Viola Liberale

Clinical-pathologic features, long term-outcome and surgical treatment in a large series of patients with invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC)

PURPOSE OF THE STUDY A retrospective analysis on 1407 patients with invasive ductal carcinoma (IDC) and 243 invasive lobular carcinoma (ILC) was performed in order to compare the histological features, the immunohistochemical characteristics, the surgical treatment and the clinical outcome in the two groups. RESULTS ILC seems to be more likely multifocal, estrogen receptor positive, HER-2 negative and to have a lower proliferative index compared to IDC. ILC, when treated with conservative surgery, required more frequently re-excision and/or mastectomy because of positive resection margins. No difference was observed in terms of 5-year disease free survival and local relapse free survival between the two groups, in the whole series and in the subgroup of patients treated with breast-conserving treatment. CONCLUSION ILC can be safely treated with conservative surgery but a more accurate preoperative evaluation of tumor size and multifocality could be advocated, in order to reduce the re-excision rate.

Role of MRI (magnetic resonance imaging) versus conventional imaging for breast cancer presurgical staging in young women or with dense breast

AIMS The role of magnetic resonance imaging (MRI) in the local staging of breast cancer is currently uncertain. The purpose of this prospective study is to evaluate the accuracy of preoperative MRI compared to conventional imaging in detecting breast cancer and the effect of preoperative MRI on the surgical treatment in a subgroup of women with dense breasts, young age, invasive lobular cancer (ILC) or multiple lesions. METHODS Between January 2006 and October 2007, 91 patients with newly diagnosed breast cancer underwent preoperative clinical breast examination, mammography, bilateral breast ultrasonography and high-resolution breast MRI. All patients had histologically verified breast cancer. The imaging techniques were compared using the final pathological report as gold standard. RESULTS The sensitivity of MRI for the main lesion was 98.9%, while for multiple lesions sensitivity was 90.7% and specificity 85.4%. After preoperative MRI, 13 patients (14.3%) underwent additional fine needle/core biopsies, 9 of whom had specimen positive for cancer. Preoperative MRI changed the surgical plan in 26 patients: in 19.8% of the cases breast conservative surgery was converted to mastectomy and in 7.7% of the patients a wider excision was performed. At a mean follow-up of 48 months, 2 local recurrences occurred (local failure rate = 2.5%). CONCLUSIONS Enhanced sensitivity of breast MRI may change the surgical approach, by increasing mastectomy rate or suggesting the need of wider local excision. MRI can play an important role in preoperative planning if used in selected patients with high risk of multifocal/multicentric lesions. However, the histologic confirmation of all suspicious findings detected by MRI is mandatory prior to definite surgery.

Role of re-excision for positive and close resection margins in patients treated with breast-conserving surgery

PURPOSE To evaluate the incidence of residual disease after additional surgery for positive/close margins and the impact on the rate of local and distant recurrence. METHODS A retrospective analysis on 1339 patients treated for breast cancer with breast conserving-surgery and radiotherapy at a single Institution between 2000 and 2009 was performed. RESULTS During primary surgery 526 patients (39.3%) underwent intraoperative re-excision. At the final pathological report, the margins were positive in 132 patients (9.9%) and close in 85 (6.3%). To obtain clear margins, 142 of these women underwent a second surgery; 35 patients with positive margins (27%) and 40 with close margins (47%) did not receive additional surgery because of different reasons (patients refusal, old age, comorbidity or for focal margin involvement). At second surgery, residual disease was found in 62.9% of patients with positive margins and in 55.5% of those with close margins. At a median follow-up time of 4 years, local recurrence (LR) rate was 2.9% for patients with clear margins, 5.2% (p = 0.67) for patients with unresected close margins and 11.7% (p = 0.003) for those with unresected positive margins. The HER-2 and the basal-like subtypes had the higher rate of LR and the luminal A the lowest. CONCLUSIONS A significantly higher LR rate was found only among patients with positive margins not receiving additional surgery, but not in those with unresected close margins. Positive margins are a strong predictor for LR and need re-excision that can be avoided for close margins.

Transient ventricular hypocinesia after in utero anthracyclines exposure: a case-report and review of the literature.

Due to the low occurrence of cancer during pregnancy, limited data are available about outcome of infants exposed to chemotherapy in utero. We report the case of a newborn who developed transient ventricular hypocinesia and late-onset infection after in utero exposure to four epirubicin cycles for pregnancy-associated breast cancer. Moreover, we provide an overview of literature on neonatal outcome after anthracyclines-based chemotherapy regimen during pregnancy. Existing data support use of anthracyclines, as few cases of fetal cardiac toxicity were reported and most of short-term complications were transient. Need for prospective collection of data and longer follow-up is highly recognized.

Risk-Reducing Surgery and Treatment of Menopausal Symptoms in BRCA Mutation Carriers (and Other Risk Women)

Women with a life expectancy ≥10 years and no diagnosis/history of breast cancer who are considered to be at increased risk for breast cancer should receive counseling to decrease breast cancer risk, considering lifestyle factors, therapy with risk reduction agents, and risk reduction surgery (in BRCA1/2 mutation carriers).Bilateral risk-reducing mastectomy decreases the risk of developing breast cancer by at least 90%; it should be proposed to carefully selected women at high risk for breast cancer considering BRCA1/2 or other genetic mutations and previous history of LCIS. In current practice, atypical hyperplasia is not an indication for prophylactic mastectomy.Bilateral risk-reducing salpingo-oophorectomy decreases the risk of developing ovarian and fallopian cancer by 85–95% and breast cancer by 50% in BRCA1/2 mutation carriers when performed in premenopausal age. Peritoneal washing should be performed at surgery, and pathologic assessment should include fine sectioning of the ovaries and fallopian tubes. The additional benefit of concurrent hysterectomy is not clear at the time. In women with no personal history of breast cancer, short-term HRT use does not negate the protective effect of RRSO on subsequent breast cancer risk, and it should be offered until the time of expected natural menopause.

Treatment of Menopausal Symptoms in Breast Cancer Survivors

Breast cancer is increasing worldwide and affects up to one in eight women who survive up to the age of 85 years in Western countries. Four out of five new cases of breast cancer are diagnosed in women over 50 years, with the peak in the 50–64 years age range. The survival rate of breast cancer patients has significantly increased due to earlier diagnosis and advances in adjuvant treatment: at 5 years after initial diagnosis around 90% of the patients survive in good health conditions. There are now more than 2.5 million breast cancer survivors (BCSs) in the USa. Menopausal symptoms are common among BCSs and can adversely affect Quality of Life and sexual health. Because a wide range of possible treatments is now available for BCSs, menopause after breast cancer should no longer be considered an unsolved problem but an interesting area of further clinical research.

Satisfaction and Impact on Quality of Life of Clinical and Instrumental Surveillance and Prophylactic Surgery in BRCA-mutation Carriers

Introduction: BRCA 1 and 2 mutation carriers are invited to follow intensive clinical and instrumental surveillance programs or are offered prophylactic breast and ovarian surgery. These recommendations impact many aspects of their life. This study aims to evaluate the satisfaction with surveillance and prophylactic surgery and the impact of these procedures on the quality of life. Patients and Methods: An anonymous questionnaire was administered to 174 BRCA1‐2 mutation carriers. Results: A total of 95% of women comply with the scheduled checks every 6 months. Periodic examinations are considered useful for early diagnosis of breast/ovarian cancer by 91.5% of responders. Among those women who received prophylactic breast surgery, 95% believe that this procedure can reduce cancer risk, but only 65% were completely satisfied by the cosmetic outcome. Among women who underwent prophylactic ovarian surgery, 90.5% would choose it again, mainly owing to a lower degree of concern about ovarian cancer risk. The early onset of menopausal symptoms was the most frequently reported side effects, but only 21% of patients use any treatment to relieve them. Conclusion: Women who follow a surveillance program show a good level of satisfaction, thanks to the lowering of concerns of cancer risk. The degree of satisfaction about the prophylactic surgery is generally high. Risk‐reducing mastectomy is usually well‐accepted, despite the fact that cosmetic results are not entirely satisfactory. Bilateral salpingo‐oophorectomy may impact on quality of life because of the symptoms associated with early surgical menopause, even if it can be treated with hormonal replacement therapies.