Youngtae Bae

Determination and prediction of P-glycoprotein and multidrug-resistance-related protein expression in breast cancer with double-phase technetium-99m sestamibi scintimammography : Visual and quantitative analyses

Purpose: To determine and predict P-glycoprotein (Pgp) and multidrug-resistance-related protein (MRP) expression in untreated breast cancer patients by visual and quantitative indices of double-phase 99mTc MIBI scintimammography (DSMM). Patients and Methods: Eighty-two patients with untreated breast cancer received DSMM. Pgp and MRP expression was assessed by immunohistochemical (IHC) staining of surgical specimens. Visual and quantitative analyses were compared with the results of IHC to determine and predict Pgp and MRP. Results: The early and delayed tumor to normal tissue ratio (T/N) of the Pgp-negative and MRP-negative group had significantly higher values than those of the Pgp-positive and MRP-positive group. However, there were no statistically significant differences in washout rate (WR, in %) according to the expression of Pgp and MRP. The optimal T/N ratios were ≤2.23 for early and ≤1.75 for delayed image for Pgp expression and ≤2.45 for early and ≤1.96 for delayed image for MRP expression. The optimal visual grades of DSMM for the determination of Pgp and MRP expression were ≤3. With logistic regression analysis, potent predictors of DSMM were visual assessment for Pgp expression and early T/N for MRP expression. Conclusion: In conclusion, despite a moderate sensitivity and specificity, visual and quantitative indices of DSMM could be used to determine and predict Pgp and MRP expression in untreated breast cancer. However, these findings need confirmation in a larger patient cohort to enable a better validation of Pgp and MRP expression to determine optimal early and delayed T/Ns and to investigate predictors of Pgp and MRP expression in breast cancer.

Clinical application of a color map pattern on shear-wave elastography for invasive breast cancer

PURPOSE The aim of this study was to classify the color map pattern on shear-wave elastography (SWE) and to determine its association with clinicopathological factors for clinical application in invasive breast cancer. METHODS From June to December 2014, 103 invasive breast cancers were imaged by B-mode ultrasonography (US) and SWE just before surgery. The color map pattern identified on the SWE could be classified into three main categories: type 1 (diffuse pattern), increased stiffness in the surrounding stroma and the interior lesion itself; type 2 (lateral pattern), marked peri-tumoral stiffness at the anterior and lateral portions with no or minor stiffness at the posterior portion; and type 3 (rim-off pattern), marked peri-tumoral stiffness at the anterior and posterior portion with no or minor stiffness at both lateral portions. RESULTS High-grade density on mammography (grade 3-4) was more frequent in the type 1 pattern than the other pattern types (80.5% in high-grade density vs. 19.5% in low-grade density). For type 1 tumors, the extent of synchronous non-invasive cancers (pT0), ductal carcinoma in situ (DCIS), was 1.8-2.0 times wider than that measured by US or magnetic resonance imaging (MRI). For type 2 tumors, the invasive tumor components (pT size) size was 1.3 times greater than measured by MRI (p = 0.049). On the other hand, the pT size and pT0 extent of type 3 tumors were almost equal to the preoperative US and MRI measurements. In terms of immunohistochemical (IHC) profiles, type 3 tumors showed a high histologic grade (p = 0.021), poor differentiation (p = 0.009), presence of necrosis (p = 0.018), and high Ki-67 (p = 0.002). The percentage of HER2-positive cancers was relatively high within the type 2 group, and the percentage of triple negative breast cancer was relatively high in the type 3 group (p = 0.011). CONCLUSIONS We expect that assessments of the SWE color map pattern will prove useful for surgical or therapeutic plan decisions and to predict prognosis in invasive breast cancer patients.

Multiple margin positivity of frozen section is an independent risk factor for local recurrence in breast-conserving surgery.

Purpose Breast-conserving surgery (BCS) with radiotherapy has become a standard treatment for early stage breast cancer, since the installation of NSABP B-06. One of the serious problems in BCS is that of local recurrence. There are many risk factors for local recurrence, such as large tumor size, multiple tumors, axillary lymph node involvement, young age, high nuclear grade, and so on. The aim of this study is to identify patients with a higher risk of local recurrence of breast cancer. Methods Between January 2002 and December 2006, 447 patients with breast cancer, and who had undergone BCS with immediate breast reconstruction, were enrolled in the study. The follow-up period was 5 years from the time of operation and we analyzed local recurrence, disease-free survival (DFS), and overall survival (OS). The analysis included various clinicopathological factors such as age, chemotherapy, radiotherapy, hormone therapy, pathologic characteristics, and margin status. Statistical analysis was performed with log-rank test and Kaplan-Meier method. The p-value <0.05 was considered statistically significant. Results The mean follow-up period was 88 months and local recurrence of breast cancer occurred only in 16 cases (3.6%). The actual 5-year DFS, and OS rates were 90.6% and 93.3%, respectively. For the local recurrence of breast cancer, positive margin status, multiple margin positivity, conversed margin cases, T/N stages showed statistical significance in univariate analysis. However, only multiple margin positivity was identified as an independent risk factor for local recurrence in multivariate analysis. Conclusion When the multiple margin positivity is diagnosed on intraoperative frozen biopsy, surgeons should consider a much wider excision of the breast and a more aggressive management.

Incremental Diagnostic Value of Quantitative Analysis of Double Phase Tc-99m MIBI Scintimammography for the Detection of Primary Breast Cancer Additive to Visual Analysis

AbstractTc-99m MIBI scintimammography (SMM) is known to be a useful diagnostic tool for primary breast cancer. We conducted this study to establish optimal visual grades for the detection of primary breast cancer and to investigate whether the quantitative indices of double phase SMM could provide incremental diagnostic value additive to visual analysis. Methods. Five hundred and twenty highly suspected breast cancer patients (malignant: 370; benign: 150) were included in this study. Double phase Tc-99m MIBI SMM (early: 10 min; delayed: 3 h) was performed after injection of 750 MBq of Tc-99m MIBI. For visual analysis, five scoring method was used. The early and delayed lesion to non-lesion ratios (L/N) and retention index (RI) were calculated. Receiver operating characteristic curve (ROC) analyses was performed to determine the optimal visual grade, to calculate cut-off value of quantitative indices for differentiation malignant and benign diseases and to investigate whether the quantitative indices could provide incremental diagnostic value additive to visual analysis. To investigate the incremental diagnostic value of quantitative index in variable tumor size groups, the patients were subdivided into four groups (group A: size ≤ 1 cm, group B: 1 cm < size ≤ 3 cm, group C: 3 cm < size ≤ 5 cm, group D: size > 5 cm). Results. When over visual grade 3 was used as the cut-off grade for the diagnosis of breast cancer, the sensitivity and specificity were 75.5, 86.4%, respectively. Early L/N of malignant breast disease was significantly higher than that of benign (2.00 ± 1.88 vs. 0.60 ± 0.7; p < 0.01). However, delayed L/N and RI had no significant difference between malignant and benign breast diseases. When early L/N of 1.27 was used as the cut-off value, the sensitivity and specificity of SMM were 77.6, 83.3%, respectively. When the early L/N was added to visual grade, the area under curve (AUC) of visual + quantitative analysis (V + Q) was higher than that of visual anlysis (V) alone (AUC 0.893 vs. 0.803; p < 0.01). In group A, the AUC of V + Q was higher than that of V alone (0.843 vs. 0.808; p = 0.029). In group B, the AUC of V + Q was also higher (0.913 vs. 0.781; p < 0.01). However, in groups C and D, the AUCs of V + Q and V were not different (0.926 vs. 0.915; p = 0.144: 0.663 vs. 0.570; p = 0.093). For axillary lymph node involvement, the sensitivity, specificity, and of SMM were 66.9, 70.1, and 68%, respectively. Conclusion. From this study, the optimal visual interpretation grades for diagnosis of breast cancer were grades 4 and 5 and cut-off value of early L/N was 1.27. Also, we found that delayed image was not required for breast cancer detection and quantitative index of early L/N provide incremental diagnostic value additive to visual analysis. Especially, when the tumor is small (size ≤ 3 cm), the early L/N should be obtained for the diagnosis of breast cancer.

The use of absorbable interceed(®) pouch with double-layer skin closure for partial defect of breast.

Generally, a partial breast defect can be covered with surrounding breast tissue. However, when the tumor is located in the upper central and inner quadrant, simple closure with breast tissue is insufficient because rotation of breast tissue is difficult in this location. We introduce a surgical technique using an absorbable Interceed® pouch with double‐layer skin closure for a remnant defect. A total of 43 patients with breast cancer underwent conventional breast‐conserving surgery, following which an Interceed® pouch with double‐layer skin closure was applied for a remnant defect of the breast. Patients assessed their own cosmetic outcomes based on a four‐point scoring system. The mean age of the patients and their mean body mass index were 51.2 years and 23.1 kg/m2, respectively. Cosmetic outcomes were self‐reported to be excellent in 13 cases (30.2%), good in 26 cases (60.5%), fair in three cases (7.0%), and poor in one case (2.3%). Postoperative complications occurred in two cases (4.6%). In conclusion, a use of an absorbable Interceed® pouch with double‐layer skin closure is a simple, feasible, ancillary surgical technique to correct an upper central and inner quadrant breast defect without significant complications.

Oncoplastic surgery for inner quadrant breast cancer: fish-hook incision rotation flap.

In oncoplastic breast surgery, the size and location of the defect are two of the major factors affecting the post‐operative cosmetic outcome after partial mastectomy. We introduce a modified superior‐based dermoglandular rotation flap technique, which can be applied for relatively large tumours and in cases of inner quadrant defects of the breast without surgery of the contralateral breast.

Trans-nipple double Z-plasty for benign periareolar disease with inverted nipple.

BackgroundVarious surgical procedures have been reported for correction of inverted nipples. The authors herein report a new procedure, “the trans-nipple double Z-plasty,” for correction of inverted nipples combined with periareolar disease requiring excision.MethodsFrom July 2010 to June 2012, 11 unilateral inverted nipples with other benign periareolar diseases were treated with this technique. A midline incision and 5-mm Z-incisions were designed on the nipple–areola complex toward the direction of the combined breast disease. After removal of combined benign disease through the trans-nipple double Z-plasty incision, the defect was filled with surrounding breast tissue, and the inverted nipple was corrected.ResultsOne case of partial necrosis improved with conservative treatment. No recurrence was reported during the follow-up period. Five patients each assessed the cosmetic result as excellent and good.ConclusionThe trans-nipple double Z-plasty is an easy and useful technique for simultaneous management of periareolar disease with an inverted nipple.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Immediate nipple reconstruction with a C-V flap and areolar reconstruction with an autograft of the ipsilateral areola

The authors report a new nipple‐areolar complex (NAC) reconstruction technique using an autograft of the ipsilateral areola for breast cancer with nipple invasion.

Synchronous BI-RADS Category 3 Lesions on Preoperative Ultrasonography in Patients with Breast Cancer: Is Short-Term Follow-Up Appropriate?

Purpose Breast ultrasonography (US) has been widely used in the preoperative examination of patients with breast cancer. Breast Imaging Reporting and Data System (BI-RADS) category 3 (C3) lesions (probably benign) are regarded as having a low probability of malignancy (≤2%). The purposes of this study were to verify the malignancy rates for synchronous BI-RADS C3 lesions in patients with breast cancer and consider appropriate management strategies for these lesions. Methods Between January 2010 and January 2013, a total of 161 patients underwent surgery in our institute for breast cancer and synchronous BI-RADS C3 lesions. In the US reports, we found records of 219 synchronous BI-RADS C3 nodules in 161 patients. They were excised during surgery for breast cancer management. Stepwise logistic regression analysis was used to identify predictors of malignancy for synchronous BI-RADS C3 lesions. Results The rate of malignancy among the 219 BI-RADS C3 lesions was 9.6%. In simple logistic regression analysis, the size of the primary tumor (p<0.001), pathologic T (pT) stage (p=0.002), and progesterone receptor (PR) status of the primary tumor (p=0.029) were significant predictive factors. In multiple logistic regression analysis, the pT stage and PR status of the primary tumor remained significant predictors (p=0.004 and p=0.003, respectively), and human epidermal growth factor receptor 2 (HER2) was identified as another significant factor (p=0.006). Conclusion In patients with breast cancer who are scheduled for surgery, needle biopsy or excision should be considered for synchronous BI-RADS C3 lesions identified on preoperative US when the primary tumor has the following risk factors: large size, high PR expression, and HER2 positivity.

Immediate chest wall reconstruction using an external oblique myocutaneous flap for large skin defects after mastectomy in advanced or recurrent breast cancer patients: A single center experience

We report 75 single‐stage chest‐wall reconstructions using ipsilateral external oblique myocutaneous flap (EOMCF) to cover the extensive skin defects following resection of advanced or recurrent breast tumours at the Pusan National University Hospital.