Tammi Meade

Pregnancy-Associated Breast Cancer Patients Can Safely Undergo Lymphatic Mapping

Abstract:  As more women put off pregnancy until their 30s and beyond, the possibility of pregnancy‐associated breast cancer (PABC) will rise. Treatment options for patients with PABC need to consider possible harm to the fetus. The goal of this study is to review our institution’s experience with sentinel lymph node (SLN) biopsies in patients with PABC. A prospectively accrued breast Institutional Review Board (IRB) approved data base was searched under separate IRB approval for cases of SLN biopsy in patients with PABC. Ten patients were identified between 1994 and 2006 out of 5,563 patients. A chart review was performed on all 10 patients. Ten patients with PABC and an average gestation age of 15.8 weeks underwent SLN biopsy. All patients successfully mapped. Positive SLN were identified in 5/10 patients (50%) while there was no evidence of metastases in 5/10 patients (50%). 9/10 (90%) of patients went on to deliver healthy children without any reported problems. One patient (10%) decided to terminate her pregnancy in the first trimester following surgery prior to the start of chemotherapy. SLN biopsy can safely be performed in patients with PABC with minimal risk to the fetus. By performing a SLN biopsy, a large proportion of patients with PABC may be spared the risk of a complete axillary lymph node dissection.

Use of Reoperative Sentinel Lymph Node Biopsy in Breast Cancer Patients

BACKGROUND Ipsilateral breast recurrence or second primary breast cancer can develop in patients who have undergone breast conservation and sentinel lymph node biopsy (SLNB). This brings into question the necessity of complete axillary lymph node dissection (CALND) versus a second SLNB (remapping). Our objective is to determine the feasibility of a reoperative SLNB. STUDY DESIGN A review of patients receiving a reoperative SLNB between April 1994 and December 2006 was conducted with IRB approval. Fifty-six patients underwent a second SLNB on the ipsilateral side an average of 42.5 months after their first SLNB. RESULTS Sentinel lymph nodes were successfully remapped in 45 of 56 (80.4%) patients. Of 45 patients successfully remapped, 36 (80%) were node negative and were spared CALND. There was only 1 patient (2.2%) in whom a sentinel lymph node was identified outside of the ipsilateral axilla. At 26 months mean followup for the second SLNB, there have been no axillary recurrences and 1 death. CONCLUSIONS Our findings demonstrate that remapping sentinel nodes in patients with ipsilateral recurrence or new primary breast cancer after SLNB achieved success in 80.4% of patients. Overall, 80.0% (36 of 45) of the successfully remapped patients were spared a CALND.

Male Breast Cancer: Management and Follow‐up Recommendations

Abstract:  National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but similar guidelines on male breast cancers are less recognized. As an NCCN institution, our objective was to examine practice patterns and follow‐up for male breast cancer compared to established guidelines for female patients. After Institutional Review Board approval, a prospective breast database from 1990 to 2009 was queried for male patients. Medical records were examined for clinico‐pathological factors and follow‐up. The 5‐year survival rates with 95% confidence intervals were estimated using Kaplan–Meier method and Greenwood formula. Of the 19,084 patients in the database, 73 (0.4%) were male patients; 62 had complete data. One patient had bilateral synchronous breast cancer. The median age was 68.8 years (range 29–85 years). The mean/median invasive tumor size was 2.2/1.6 cm (range 0.0–10.0 cm). All cases had mastectomy (29 with axillary node dissection, 23 with sentinel lymph node biopsy only, 11 with sentinel node biopsy followed by completion axillary dissection). Lymph node involvement occurred in 25/63 (39.7%). Based on NCCN guidelines, chemotherapy, hormonal therapy, and radiation are indicated in 34 cases, 62 cases, and 14 cases, respectively. Only 20/34 (59%) received chemotherapy, 51/62 (82%) received hormonal therapy, and 10/14 (71%) received post‐mastectomy radiation. Median follow‐up was 26.2 months (range: 1.6–230.9 months). The 5‐year survival estimates for node positive and negative diseases were 68.5% and 87.5%, respectively (p = 0.3). Despite the rarity of male breast cancer, treatment options based on current female breast tumors produce comparable results to female breast cancer. Increased awareness and a national registry for patients could help improve outcomes and tailor treatment recommendations to the male variant.

Sentinel Lymph Node Biopsy in Patients with Previous Ipsilateral Complete Axillary Lymph Node Dissection

BackgroundPrior ipsilateral completion axillary lymph node dissection (CALND) may be considered a contraindication to performing a sentinel lymph node (SLN) mapping in a patient with recurrent breast carcinoma. However, reoperative SLN biopsy following axillary dissection would determine if alternative lymphatic drainage pathways exist. If nodes were found to contain metastatic disease, staging and locoregional control of the disease could be affected.Materials and MethodsAn institutional breast cancer database and electronic health record (IRB No. 102554) prospectively accrued 6225 patients between 1994 and 2007. Under separate IRB approval (IRB No. 102552), this database was queried for patients with a prior history of CALND who received a SLN biopsy. Patients’ demographic, clinical, and treatment variables were recorded.ResultsOf the 6225 patients, 45 (0.7%) were identified as having previously undergone breast-conservation surgery, CALND, and ipsilateral reoperative SLN mapping and biopsy. Of the 45 patients, 13 (29%) had a successful ipsilateral reoperative SLN mapping and biopsy. Nonaxillary drainage was identified in 5 patients with reoperative SLN biopsy.ConclusionReoperative SLN mapping and biopsy is feasible in the setting of local recurrence after previous CALND. This procedure performed for breast cancer recurrence provides important staging information while identifying extra-axillary drainage that could affect both staging and local control.

Factors associated with improved outcome after surgery in metastatic breast cancer patients

BACKGROUND Recent studies suggest local surgical therapy improves survival in metastatic breast cancer (MBC). We evaluate the difference in outcome in patients with MBC after mastectomy versus breast conservation (BCT) and factors that influence outcome. METHODS In a retrospective review of our prospective database, we identified patients who presented with MBC (1990 to 2007). Patient surgery type and clinicopathologic factors were reviewed. We compared OS between pts dependent on surgery and clinicopathologic factors. RESULTS Of the 566 patients with MBC, 154 (27%) underwent removal of the primary tumor. Surgery was associated with an improved OS (33%) versus no surgery (20%) (P = 0.0015). Of those undergoing local therapy; mastectomy was associated with a 37% OS vs BCT with a 20% OS (P = 0.04). CONCLUSIONS Our study confirms that removal of the primary tumor in MBC is associated with improved overall survival. It appears that mastectomy is associated with a significantly improved overall survival.

Feasibility of Sentinel Lymph Node Biopsy Through an Inframammary Incision for a Nipple-Sparing Mastectomy

BackgroundNipple-sparing mastectomy (NSM) via an inframammary (IM) incision has been described for selected patients with breast cancer. However, the application of sentinel lymph node (SLN) mapping via an IM incision for NSM has yet to be reported. The objective of this study is to determine the technical feasibility of performing SLN through an IM incision without making an axillary counterincision.MethodsWe retrospectively reviewed our single-institutional experience with SLN biopsy and NSM through IM incisions between January 2006 and March 2008. Clinicopathologic factors were analyzed regarding indications, technical details, postoperative morbidity, and follow-up.ResultsFifty-two patients underwent 87 NSM through an IM incision (17 unilateral, 35 bilateral) with immediate reconstruction and SLN biopsy. Indications for surgery included invasive breast cancer (n = 21), ductal carcinoma in situ (DCIS) (n = 18), and prophylactic (n = 48). Mean tumor size of invasive carcinoma was 2.1 cm. The mean mastectomy specimen weight was 437 g. Subareolar injection consisted of blue dye (n = 43), technetium sulfur colloid (n = 2), or combination injection (n = 42). SLN biopsy through an IM incision was successfully performed in 84 of 87 cases (96.6%). A mean of 2.8 SLN were removed with a positive sentinel node encountered in 8 of 21 patients (38%) with invasive cancer. No complications were observed regarding the SLN portion of the operation. With a median follow-up of 6.5 months (range, 0.4–23 months), there have been no axillary local recurrences.ConclusionSLN biopsy can be performed through an IM incision during a NSM, avoiding a secondary axillary incision.

The surgical treatment of breast cancer in the elderly: a single institution comparative review of 5235 patients with 1028 patients ≥70 years.

Abstract:  As the wave of the baby boomers shifts the age demographic of patients, the current surgical management of breast cancer in elderly women (≥70 years of age) becomes relevant because deviation from standard treatment often occurs in this group. The purpose of this study was to determine the operative mortality when treated with standard surgical procedures and to investigate trends in the surgical management of breast cancer in the elderly. A total of 5,235 patients undergoing either mastectomy or breast conservation surgery (BCS) for invasive and ductal carcinoma in situ (DCIS) were identified in a retrospective review of a prospectively accrued data base between the years of 1994 and 2007 at the Moffitt Cancer Center. Of the 5,235 patients, 1,028 (20%) patients were ≥70 years of age. The 30‐day and 90‐day mortality in the elderly group (age ≥70 years) was 0.2% (95% CI 0.02–0.7%) and 0.7% (95% CI 0.3–1.4%), respectively. The 30‐day and 90‐day mortality among patients <70 years was 0 and 0.05% (2 of 4,207 patients) (95% CI 0.005–0.2), respectively. BCS rates for invasive carcinomas were the highest for patients between 40 and 70 years of age, whereas the mastectomy rates were higher among patients <40 years of age (53%). Elderly women were as likely as women <40 years to have BCS for invasive carcinoma (OR 1.1, 95% CI 0.8–1.5), but more likely to have BCS for DCIS (OR 1.9, 95% CI 1.1–3.3). Surgical mortality in elderly women treated for breast cancer was extremely low and was related to the extent of surgery performed. Breast cancer treatment differed by age groups.

Effects of Prior Augmentation and Reduction Mammoplasty to Sentinel Node Lymphatic Mapping in Breast Cancer

Abstract:  Previous plastic surgery procedures such as breast augmentation or reduction mammoplasty can potentially alter the lymphatic drainage of the breast. The purpose of this study is to determine the success rates of sentinel node lymphatic mapping in patients with previous plastic surgical procedures of the breast. A total of 83 patients with a history of plastic surgery of the breast that underwent subsequent sentinel node mapping between 1996 and 2008 were retrospectively analyzed. Eight‐three patients that underwent a total of 108 sentinel node biopsies. Hundred cases (93%) previously underwent breast augmentation and eight cases (7%) previously underwent reduction mammoplasty. The mean time between the previous plastic surgical procedures and the sentinel node biopsy was 10.3 years (range: 2 months–32 years). Indications for the mapping procedure were invasive cancer (n = 64), ductal carcinoma in situ (n = 17), and prophylactic mastectomy (n = 27). The identification rate of the sentinel node was 95.3% (103/108). The success rate based on type of procedure was 96% (96/100) for augmentation and 87.5% (7/8) for reduction mammoplasty. With a mean follow‐up of 3.4 years, there has been only one local axillary recurrence that occurred at the time of an ipsilateral breast recurrence following lumpectomy. Lymphatic mapping can be successfully performed in patients who have previously undergone plastic surgery operations.

Problems with the use of breast conservation therapy for breast cancer in a patient with neurofibromatosis type 1: a case report.

Abstract:  Patients with Neurofibromatosis type I and breast cancer represent a subset of people who may be considered at high risk for secondary cancers after conventional whole breast radiation therapy and breast conservation surgery. A case of a 49‐year‐old woman with neurofibromatosis type I is presented. She was diagnosed with a 1.1‐cm right breast infiltrating ductal carcinoma. Clinical, diagnostic imaging, and pathologic features are discussed. Her initial treatment plan of breast conserving therapy was thwarted when her sentinel node biopsy was positive for micrometastatic disease in 1/14 lymph nodes. She elected to have a bilateral simple mastectomy. This case addresses the rare dilemma of offering breast conservation therapy as a viable option for patients with neurofibromatosis type I. Current data on radiation‐induced secondary cancers such as sarcoma after treatment for breast and other cancers are reviewed.

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