Youwanush Kongdan

Androgenic pathway in triple negative invasive ductal tumors: Its correlation with tumor cell proliferation

Triple negative breast cancer (TNBC) is defined by estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 negativity. Patients with TNBC frequently undergo an aggressive clinical course due to the unavailability of specific targeted therapies. Androgen receptor (AR) was reported to be expressed in up to 60% of TNBC cases but there have been controversies as to the roles of androgen signaling through AR in TNBC. Therefore, in this study, we analyzed the status of AR in combination with androgen synthesizing enzymes (5α‐reductase type 1 (5αR1) and 17β‐hydroxysteroid dehydrogenase type 5 (17βHSD5)] in order to further understand androgenic actions in TNBC. Androgen receptor, 5αR1, and 17βHSD5 were immunolocalized in a cohort of 203 TNBC patients from Thailand and Japan. We then correlated the findings with clinicopathological characteristics (age, stage, tumor diameter, lymph node invasion, metastatic spread, Ki‐67 labeling index, disease‐free survival, and overall survival) of the patients. Univariate analysis revealed that AR+/enzyme+ cases were associated with a significantly lower Ki‐67 labeling index than AR−/enzyme− samples. Multivariate analysis indicated the presence of significant positive correlations between AR and enzyme status in tumor cells, and between tumor diameter, lymph node invasion, and distant metastasis. Significant negative correlations were also detected between Ki‐67 labeling index and AR status (P = 0.04) or 5αR1 (P < 0.001). Cox proportional hazards analysis showed that Ki‐67 labeling index and stage were the only factors predicting disease‐free and overall survival of the patients, although univariate Kaplan–Meier analysis revealed AR/5αR1 negativity suggested a more adverse clinical course up to 80 months after surgery. These results suggest that the presence of androgen synthesizing pathways in addition to AR expression in tumor cells could confer a better clinical outcome through suppression of cell proliferation.

Effectiveness and reliability of sentinel lymph node biopsy under local anesthesia for breast cancer

The objective of the present study was to determine the effectiveness and reliability of sentinel lymph node biopsy (SLNB) performed under local anesthesia (LA) for patients with breast cancer, by comparing the results with those obtained under general anesthesia (GA). Between January 2006 and February 2007, SLNB was performed under LA or GA in 37 and 94 patients with clinical Tis, T1, T2 or T3 N0 breast cancer, respectively. All underwent radiocolloid and blue dye injections to identify sentinel nodes. The sentinel node detection rate, the number of nodes harvested and the number of positive nodes were compared between the two groups. The sentinel node identification rates were similar for both groups. The number of sentinel and axillary nodes removed and number of positive nodes did not differ significantly between the two groups. SLNB performed under LA is an effective and reliable alternative to SLNB done under GA.

Sentinel lymph node biopsy under local anesthesia in patients with breast cancer

The concept of breast cancer treatment is changed from maximal tolerable treatment to minimal effective treatment. There has been a change from axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB). The current theory of breast cancer spreading to the axillary lymph nodes is established that if the metastatic cancer cell has spread to the axillary lymph node.

Oncoplastic techniques in breast surgery for special therapeutic problems.

Resection of large tumors can be challenging, from the view point of breast preservation. Oncoplastic techniques are a valuable component of breast surgery in patients with large breast tumors who desire breast preservation. These techniques have been shown to be oncologically safe, while maintaining acceptable breast cosmesis. For locally advanced or recurrent breast cancers, the goals of surgery include local disease control and palliation of clinical symptoms. Oncoplastic surgery is also effective and oncologically safe in these situations. The need to completely remove all foci of cancers with adequate surgical margins often requires the displacement of adjacent or distant skin and soft tissue to cover the resulting soft tissue defect. Sometimes doing so can be cosmetically pleasing as well. In this article we present three special therapeutic problems in three distinct conditions, all resolved with oncoplastic techniques: the benign breast condition, malignant breast condition, and the palliative setting.

Effect of young age, positive margins, and triple negative status on disease recurrence after breast conserving therapy

BACKGROUND To determine the risk factors for disease recurrence after breast conserving therapy (BCT) for breast cancer in a group of South-East Asian women. METHODS Medical and pathological records of women who underwent BCT during the 10-year period from 2001 to 2010 were reviewed. Data collected included age ≤35 years defined as the young, type of operation, pathological data, hormonal receptor (HR) status, human epidermal growth factor receptor-2 (HER-2) expression status, and surgical margin status. Data on adjuvant therapy were also collected. Main outcomes were overall breast cancer recurrence, locoregional, and distant recurrence. Risk factors for each type of recurrence were identified using Cox proportional hazards regression models. RESULTS There were 294 BCTs in 290 patients during the study period. The overwhelming majority (91%) had early stage (stages I-II) breast cancers. Young age patients constituted 9% of all patients, and triple negative cancers (HR negative and HER-2 negative) were seen in 19%. Involved margins on initial surgery were found in 9% of cases, and after reoperation, only 2% had involved margins. After a median follow-up of 50 months, and a maximum follow-up of 135 months, there were 30 recurrences and 6 deaths. Of the 30 recurrences, 19 included locoregional, 20 included distant, and 13 had in-breast recurrences. The disease-free survival at 10 years was 82.5% (95% CI: 74.8% to 88.1%), and the cumulative in-breast recurrence was 9.3% (95% CI: 4.9% to 17.2%) at 10 years. Multivariable Cox regression analysis revealed that young age, larger tumor size, involved margins, and no breast irradiation were associated with higher risk of locoregional recurrence. Triple negative status, larger tumor size, more positive nodes, and involved margins were associated with higher risk of distant recurrence. CONCLUSIONS We found young age to be a significant prognosticator of locoregional recurrence, and triple negative status of distant recurrence. Involved surgical margin status was associated with both recurrences. Tumor size was associated with both recurrences, and axillary lymph node metastasis was associated with distant recurrence.

Malignant transformation of phyllodes tumor: a case report and review of literature

Malignant phyllodes may transform from benign phyllodes; low‐aggressive malignant phyllodes tumor is manageable by locally wide excision.

Inferior dermoglandular flap for central quadrantectomy in non-ptosis breast cancer patients

The central located tumors has been reported to have nipple areola complex (NAC) involvement, most of the time NAC resection is also required to achieve good oncologic outcome. The tumor in this location used to be one of the indication for mastectomy. Clinical trials have proved that breast conservative surgery in centrally located tumor is similar to those who undergo mastectomy. However, in this particular situation, lumpectomy alone with simple closure may cause the deformities of the breast. This highlights the concepts of ‘immediate partial reconstruction’ during the breast conservative surgery to be able to prevent the poor cosmetic sequelae. In this study, we describe the surgical technique used in retroareolar breast cancer in non ptotic breast. The patient underwent central quadrantectomy with sentinel lymph node biopsy. Reshaping the breast by using the vertical skin pattern technique with inferior dermoglandular flap is required to fill the defect after removing central volume of the breast from breast conservative surgery (BCS). Inferior dermoglandular flap shows good outcome in non-ptotic breast with retroareolar tumor. However, a major disadvantage of our technique is the high-riding of the new NAC location. A simple and effective technique of the inferior dermoglandular flap is presented, in combination with the vertical skin pattern. This combined method allows correction of the central located tumor and parenchyma defect after BCS in all cases with acceptable results.

Complications and oncologic outcomes of pedicled transverse rectus abdominis myocutaneous flap in breast cancer patients

BACKGROUND There are several techniques for harvesting the pedicled transverse rectus abdominis myocutaneous (TRAM) flap after mastectomy in breast cancer patients. We examined the whole muscle with partial sheath sparing technique and determined factors associated with its complications and oncological outcomes. METHODS We retrospectively reviewed the results of 168 TRAM flaps performed between January 2003 and December 2010, focusing on complications and oncologic outcomes. RESULTS Among the 168 pedicled TRAM flap procedures in 158 patients, flap complications occurred in 34%. Most of the flap complications included some degree of fat necrosis. There was no total flap loss. Flap complications were associated with elderly patients and the presence of major donor site complications. Abdominal bulging and hernia occurred in 12% of patients. The bi-pedicled TRAM flap and higher body mass index (BMI) were significant factors associated with increased donor site complications. Seven patients (4%) developed loco-regional recurrence. Within a median follow-up of 27 months, distant metastasis and death occurred in 6% and 4% of patients, respectively. CONCLUSIONS The pedicled TRAM flap using the whole muscle with partial sheath sparing technique in the present study is consistent with the results from previous studies in flap complication rates and oncological outcomes.

Bilateral pseudoangiomatous stromal hyperplasia in a human immunodeficiency viral-infected patient.

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon mesenchymal neoplasm of the breast demonstrating stromal myofibroblastic proliferation and having the appearance of anastomosing slit-like pseudovascular spaces lined by spindle-shaped cells. A case of nodular PASH of the bilateral breasts in a 40-year-old woman with clinically presenting with a progressive enlarged breast lump is reported. Mammographic and ultrasonographic features of the right and left breasts showed a large solid lump with well-circumscribed border measuring 4 cm × 1.7 cm × 3.4 cm and 13.8 cm × 10.9 cm × 12.1 cm, respectively. Wide excision of the right breast and quadrantectomy of the left breast were performed. The histopathological examination of the lesion showed anastomosing slit-like pseudovascular spaces. The stromal cells were immunoreactive for muscle actin (HHF35), smooth muscle actin, and progesterone receptor. Clinical and pathological findings with briefly reviewed relevant literatures are discussed. This is the first clinicopathological and radiological report of bilateral mammary nodular PASH in a human immunodeficiency viral-infected patient.

Oncoplastic technique in breast conservative surgery for locally advanced breast cancer

Locally advanced breast cancer (LABC) should be taken into decision making when planning breast conservative surgery, but this procedure should be done on the principle of oncologic safety in order to achieve negative surgical margin and maintain aesthetic result. This procedure should be offered as the choice of treatment in selected patients.