N Beechey-Newman

Paget disease of the nipple - A multifocal manifestation of higher-risk disease

The treatment of Paget disease by mastectomy has been challenged recently in favor of breast‐conserving techniques. A large series of patients treated with mastectomy has been reviewed to assess the feasibility of less radical surgery.

MR Navigated Breast Surgery: Method and Initial Clinical Experience

3D dynamic contrast enhanced magnetic resonance (MR) images may help to reduce the high re-excision rate associated with breast conserving surgery. However these images are acquired prone, whilst surgery is performed supine which results in a large deformation that limits their usefulness. We describe here a registration technique based on a biomechanical model to account for soft tissue deformation between prone MR imaging and surgery. The accuracies of the individual registration steps are assessed off-line. We then report our first clinical experience with an image-guided surgery system which incorporates these algorithms. The systems accuracy is assessed against tracked ultrasound images, and is determined to be around 5mm for this case.

Sentinel node biopsy: an in depth appraisal

Sentinel node biopsy (SNB) in primary breast cancer has been taken-up widely to avoid the morbidity attributable to axillary node clearance (ANC). Currently many issues surrounding SNB are undecided. This review summarises why some form of axillary surgery is required and presents data on all aspects of SNB including methodology, clinical results and problems that may delay the introduction of SNB as best practice for all patients with primary breast cancer. There is no long or medium term data relating to the consequences of replacing ANC with SNB, but the mechanisms and probable magnitude of both beneficial and detrimental effects are estimated. A low level of false negative results are inherent to the technique but it is demonstrated that SNB is likely to have an only marginal (0.6%) effect on survival that would be undetectable by clinical trials. Patient sub-groups particularly likely to benefit from SNB are identified.

Breast duct microendoscopy in nipple discharge: microbrush improves cytology

BackgroundBreast duct microendoscopy is a new technique that allows direct visualization of the mammary ductal epithelia and has the potential to provide greater accuracy in the diagnosis of benign and malignant breast conditions. We have already established the feasibility of BDME on mastectomy specimens and in patients both under general and local anesthesia. It was the aim of this study to investigate the use of BDME in patients with pathological nipple discharge and to explore the feasibility of using an endoluminal microbrush to take cytology samples from specific lesions.Materials and methodsBreast duct microendoscopy was offered to all patients undergoing surgery for nipple discharge. Surgery included microdochectomy (younger women) and total duct excision (especially in postmenopausal women). The microbrush was used to collect samples whenever an endoluminal papilloma was seen on endoscopy. The results of microbrush cytology samples were compared to ductal lavage samples.ResultsFifty consecutive patients undergoing microdochectomy or total duct excision for nipple discharge had breast microendoscopy (28 general, and 22 under local anesthesia). Thirty-one patients had microdochectomy and nineteen had total duct excision. Visualiza- tion of discharging ducts was accomplished in 100% cases. Endoluminal abnormalities were seen in 33 (66%) patients and dilated ducts were seen in 17 patients. Among the 33 patients, 15 had single papilloma, 3 multiple papilloma and 15 inflammation (erythema, fronds, adhesions). Seven out of eight patients with an intraductal papillorna who had microbrush cytology showed papillary cells whereas only 2 out of 11 patients who had ductal lavage were positive for papillary cells. Thus the sensitivity of the brush cytology technique for the diagnosis of papilloma was 87.5% and the sensitivity of ductal lavage 18% (p = 0.0055).ConclusionBreast duct microendoscopy is an effective way of establishing the etiology of nipple discharge. The microbrush increases the sensitivity of cytology significantly.

A framework for image-guided breast surgery

Breast-conserving surgery for the treatment of cancer frequently requires a repeat operation due to the initial excision of the tumour being incomplete. Improved image guidance, using preoperative MR images, might help to reduce this high re-excision rate. Since the diagnostic MR images are acquired prone, but surgery is performed supine, significant deformation of the soft tissue of the breast occurs. We have developed an approach to account for this deformation based on a patient-specific biomechanical model. The model is constructed from a supine MR image, and it is used to initialize a non-rigid intensity-based registration of the diagnostic prone MR image with the supine image. In the operating theatre the surface of the breast is acquired with a stereo camera, and the model is deformed to match this surface in order to predict the position of the lesion. We illustrate our framework with initial results for one patient case, in which we estimate our target registration error to be 4mm.

Paget's disease of the nipple: A multi-focal manifestation of higher risk disease

BACKGROUND The treatment of Paget disease by mastectomy has been challenged recently in favor of breast-conserving techniques. A large series of patients treated with mastectomy has been reviewed to assess the feasibility of less radical surgery. METHODS The cases of 70 women with a clinical diagnosis of Paget disease were reviewed. The type, grade, receptor and node status, and the mammographic and pathologic extent of the underlying breast malignancy were determined. The survival of patients with invasive disease was compared with matched controls without Paget disease. RESULTS The underlying malignancy was invasive in 58% of cases. Despite the fact that only one third of women presented with a palpable mass, the malignancy was frequently extensive, being confined to the retroareolar region in only 25% of cases. The true extent of the disease was underestimated by mammography in 43% of cases. Of the patients with ductal in situ carcinoma, 96.5% had high-grade carcinomas and 100% had invasive carcinomas of high cytonuclear grade. Overexpression of the c-erb-B2 oncogene was detectable in 83% of cases. Patients with Paget disease had a significantly worse survival than matched controls, but this difference was eliminated if they were also matched for c-erb-B2 status. CONCLUSIONS Paget disease is often associated with extensive underlying malignancy, which is difficult to assess accurately either clinically or mammographically. As a consequence, cone excision of the nipple would have resulted in incomplete excision in 75% of cases. The underlying disease is of high grade and is frequently c-erb-B2 positive with a resulting poor prognosis. Aggressive local and systemic treatment would seem to be merited.