). This trial investigated the ability of RSL to reduce the need for specimen radiographs and operating room delays associated with WL. Methods: A total of 134 women were entered onto an institutional review board–approved study. RSL was performed by placing a titanium seed containing .29 to 20 mCi of iodine-125 to within 1 cm of the suggestive breast lesion. The surgeon used a handheld gamma detector to locate and excise the iodine-125 seed and the lesion. Results: Specimen radiographs were eliminated in 98 (79%) of 124 patients. Surgical seed retrieval was 100% in 124 patients. No seed migration occurred after correct radiographical placement. A total of 26 (21%) of 124 patients required a specimen radiograph; 22 (85%) of these 26 were performed for microcalcifications. Conclusions: After surgical removal, RSL can eliminate specimen radiographs when the radiologist accurately places the seed and the pathologist grossly identifies the lesion. If small microcalcifications are noted before surgery, then specimen radiographs may be necessary. RSL reduced requirements for specimen radiographs, decreased OR time, improved incision placement, and improved resections to clear margins.

Breast cancer in patients with prior augmentation: Presentation, stage, and lymphatic mapping

The purpose of this study was to determine whether breast cancer patients who had prior breast augmentation presented at a more advanced stage than nonaugmented breast cancer patients, and to determine the mode of presentation and effectiveness of lymphatic mapping and sentinel lymph node biopsy in this same group of patients. A total of 4186 breast cancer patients from 1987 to 2002 were reviewed. Patients who had augmentation before their diagnosis of breast cancer were compared with a control group of nonaugmented breast cancer patients. The Wilcoxon rank sum test was used to compare tumor size, node positivity, and stage. The patient’s age at presentation was also compared by the two-sided pooled t test. Seventy-six patients who previously underwent augmentation were identified with 78 breast cancers. Seventy percent (48 of 69) were initially detected by palpation, whereas 30 percent (21 of 69) were initially identified mammographically. Fifty-three percent (n = 41) underwent mastectomy and 47 percent (n = 37) underwent a lumpectomy. This compares with a 63.6 percent (2615 of 4110) breast conservation rate in the nonaugmented population during the same time period. The two groups did not differ regarding (tumor) size (p = 0.77), nodal positivity (p = 0.32), or stage (p = 0.34). The mean time between implant placement and a diagnosis of breast cancer was 14 years. The average age of the patients who had previously undergone augmentation at breast cancer diagnosis was 49.5 years (SD, 9.0 years) versus 57.1 years (SD, 13.5 years) for the nonaugmented patients (p < 0.0001). Forty-nine of the patients underwent lymphatic mapping, with a 100 percent success rate in identifying the sentinel lymph node. There have been no clinically detected axillary recurrences in the patients who had a negative sentinel lymph node biopsy. Breast cancer patients who have undergone previous augmentation are more likely to present with a palpable mass. This initial mode of detection does not appear to translate into a larger tumor size or worse prognosis. Breast conservation and lymphatic mapping can be performed successfully in previously augmented patients.

The role of sentinel lymph node biopsy in patients with ductal carcinoma in situ or with locally advanced breast cancer receiving neoadjuvant chemotherapy

BACKGROUND A significant number of patients who are initially diagnosed with pure DCIS will harbor missed or occult invasive disease at their definitive surgery. To provide more accurate staging information and to avoid a second operation, some investigators believe that SLN mapping should be performed in DCIS patients. The role of SLN biopsy after neoadjuvant chemotherapy in patients with advanced breast cancer is controversial. METHODS A review of the literature was performed to determine the role of SLN biopsy in patients with DCIS or advanced breast cancer receiving neoadjuvant chemotherapy. The success rate of SLN biopsy after neoadjuvant chemotherapy was investigated as well as the percentage of positive SLNs in patients with DCIS. RESULTS Two consecutive studies revealed metastatic disease to the regional lymph nodes in up to 13% of DCIS patients. In addition, 10% of DCIS patients were upstaged to infiltrating ductal carcinoma at their definitive therapy. The ability of the SLN to predict the status of the remaining non-SLNs after neoadjuvant chemotherapy is unknown. False-negative rates range from 0% to 33%. The success rate for SLN identification for the combined series varies from 84% to 97%. CONCLUSIONS SLN biopsy is a minimally invasive technique that can be used to evaluate the regional nodal status of DCIS patients. Performing a SLN biopsy during the initial surgical procedure may avoid a second operation in some DCIS patients who are diagnosed with invasive disease at their definitive operation. The success rate of sentinel node identification does not seem to be altered after neoadjuvant therapy. However, the ability of the SLN to predict the pathologic status of the adjacent non-SLNs remains unknown. Therefore, until further prospective randomized trials are conducted, it cannot be assumed that all the regional nodes have the same biologic response to chemotherapy as the SLN.

Discrepancies between film and digital mammography interpretations

The purpose of this study was to evaluate the frequency and reasons of disagreement between film and full-field digital mammography (FFDM) interpretations observed in a prospective clinical trial performed with the GE Senographe 2000D system. The data from 643 mammography examinations comprising both digital and film mammograms were analyzed for this purpose. Reports indicated that 455 findings were identified on the digital softcopy reading and 457 findings on the standard film mammography with 408 discrepancies. Findings with discrepancies were matched and analyzed. A reason was identified and a relative conspicuity score of 0 to 10 was assigned to each finding at the time of resolution; 0 corresponded to a finding highly conspicuous on digital, 10 to a finding highly conspicuous on film, and 5 denoted equal visibility on both. After review, agreement was established between the two modalities in 73.3% of the findings; 13.5% of findings were seen better on digital and 13.2% of the findings were seen better on film. Approximately 63% of the discrepancies occurred due to variability in the reporting style of the radiologists and/or unavailability of prior films for comparison. Three cancer cases were identified in this study; two were seen on both modalities and one only on film. In conclusion, no statistically significant differences were observed between digital and film mammography, a result that despite the small size of our dataset is in agreement with previous reports. Inter-observer variability, display differences, and presentation disagreements are the main reasons for interpretation differences that are primarily identified in the classification and BIRADS assignment.

A case report of invasive ductal adenocarcinoma identified in a lymphatic channel: a staging controversy.

A 65-year-old woman underwent core biopsy of a palpable left breast mass. This was a Nottingham grade II invasive ductal carcinoma with lymphovascular invasion. The tumor was ER/PR positive and Her-2/neu negative. The patient agreed to participate in the American College of Surgeon’s Oncology Group Z00100 trial. Two weeks later, the patient underwent a left breast lumpectomy, sentinel lymph node (SLN) biopsy, and bone marrow biopsy. Lymphatic mapping and SLN biopsy were performed utilizing a combination mapping agent technique. Manual intermittent breast massage was performed for 5 minutes after injection of the mapping agents. A single SLN was identified that was both blue and “hot.”