Nicole Hodgson

Angiosarcomas of the breast: a review of 70 cases.

Objective:Angiosarcoma arising in the irradiated breast after breast-conserving therapy is being reported with increasing frequency. As more women undergo breast-conserving therapy, the incidence can be expected to increase. The objective of this study was to review breast angiosarcomas diagnosed from 1981 to 2000 from our state cancer registry. Methods:A comprehensive review of a population-based registry, Florida Cancer Data System, identified 70 cases of breast angiosarcomas from 1981 to 2000. Descriptive statistical and &khgr;2 analyses were performed. Results:Of the 70 cases at presentation, 39 were primary breast angiosarcomas (PBAs) and 31 were secondary breast angiosarcomas (SBAs). The mean ages were 59 and 72.9 for the PBA and SBA groups, respectively. In the SBA group the mean age of breast cancer diagnosis was 67.6. The mean time to diagnosis of the angiosarcoma was 5.2 years after breast cancer irradiation. At presentation 82% (n = 32) and 48% (n = 15), in the PBA and SBA groups, respectively had local disease (P = 0.003). The primary treatment was mastectomy in each group. There was no difference in mortality between the 2 groups (PSA; n = 18, SBA; n = 17). Conclusion:Angiosarcoma of the breast is rare and this study reports a review of 70 cases from 1980 to 2000. Angiosarcoma after breast-conserving therapy is increasingly diagnosed in a small but significant portion of breast carcinoma survivors. SBA patients present with more advance disease. Surgical resection is the primary therapy. The aggressive nature of this disease demands further investigation of adjuvant therapy to prevent recurrence of disease after surgery.

Prospective Study of 2-[18F]Fluorodeoxyglucose Positron Emission Tomography in the Assessment of Regional Nodal Spread of Disease in Patients With Breast Cancer: An Ontario Clinical Oncology Group Study

PURPOSE 2-[(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer. PATIENTS AND METHODS Women diagnosed with operable breast cancer within 3 months underwent FDG-PET at one of five Ontario study centers followed by axillary lymph node assessment (ALNA) consisting of sentinel lymph node biopsy (SLNB) alone if sentinel lymph nodes (SLNs) were negative, SLNB with axillary lymph node dissection (ALND) if SLNB or PET was positive, or ALND alone if SLNs were not identified. RESULTS Between January 2005 and March 2007, 325 analyzable women entered this study. Sentinel nodes were found for 312 (96%) of 325 women and were positive for tumor in 90 (29%) of 312. ALND was positive in seven additional women. Using ALNA as the gold standard, sensitivity for PET was 23.7% (95% CI, 15.9% to 33.6%), specificity was 99.6% (95% CI, 97.2% to 99.9%), positive predictive value was 95.8% (95% CI, 76.9% to 99.8%), negative predictive value was 75.4% (95% CI, 70.1% to 80.1%), and prevalence was 29.8% (95% CI, 25.0% to 35.2%). Using logistic regression, tumor size was predictive for prevalence of tumor in the axilla and for PET sensitivity. PET scan was suspicious for distant metastases in 13 patients; three (0.9%) were confirmed as metastatic disease and 10 (3.0%) were false positive. CONCLUSION FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.

National adoption of sentinel node biopsy for breast cancer: lessons learned from the Canadian experience.

Abstract:  Sentinel lymph node biopsy (SLNB) in breast cancer has not been readily adopted into Canadian surgical practice in comparison with the United States. We sought to evaluate current national practice patterns and explore barriers to direct efforts to improve the adoption of SLNB in Canada. All active (n = 1413) general surgeons in Canada were surveyed by mail. Surgeon demographics, practice patterns, skill acquisition and attitudes towards SLNB were assessed. The response rate was 63% (n = 889). Of the 506 (57%) surgeons who treated breast cancer, half were community based with breast surgery comprising <25% of their practices. Most (70%) performed ≤5 breast surgeries/month. Almost all (96%) believed SLNB was standard of care or an acceptable alternative to axillary lymph node dissection (ALND). Of these, 306 (61%) performed SLNB. Predictors of performing SLNB were breast/oncology fellowship (p = 0.03) or greater percentage of practice dedicated to breast (p = 0.02) but not region, type of practice (community versus academic), gender or year of residency completion. Reasons for performing SLNB were decreased morbidity (85%) and enhanced staging (59%) as opposed to competitive pressure (13%). The majority (75%) performed SLNB as a stand‐alone procedure for T1/T2 cancers and high‐risk ductal carcinoma in situ (70%). Almost half (46%) abandoned back up ALND after 30 or fewer cases even though the majority (75%) acknowledged the false‐negative rate should be <5%. Most (76%) learned SLNB through mentoring or a formal course/residency. Of the 197 (39%) not performing SLNB, 53% felt that inadequate access to nuclear medicine and gamma probe equipment was the predominant barrier. SLNB has been adopted into Canadian surgical practice. The majority of surgeons believe that SLNB is an acceptable alternative to ALND, with 61% now performing SLNB compared to 27% in 2001. Barriers to implementation appear to be related to inadequate resources as opposed to lack of belief in the procedure.

A prospective study of tumor and technical factors associated with positive margins in breast-conservation therapy for nonpalpable malignancy.

BACKGROUND The purpose of this study was to identify factors that predict an increased risk of a positive surgical margin after breast-conserving therapy for nonpalpable carcinoma of the breast. METHODS In this prospective study, 305 patients with nonpalpable invasive breast cancer or ductal carcinoma in situ were identified and underwent localization lumpectomy. Patient, technical, and tumor factors with a potential to predict margin status were documented. RESULTS A 20% positive margin rate was observed. Univariate analysis of patient, tumor, and technical factors revealed that localizations performed under stereotactic guidance (P < .001), presence of in situ disease, high tumor grade, larger tumor size, multifocal disease, and presence of mammographic microcalcifications (P < .02) were predictive of positive margins. With the exception of tumor grade and mammographic microcalcifications, multivariable analysis identified the same factors. CONCLUSIONS This study identified several factors associated with positive margins that should be considered when planning breast-conserving therapy for nonpalpable tumors.

Physician-related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: perspectives of physicians and patients

Objective  To identify patients’ and physicians’ perceptions of physician‐related verbal and nonverbal facilitators and barriers to patient involvement in treatment decision making (TDM) occurring during clinical encounters for women with early stage breast cancer (ESBC).

Adenoid cystic breast carcinoma: high rates of margin positivity after breast conserving surgery.

Introduction:Adenoid cystic carcinoma of the breast (ACCB) is a rare malignancy with favorable prognosis: axillary lymph node involvement, distant metastases, and death due to disease are uncommon. ACCB may recur locally many years after primary surgical excision and may be substantially higher if primary procedure is lumpectomy rather than mastectomy. Methods:Pathology database searched to identify patients diagnosed with ACCB between 1988 and 2007 at Hamilton Health Sciences Centre, Hamilton, Ontario, Canada. Two pathologists independently reviewed histology to confirm diagnosis of ACCB, and documented surgical procedure, tumor size, tumor grade, surgical margin, and lymph node status. Immunohistochemistry was performed on representative blocks and independently reviewed by 2 pathologists. Clinical and radiologic data were retrospectively reviewed. Results:Fifteen cases of ACCB were identified and pathology slides were available for 12. The median age was 62 years. Seven patients presented with a palpable mass and breast pain was described in 3. Positive surgical margins were identified in 5 patients (42%). Only 3 patients had postoperative radiation therapy. Conclusions:Our series shows frequent resection margin involvement in ACCB. Neither clinical nor mammographic examination consistently delineated full tumor extent preoperatively. Future use of magnetic resonance imaging in preoperative assessment may prevent high positive margin rate when lumpectomy is planned. Histologic assessment of tumor extent may be difficult, but immunohistochemistry may be helpful in this regard.

Borderline phyllodes tumor with an incidental invasive tubular carcinoma and lobular carcinoma in situ component: a case report.

Phyllodes tumors are an infrequent breast tumor presentation. A phyllodes tumor with a synchronous invasive ductal carcinoma is rarely described and has never been reported with lobular carcinoma in situ component. A 53-year-old female presented with a nine-year history of twice core biopsy proven fibroadenoma. After an increase in the tumors growth velocity it was decided upon to undergo an excisional biopsy. Microscopic examination of the well-circumscribed pale-tan mass found focal areas of leaf like architecture with variable number of mitoses present, representing a phyllodes tumor of borderline malignant potential. Incidentally, at one edge of the mass was found a tubular carcinoma and lobular carcinoma in situ components. Thorough, routine follow-up of patients with biopsy proven benign breast masses is important to finding a masked malignant component.

Results of a Surgeon-Directed Quality Improvement Project on Breast Cancer Surgery Outcomes in South-Central Ontario

BackgroundGaps in breast cancer (BC) surgical care have been identified. We have completed a surgeon-directed, iterative project to improve the quality of BC surgery in South-Central Ontario.MethodsSurgeons performing BC surgery in a single Ontario health region were invited to participate. Interventions included: audit and feedback (A&F) of surgeon-selected quality indicators (QIs), workshops, and tailoring interviews. Workshops and A&F occurred yearly from 2005–2012. QIs included: preoperative imaging; preoperative core biopsy; positive margin rates; specimen orientation labeling; intraoperative specimen radiography of nonpalpable lesions; T1/T2 mastectomy rates; reoperation for positive margins; sentinel lymph node biopsy (SLNB) rates, number of sentinel lymph nodes; and days to receive pathology report. Semistructured tailoring interviews were conducted to identify facilitators and barriers to improved quality. All results were disseminated to all surgeons performing breast surgery in the study region.ResultsOver 6 time periods, 1,828 BC charts were reviewed from 12 hospitals (8 community and 4 academic). Twenty-two to 40 participants attended each workshop. Sustained improvement in rates of positive margins, preoperative core biopsies, specimen orientation labeling, and SLNB were seen. Mastectomy rates and overall axillary staging rates did not change, whereas time to receive pathology report increased. The tailoring interviews concerning positive margins, SLNB, and reoperation for positive margins identified facilitators and barriers relevant to surgeons.ConclusionsThis surgeon-directed, regional project resulted in meaningful improvement in numerous QIs. There was consistent and sustained participation by surgeons, highlighting the importance of integrating the clinicians in a long-term, iterative quality improvement strategy in BC surgery.

A Retrospective Study Evaluating the Impact of Preoperative Breast MRI on Surgical Decision-Making in Young Patients (≤50 Years) with Invasive Breast Cancer

Introduction Breast magnetic resonance imaging (MRI) is considered a more sensitive diagnostic test for detecting invasive breast cancer than mammography or breast ultrasound. Breast MRI may be particularly useful in younger premenopausal women with higher density breast tissue for differentiating between dense fibroglandular breast tissue and breast malignancies. The main objective of this study was to determine the impact of preoperative breast MRI on surgical decision-making in young women with breast cancer. Methods A retrospective review of patients with newly diagnosed invasive breast cancer and age of ≤50 years was performed. All patients underwent physical examination, preoperative mammogram, breast ultrasound, and bilateral breast MRI. Two breast cancer surgeons reviewed the preoperative mammogram report, breast ultrasound report, and physical examination summary and were asked if they would recommend a lumpectomy, a quandrantectomy, or a mastectomy. A few weeks later, the two surgeons were shown the same information with the breast MRI report and were asked what type of surgery they would now recommend. In each case, MRI was classified by two adjudicators as having affected the surgical outcome in a positive, negative, or neutral fashion. A positive impact was defined as the situation where breast MRI detected additional disease that was not found on physical examination, mammogram, or breast ultrasound and led to an appropriate change in surgical management. A negative impact was defined as the situation where breast MRI led the surgeon to recommend more extensive surgery, with less extensive disease actually found at pathology. No impact was defined as the situation where MRI findings did not alter surgical recommendations or outcomes. Results Of 37 patients whose charts were reviewed, five patients were deemed to be ineligible due to having received neoadjuvant chemotherapy, having previous breast implants, or having had their tumor fully excised during biopsy. In total, 32 patients met the inclusion criteria of this study and were appropriate for analysis. The median age of our study patient population was 42 years. The pathologic diagnosis was invasive ductal carcinoma in 91% (29/32) of patients and invasive lobular carcinoma in 9% (3/32) of patients. For surgeon A, clinical management was altered in 21/32 (66%) patients, and for surgeon B, management was altered in 13/32 (41%) patients. The most common change in surgical decision-making after breast MRI was from breast-conserving surgery to a mastectomy. Mastectomy rates were similar between both surgeons after breast MRI. After reviewing the pathology results and comparing them with the breast MRI results, it was determined that breast MRI led to a positive outcome in 13/32 (41%) patients. Breast MRI led to no change in surgical management in 15/32 (47%) patients and resulted in a negative change in surgical management in 4/32 (13%) patients. Bilateral breast MRI detected a contralateral breast cancer in 2/32 (6%) patients. Conclusions Preoperative breast MRI alters surgical management in a significant proportion of younger women diagnosed with breast cancer. Prospective studies are needed to confirm these findings and to help determine if this change in surgical decision-making will result in improved local control.

One stage placement of permanent implant compared to two stage tissue expander reconstruction

Abstract With the advent of the skin sparing mastectomy, immediate breast reconstruction with placement of the definitive prosthesis at the time of mastectomy is possible. The question remains: does single-stage prosthetic reconstruction result in greater numbers of complications or rates of re-operation, compared to two-stage tissue expander reconstruction? A retrospective cohort study of a single centre?s experience with these techniques was carried out. From 2004 to 2012, 54 cases of immediate breast reconstruction with implant were identified, and 108 cases of immediate breast reconstruction using a tissue expander were identified. Gathered preoperative data included tumour, prior exposure to radiation, preoperative chemotherapy, smoking, and comorbidities. Complication rates, as well as the rate of secondary operations, were examined. There were no significant increased risks in the rate of post-operative complications (p = .910, odds ratio = 0.9) nor in the rate of re-operation (p = 0.421, odds ratio = 1.4) associated with the insertion of a definitive prosthesis at the time of skin sparing mastectomy. However, previously radiated breasts experienced a 100% rate of wound complications in our subset of 9 breasts that underwent one stage breast reconstruction with immediate final prosthesis placement. Our study suggests that patients with early stage disease can undergo single stage breast reconstruction without increased risk of complications nor need for secondary operations. While the mean time to completion of the reconstructive process is shortened by 5 months with the single stage technique, implant based breast reconstruction requires careful counseling and patient selection in radiated patients.