Rebecca J. Patrick

Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes.

OBJECTIVES To describe our experience with patients who underwent the nipple-sparing mastectomy procedure developed and standardized at our institution and to report clinical outcomes for those patients with a breast cancer diagnosis. DESIGN Prospective study for consecutive nipple-sparing mastectomy procedures. SETTING Multidisciplinary breast center at a large tertiary care facility. PATIENTS One hundred ten consecutive patients underwent nipple-sparing mastectomy between July 2001 and June 2007. INTERVENTION Nipple-sparing mastectomy was offered to carefully screened patients; the nipple-areola tissue was cored and sent for histologic frozen-section analysis intraoperatively. MAIN OUTCOME MEASURES Assessment of nipple-areola cored tissue for neoplastic involvement; postoperative stability of retained nipple-areola complex; and clinical outcomes. RESULTS Data were available for 149 nipple-sparing mastectomies performed on 110 patients. No procedure performed for prevention had neoplastic involvement of the cored nipple-areola tissue, while 9 procedures performed for breast cancer treatment were found to have neoplastic involvement. Postoperatively, 2 patients had partial loss of the nipple-areola complex due to sloughing and a third patient developed an infection that required surgical removal of the nipple-areola complex. Among patients with breast cancer, none with ductal carcinoma in situ has developed a recurrence, while 4 patients with infiltrating breast cancer have, including 2 patients with distant metastases only, a third with a chest wall recurrence, and a fourth with an axillary recurrence. CONCLUSION A low incidence of neoplastic involvement of the nipple-areola cored tissue leads to successful completion of nipple-sparing mastectomy for most patients.

Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ

BACKGROUND Recent studies report the incidence of axillary metastases in patients with ductal carcinoma in-situ (DCIS) approaches 13%. The purpose of this study was to define the incidence of axillary micrometastases in patients with pure DCIS before and after the introduction of sentinel lymph node biopsy. METHODS Patients with a final diagnosis of DCIS form the basis of this study. Data were entered prospectively into an Institutional Review Board approved Oracle database from January 1997 through July 2002. RESULTS One hundred and thirty-four patients had lymph nodes evaluated. Ninety-eight percent of patients had no evidence of metastatic disease and 2% were found to have micrometastases. This was consistent in those who had level I or II lymph node sampling or both and those who had lymphatic mapping and a sentinel lymph node biopsy procedure. CONCLUSIONS These data do not support axillary lymph node removal of any type in patients with pure DCIS.

A prospective review of the decline of excisional breast biopsy

BACKGROUND Although excisional breast biopsy has long been considered the standard for breast cancer diagnosis, core biopsies are now used more frequently. Whether core biopsy can eventually replace excisional biopsy remains unknown. The purpose of this study was to evaluate the relationship between diagnostic excisional and core biopsies relative to surgical treatment procedures. METHODS We analyzed our data collected prospectively from 1995 through 2000, which included inpatient and outpatient surgical data, office visits, and radiology biopsy data including stereotactic, mammotome, and ultrasound core biopsies. The Cochran-Armitage trend test was used to assess the shift in diagnostic technique. RESULTS From 1995 through 2000 there were 2,631 core biopsies performed, 2,685 excisional biopsies, 2,881 surgical procedures for breast cancer, and 51,109 office visits. Although the percentage of core biopsies relative to excisional biopsies increased from 31% to 68% (P <0.001), the percentage of biopsies relative to the number of office visits remained stable at 10% to 11%. The percentage of breast cancer procedures relative to office visits also remained stable at 5% to 6%. CONCLUSIONS Our data indicate that core biopsies are being performed more often than excisional biopsies. Nevertheless, one in three biopsies done at our institution is excisional.

Does ultrasound core breast biopsy predict histologic finding on excisional biopsy

BACKGROUND The purpose of this study was to determine whether ultrasound-guided core breast biopsy accurately predicts the histologic finding of a subsequent excisional procedure. METHODS Data were collected prospectively from 1997 to 2001 for 832 ultrasound-guided core breast biopsies (USB) that were followed by excisional breast procedure (EP) within 1 year at our institution. The principal histologic finding obtained at USB and EP was identified for each procedure and the degree of agreement was assessed. RESULTS The USB histology predicted EP histology in 90% (n = 746) of the procedures. The USB histology was more significant than EP histology in 3% (n = 22) of procedures; USB histology underdetermined EP histology in 7% (n = 64) of procedures. Overall, our results indicate moderate agreement between the principal histology identified at USB relative to that identified at EP. CONCLUSIONS Ultrasound-guided core breast biopsy is an effective diagnostic method, but sampling limitations do exist.

Does core needle breast biopsy accurately reflect breast pathology

BACKGROUND Core needle breast biopsy (CB) has replaced excisional biopsy as the initial diagnostic biopsy procedure for many suspicious breast lesions; however, CB remains a sampling procedure. The purpose of this study was to determine the degree of agreement between histology obtained at CB and that obtained at a subsequent excisional procedure (EP). We hypothesized a high degree of agreement. METHODS Data were collected prospectively for 3035 CBs performed by breast radiologists using either ultrasound or stereotactic guidance between January 1995 and July 2002, 1410 (46%) of which had a subsequent EP within 1 year. Histologic categories were defined as invasive breast cancer, duct carcinoma in-situ, atypia/lobular carcinoma in-situ, and benign. The principal histology (PH) from CB and EP was identified and compared. RESULTS Overall, there was moderate agreement (kappa=0.669) between CB and EP histology. Complete agreement occurred in 1168 (83%) procedures. For the remaining 242, the PH was identified only at CB for 78 (5%) procedures, and only after EP for 164 (12%) procedures. CONCLUSIONS Although the majority (83%) of CB and EP demonstrated exact histologic agreement, CB was diagnostic for 1246 (88%) procedures.

Race is a Fundamental Prognostic Indicator for 2325 Northeastern Ohio Women with Infiltrating Breast Cancer

Abstract:  The goal of this research was to determine if race, independent of socioeconomic status, is a prognostic indicator for women diagnosed with infiltrating breast cancer. We hypothesized that black patients would present with breast cancers having less favorable prognostic indicators relative to white patients, regardless of socioeconomic status. Using data collected prospectively in our institutional review board approved breast center patient registry and 2000 Census Tract data for northeastern Ohio, we compared tumor size, node status, hormone receptor status, clinical outcomes, and socioeconomic status for patients who were self‐described as either black or white and who had been diagnosed with infiltrating breast cancer. The chi‐square test, t‐test, log‐rank test, and Cox proportional hazards analysis were used to analyze the data. Kaplan‐Meier outcome curves were generated. Data were available for 2325 women, including 313 who were black and 2012 who were white. Compared to white patients, black patients were more likely to have positive axillary nodes and to have hormone receptor‐negative tumors. Black patients were also more likely to have positive axillary nodes associated with smaller tumors. Independent of socioeconomic status, black patients were more likely to have poorer overall survival and disease‐free survival rates for breast cancer relative to white patients. The prognostic significance of race was not dependent on a concomitant relationship with socioeconomic status. 

The importance of preoperative breast MRI for patients newly diagnosed with breast cancer

Abstract:  The use of preoperative breast magnetic resonance imaging (bMRI) for patients newly diagnosed with breast cancer has been criticized for increasing the number of therapeutic mastectomies performed, as well as increasing the cost of treatment. The purpose of this report is to examine one surgeon’s practice and to describe the MRI findings for patients with breast cancer to determine if those findings changed the therapeutic options for those patients in. Data were collected prospectively between August 2003 and January 2006 for patients newly diagnosed with breast cancer. Diagnoses were made by core biopsy or fine‐needle aspiration; all lesions were intact at the time of MRI. Twenty‐five percent of patients were found to have previously occult, but suspicious lesions on MRI that required additional diagnostic evaluation, including ultrasound, core biopsy, excisional biopsy, or any combination; for approximately half of these patients a separate cancer was confirmed. For most of these patients, the new lesion was ipsilateral and multicentric, and most required mastectomy. For the remaining 75% of patients, MRI confirmed the index lesion was the only area of concern, and appropriate surgical treatment was completed. Preoperative bMRI for patients newly diagnosed with breast cancer identified previously occult and separate tumors in 13% of patients, resulting in surgical treatment change for many.

The 2003 revised TNM staging system for breast cancer: results of stage re-classification on survival and future comparisons among stage groups.

BackgroundChanges to TNM staging criteria for breast cancer, introduced in 2003, have resulted in stage re-classification for some tumors. The most frequently implemented change has resulted in tumors associated with more than three positive axillary nodes being upstaged.We hypothesize these TNM staging changes would result in more TNM Stage IIB, IIIA, and IIIB tumors and that disease-specific survival estimates would change under the new staging system.MethodsA review of data was completed for patients diagnosed with breast cancer between 1 January 1995 and 31 December 2000. Tumors that would have been staged differently under the 2003 system were identified and re-classified.Clinical outcomes were determined and disease-specific survival estimates were compared relative to TNM Stage using the old and new staging systems.Data were analyzed using the log-rank test and the method of Kaplan and Meier was used to generate survival curves.ResultsData were available for 2492 tumors, of which 919 were candidates for re-classification, including 829 old Stage II, 59 old Stage III, and 31 old Stage IV. Of these 919, 159 (17%) underwent stage re-classification using the new system. Separate survival estimates for patients who had been under old stage IIA/B, IIIA/B were generated; patients upstaged from IIA or IIB demonstrated a significant difference in survival.ConclusionsStage specific survival curves indicated decreased survival for patients whose tumors had been upstaged from IIA or IIB under the old system; survival for all other patients remained unchanged.

Prognostic significance of residual breast disease and axillary node involvement for patients who had primary induction chemotherapy for advanced breast cancer

BackgroundWe performed this study to determine the prognostic significance of clinical tumor size, pathologic measurement of residual tumor, and number of positive axillary nodes in the surgical specimen relative to overall survival for patients who underwent primary induction chemotherapy for advanced breast cancer.MethodsData, collected prospectively between 1997 and 2002, included clinical tumor-node-metastasis stage, age at diagnosis, hormone receptor status, type of preoperative chemotherapy, histological type, surgical procedure, pathologic measurement in centimeters of residual breast tumor, and the number of positive axillary nodes in the surgical specimen. Univariable correlates of residual breast disease were assessed by using the χ2 test. Recursive partitioning analysis was used to determine the prognostic significance of clinical tumor size, residual tumor size, and pathologic node involvement relative to overall survival. Survival was estimated by using the method of Kaplan and Meier and compared by using the log-rank test. A P value of < .05 was considered significant.ResultsData were available for 85 patients with advanced breast cancer. Although univariable analysis identified increasing age, clinically involved axillary nodes, and a higher clinical tumor-node-metastasis stage as predictors of an increased risk of residual disease, recursive partitioning analysis identified more than three involved axillary nodes in the surgical specimen, with or without any measurable residual breast disease, as the most significant predictor of decreased survival (P < .001).ConclusionsPathologic axillary node involvement was the most significant predictor of decreased survival for patients who had undergone primary induction chemotherapy for advanced breast cancer.

Guidelines for using breast magnetic resonance imaging to evaluate implant integrity.

The purpose of this report was to review our experience with using breast magnetic resonance imaging to evaluate breast implant integrity and to offer a decision tree to assist physicians in managing these patients. Data were available for 81 patients with 146 implants placed either unilaterally or bilaterally for either cosmesis or breast reconstruction. The chief complaint for a majority of patients (n = 24) was breast pain. Thirty-two patients were found to have 44 ruptured implants, the majority of whom were found to have either contracture (n = 7) or negative findings (n = 7) on physician examination. The likelihood of rupture increased with number of years in place. When a patient presents for a possible implant rupture, the initial concern is to rule out malignancy, but because clinical and radiologic findings are often convoluted and complicated, a decision tree is helpful.