Susan Hoover

Breast cancer screening and diagnosis: Clinical practice guidelines in oncology™

The intent of these guidelines is to give health care providers a practical, consistent framework for screening and evaluating a spectrum of breast lesions. Clinical judgment should always be an important component of optimal management. If the physical breast examination, radiologic imaging, and pathologic findings are not concordant, the clinician should carefully reconsider the assessment of the patients problem. Incorporating the patient into the health care teams decision-making empowers the patient to determine the level of breast cancer risk that is personally acceptable in the screening or follow-up recommendations.

High-risk benign breast lesions: current strategies in management.

BACKGROUND High-risk benign breast lesions can create confusion for both the patient and the clinician. This paper reviews the characteristics of these lesions to help direct appropriate management. METHODS The authors reviewed the literature regarding high-risk breast lesions and include management guidelines that we employ at our institute. RESULTS High-risk breast lesions offer varying degrees of increased risk for the future development of breast cancer. Chemoprevention may be used to help decrease the risks from some lesions. CONCLUSIONS The management of high-risk benign breast lesions can be confusing. Clinicians should assess the risk of future breast cancer and develop a proper screening and prevention strategy for each individual patient.

Magnetic Resonance Imaging for Axillary Breast Cancer Metastasis in the Neoadjuvant Setting: A Prospective Study

Background: Breast magnetic resonance imaging (MRI) for assessment of regional breast cancer metastasis is controversial owing to the variable specificity. We evaluated breast MRI for axillary metastasis in neoadjuvant chemotherapy patients. Materials and Methods: A single‐institution, institutional review board–approved prospective trial enrolled female breast cancer patients receiving neoadjuvant chemotherapy from 2008 to 2012 and collected the pre‐ and post‐treatment MRI, pretreatment axillary ultrasound, axillary biopsy, and surgical pathologic findings. The kappa coefficient was used to evaluate the strength of the agreement between the 2 modalities and Fishers exact test was used to evaluate the association. Results: A total of 43 patients were included. Of these 45 patients, 35 had stage N1‐N2 before treatment. Comparing the abnormal results on the pretreatment MRI scans and axillary biopsy examinations, a consistent diagnosis was found for 92%, with a moderate strength of agreement (kappa coefficient, 0.54). The pretreatment MRI findings were significantly associated with the axillary biopsy results (P = .014). The false‐positive rate, false‐negative rate, sensitivity, and specificity were 50%, 3%, 97%, 50%, respectively. Comparing the post‐treatment MRI and surgical pathologic findings revealed a consistent diagnosis rate of, with a slight strength of agreement (kappa, 0.16). The false‐positive rate, false‐negative rate, sensitivity, and specificity were 38%, 46%, 55%, and 63%, respectively. The post‐treatment MRI findings were not associated with the pathologic lymph node results (P = .342). Conclusion: Pretreatment breast MRI was more specific for axillary metastasis than was axillary ultrasonography. However, post‐treatment breast MRI was not predictive of residual axillary disease and should be used cautiously when altering treatment plans. Micro‐Abstract: Evaluation of the axilla on breast magnetic resonance imaging (MRI) for breast cancer is a growing practice. We reviewed a prospective breast cancer cohort undergoing neoadjuvant chemotherapy to compare the pretreatment breast MRI findings with the axillary ultrasound/fine needle aspiration findings and the post‐treatment breast MRI findings with the surgical pathologic findings. The prechemotherapy MRI findings were more specific for axillary metastasis than were the focused ultrasound findings. However, the postchemotherapy MRI findings were not predictive of residual axillary disease.

Adenoid Cystic Carcinoma of the Breast: A Review of a Single Institution’s Experience

To the Editor: Adenoid cystic carcinoma of the breast (ACCB) is rare, comprising less than 0.1% of breast cancers, and may be under-reported due to misclassification (1). Such misclassification has negative impact, as this tumor requires different clinical management when compared to breast adenocarcinoma. We reviewed our institutional experience by searching a prospectively accrued database of 17,703 patients from 1989–2006 for ‘‘cylindroma,’’ ‘‘cribriform,’’ ‘‘papillary,’’ or ‘‘adeno’’ to minimize misclassification. After histological confirmation, records were reviewed for presentation, staging, therapy, and outcome. Eighty-eight potential patients with ACCB were identified, but after slide review, only seven true ACCB cases were identified (Table 1). Six patients presented with either breast pain or palpable mass. Median age was 49 years (range 37–82 years) and median tumor size was 1.8 cm (range 1.3–5 cm). Imaging studies included mammography in all seven patients that revealed spiculated masses, and ultrasonography in six patients that revealed hypoechoic, well-circumscribed masses. Diagnosis of ACCB was made by core biopsy in one patient and excisional biopsy in six patients performed prior to referral to our institution. Definitive surgery included partial mastectomy in four and total mastectomy in three patients. While at operative resection all lesions appeared grossly wellcircumscribed, histological analysis revealed microscopic tumor extending away from the gross margin, requiring re-excision in all who underwent partial mastectomy. While acceptable margin width has not been definitively established, a minimum of one millimeter seems advisable due to the high rate of margin positivity in this study, and the local recurrence rates of 30–40% reported previously (2). Histologically, ACCB appeared different from the common forms of breast cancer and similar to adenoid cystic carcinomas seen in the head and neck (Fig. 1). The tumor is characterized by a mixture of proliferating epithelial cells forming ductule-like structures and glands (true lumina), and modified myoepithelial elements forming cribriform spaces (‘‘pseudolumens’’). In our series, all but one of our patients underwent sentinel node biopsy, with one patient having isolated tumor cell clusters in the sentinel node detected on IHC only. For this patient, on complete node dissection, the remaining 21 nodes were all negative. In review of the literature, axillary involvement appears in approximately 15% (3). While routine complete node dissection in modern practice is unwarranted, consideration for the low morbidity procedure of a sentinel lymph node biopsy should be given. Omission of sentinel node biopsy in the absence of palpable axillary disease can be weighed on an individual basis. As in our series, this includes small, medial tumors in patients with significant co-morbidity. The follow-up of patients included a clinical examination every 6 months for 5 years, and mammography every 6 months for 2 years and annually thereafter. The three patients treated with partial mastectomy received adjuvant whole breast radiation (range 50– 65 Gy). None of the seven patients received adjuvant hormonal or chemotherapy. All seven tumors were estrogen receptor, progesterone receptor, and HER2 ⁄ neu negative. Despite the ‘‘triple negative’’ hormone receptor status and histological similarity to the clinically aggressive adenoid cystic carcinomas of the head and neck, ACCB had an indolent clinical course. At a median follow-up of 49 months after resection, only one patient had a local recurrence. This patient initially presented to an outside institution and Address correspondence and reprint requests to: Christine Laronga, MD, Comprehensive Breast Program, 12902 Magnolia Drive, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, or e-mail: Christine. Laronga@moffitt.org

Menopausal status does not predict Oncotype DX recurrence score

BACKGROUND Adjuvant treatment for early stage, estrogen receptor (ER) positive invasive breast cancer has been based on prognosticators such as menopausal status. The recurrence score (RS) from the 21-gene assay Oncotype DX (ODX) is predictive of a 10-y distant recurrence in this population but is rarely applied to premenopausal patients. The relationship between menopausal status and RS was evaluated. MATERIALS AND METHODS An institutional review board-approved retrospective review was conducted of invasive breast cancer patients with known RS. ODX eligibility was based on National Comprehensive Cancer Network guidelines or physician discretion. Perimenopausal women were classified as premenopausal for statistical analyses. Comparisons of menopausal status and RS were made using general linear regression model and the exact Wilcoxon rank-sum test. RESULTS Menopausal status was available for 575 patients (142 premenopausal, 433 postmenopausal). Median age was 46 y for premenopausal and 62 y for postmenopausal. Median invasive tumor size was 1.5 cm for both cohorts. Mastectomy rate was higher in the premenopausal group (54.8%) than postmenopausal (42%; P = 0.0001). Premenopausal women had a higher local-regional recurrence rate (2.8% versus 0%; P = 0.0384) but distant recurrence and overall survival were not statistically different (P = 0.6808). Median ER H-score was lower in premenopausal (H-score = 270) than postmenopausal women (H-score = 280; P < 0.0001). Median RS was 16 for both premenopausal (range, 0-54) and postmenopausal (range, 0-63) women. Menopausal status as a categorical variable was not predictive of RS (P-value = 0.6780). CONCLUSIONS Menopausal status has limited predictive power for distant recurrence. Therefore, menopausal status alone should not preclude performance of ODX in ER-positive, early stage breast cancer.

Early Postoperative Complications after Oncoplastic Reduction

Background Breast-conserving surgery with adjuvant radiation therapy (BCT) has been established as safe oncologically. Oncoplastic breast surgery uses both oncologic and plastic surgery techniques for breast conservation to improve cosmetic outcomes. We evaluated the risk factors associated with complications after oncoplastic breast reduction. Methods A single-institution, institutional review board–approved, retrospective review of electronic medical records of female patients with breast cancer who underwent oncoplastic breast reduction from 2008 to 2014. A review of electronic medical records collected relevant medical history, clinical and pathological information, and data on postoperative complications within 6 months stratified into major or minor complications. Categorical variables analyzed with the &khgr;2 exact method; continuous variables were analyzed with the Wilcoxon rank sum test exact method. Results We identified 59 patients; 4 required re-excision for positive margins, and 1 moved on to completion mastectomy. The overall complication rate was 33.9% (n = 20): 12 major (20.3%) and 8 minor (13.6%). Of the continuous variables (age, body mass index, and tissue removed), increased age was associated with minor complications (P = 0.02). Among the categorical variables (stratified body mass index, prior breast surgery, hypertension, diabetes mellitus, hyperlipidemia, vascular disease, pulmonary disease, and stratified weight of tissue removed), none were associated with overall or major complications. Pulmonary disease was associated with minor complications (P = 0.03). Bilateral versus unilateral oncoplastic breast reduction showed no statistically significant increase in complications. Conclusions The overall complication rate after oncoplastic breast reduction was markedly higher than that in nationally published data for breast-conserving surgery. The complication rate resembled more closely the complication rate after bilateral mastectomy with immediate reconstruction. No risk factors were associated with major or overall complications. Age and pulmonary disease were associated with minor complications. Patients should be selected and counseled appropriately when considering oncoplastic breast reduction.

Distant recurrence risk with prospective use of the 21-gene assay at a single institution.

131 Background: Distant recurrence (DR) is the cause of most breast cancer deaths. The 21-gene assay (ODX) Recurrence Score (RS) result predicts both 5 and 10-yr DR risk and can guide adjuvant chemotherapy (CT) recommendations to mitigate this risk. This study analyzed the use of the RS result to guide adjuvant treatment decisions in a large single-institution, prospective cohort of patients (pts). METHODS This is an IRB-approved review of a prospective database of pts receiving ODX on an initial primary breast cancer. Data collected included demographics, primary operation, margin status, receptor status, RS, adjuvant treatment, recurrence, and survival. Pts were stratified as low risk (RS < 18), intermediate risk, or high risk (RS > 30). The primary analysis computed Kaplan-Meier estimates for rate of DR at 5 yrs when pts were stratified by RS. RESULTS From 2003 to 2009, a RS result was obtained on 606 pts. Median follow up was 2.9 yrs (0.1-9.7) and median age was 58 yrs (27-84). Median RS result was 16 (0-63); 344(57%) pts were low, 212(35%) intermediate, 50(8%) high. Endocrine therapy was given to 92.4%, 94.3%, and 87.5% low, intermediate, and high risk pts, respectively. Adjuvant CT was given to 8.6%, 47.6%, and 70.8% low, intermediate, and high risk pts, respectively. There were 8 DR events with 1.8% 5-yr estimated risk of DR. The 5-yr estimated risk of DR was 0.7% for low risk (344) pts, 3.4% for intermediate risk (211) pts, and 2.6% for high risk (50) pts. Among node negative [N(-)] pts (502), the 5-yr estimated risk of DR was 0.8% for low risk (287) pts, 3.7% for intermediate risk (174) pts, and 3.3% for high risk (41) pts. Among node positive [(N+)] pts (54) there was only 1 DR, which was in a high risk pt. Of pts with unknown nodal status (50), there were no DRs. CONCLUSIONS The RS result is predictive of DR at 5 yrs as shown in historical datasets (Table). The use of ODX to guide adjuvant treatment recommendations in our contemporary, prospective cohort resulted in a much lower 5-year DR rate and thus supports its use to guide adjuvant treatment decisions. [Table: see text].