Prolonged Time from Diagnosis to Breast-Conserving Surgery is Associated with Upstaging in Hormone Receptor-Positive Invasive Ductal Breast Carcinoma

BACKGROUND

Time to surgery (TTS) has been suggested to have an association with mortality in early-stage breast cancer.

OBJECTIVE

This study aims to determine the association between TTS and preoperative disease progression in tumor size or nodal status among women diagnosed with clinical T1N0M0 ductal breast cancer.

METHODS

Women diagnosed with clinical T1N0M0 ductal breast cancer who had breast-conserving surgery as their first definitive treatment between 2010 and 2016 (n = 90,405) were analyzed using the National Cancer Database. Separate multivariable logistic regression models for hormone receptor (HR)-positive and HR-negative patients, adjusted for clinical and demographic variables, were used to assess the relationship between TTS and upstaging of tumor size (T-upstaging) or nodal status (N-upstaging).

RESULTS

T-upstaging occurred in 6.76% of HR-positive patients and 11.00% of HR-negative patients, while N-upstaging occurred in 12.69% and 10.75% of HR-positive and HR-negative patients, respectively. Among HR-positive patients, odds of T-upstaging were higher for 61-90 days TTS (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.05-1.34) and ≥91 days TTS (OR 1.47, 95% CI 1.17-1.84) compared with ≤30 days TTS, and odds of N- upstaging were higher for ≥91 days TTS (OR 1.35, 95% CI 1.13-1.62). No association between TTS and either T- or N-upstaging was found among HR-negative patients. Other clinical and demographic variables, including grade, tumor location, and race/ethnicity, were associated with both T- and N-upstaging.

CONCLUSION

TTS ≥61 and ≥91 days was a significant predictor of T- and N-upstaging, respectively, in HR-positive patients; however, TTS was not associated with upstaging in HR-negative breast cancer. Delays in surgery may contribute to measurable disease progression in T1N0M0 ductal breast cancer.

A prospective single-institution study of intraoperative radiotherapy (IORT) for early-stage breast cancer

Intraoperative radiation therapy (IORT) is an option for breast-conserving therapy in early-stage breast cancer. IORT is given in one fraction at the time of surgery and eliminates the need for adjuvant external beam radiation therapy. However, previous trials indicate increased local failure rates compared with whole-breast irradiation, which engenders controversy around the appropriate use of IORT. We conducted a prospective study of patients diagnosed with early-stage breast cancer (T1-T2, N0-N1) at the University of Oklahoma Health Sciences Center (OUHSC) between 2013 and 2017 and treated with lumpectomy followed by intraoperative radiation therapy (IORT). Data collected included stage of disease, tumor location, histology, tumor markers, lymph node status, surgical margin size, recurrence, cosmetic outcomes, and length of follow-up. In-breast tumor recurrence rate (IBTR) in the 77 evaluable patients was 3.9% (3 patients). Margins were close (1 mm or less) in all three recurrent patients, and two were initially diagnosed with DCIS. Recurrence rates in our patients were comparable to prior reports. All recurrences were in patients with close margins indicating that this may represent a predictive feature for exclusion from IORT; additional studies are essential to determine the recurrence rates among patients treated with IORT and to identify potential predictors of IORT eligibility.

Women survive longer than men undergoing cytoreductive surgery and HIPEC for appendiceal cancer

BACKGROUND

We hypothesize that women undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis from appendiceal cancer will have a survival advantage compared to men.

METHODS

The National Cancer Database (NCDB) public user file (2004-2014) was used to select patients with PC undergoing CRS and HIPEC from appendiceal cancer. Univariate and multivariable analyses were performed.

RESULTS

1,190 patients with PC from appendiceal cancer underwent HIPEC and CRS. OS was significantly longer for women than for men, with mean and median OS being 73.8 months and 98.2 months for women vs 58.7 months and 82.5 months for men, respectively (p = 0.0032). On multivariable analysis, male sex (HR: 1.444, 95% CI: 1.141-1.827, p = 0.0022) and increasing age (HR: 1.017, 95% CI: 1.006-1.027, p = 0.0017) were both found to be independent risk factors for worse OS.

CONCLUSION

Women undergoing CRS and HIPEC for PC from appendiceal origin live longer than men undergoing the same treatment. Increasing age was also found to be independent risk factors for worse survival.

Randomized Phase IIB Trial of the Lignan Secoisolariciresinol Diglucoside in Premenopausal Women at Increased Risk for Development of Breast Cancer

We conducted a multiinstitutional, placebo-controlled phase IIB trial of the lignan secoisolariciresinol diglucoside (SDG) found in flaxseed. Benign breast tissue was acquired by random periareolar fine needle aspiration (RPFNA) from premenopausal women at increased risk for breast cancer. Those with hyperplasia and ≥2% Ki-67 positive cells were eligible for randomization 2:1 to 50 mg SDG/day (Brevail) versus placebo for 12 months with repeat bio-specimen acquisition. The primary endpoint was difference in change in Ki-67 between randomization groups. A total of 180 women were randomized, with 152 ultimately evaluable for the primary endpoint. Median baseline Ki-67 was 4.1% with no difference between arms. Median Ki-67 change was -1.8% in the SDG arm (P = 0.001) and -1.2% for placebo (P = 0.034); with no significant difference between arms. As menstrual cycle phase affects proliferation, secondary analysis was performed for 117 women who by progesterone levels were in the same phase of the menstrual cycle at baseline and off-study tissue sampling. The significant Ki-67 decrease persisted for SDG (median = -2.2%; P = 0.002) but not placebo (median = -1.0%). qRT-PCR was performed on 77 pairs of tissue specimens. Twenty-two had significant ERα gene expression changes (<0.5 or >2.0) with 7 of 10 increases in placebo and 10 of 12 decreases for SDG (P = 0.028), and a difference between arms (P = 0.017). Adverse event incidence was similar in both groups, with no evidence that 50 mg/day SDG is harmful. Although the proliferation biomarker analysis showed no difference between the treatment group and the placebo, the trial demonstrated use of SDG is tolerable and safe.

Plasma exosome microRNAs are indicative of breast cancer

BACKGROUND

microRNAs are promising candidate breast cancer biomarkers due to their cancer-specific expression profiles. However, efforts to develop circulating breast cancer biomarkers are challenged by the heterogeneity of microRNAs in the blood. To overcome this challenge, we aimed to develop a molecular profile of microRNAs specifically secreted from breast cancer cells. Our first step towards this direction relates to capturing and analyzing the contents of exosomes, which are small secretory vesicles that selectively encapsulate microRNAs indicative of their cell of origin. To our knowledge, circulating exosome microRNAs have not been well-evaluated as biomarkers for breast cancer diagnosis or monitoring.

METHODS

Exosomes were collected from the conditioned media of human breast cancer cell lines, mouse plasma of patient-derived orthotopic xenograft models (PDX), and human plasma samples. Exosomes were verified by electron microscopy, nanoparticle tracking analysis, and western blot. Cellular and exosome microRNAs from breast cancer cell lines were profiled by next-generation small RNA sequencing. Plasma exosome microRNA expression was analyzed by qRT-PCR analysis.

RESULTS

Small RNA sequencing and qRT-PCR analysis showed that several microRNAs are selectively encapsulated or highly enriched in breast cancer exosomes. Importantly, the selectively enriched exosome microRNA, human miR-1246, was detected at significantly higher levels in exosomes isolated from PDX mouse plasma, indicating that tumor exosome microRNAs are released into the circulation and can serve as plasma biomarkers for breast cancer. This observation was extended to human plasma samples where miR-1246 and miR-21 were detected at significantly higher levels in the plasma exosomes of 16 patients with breast cancer as compared to the plasma exosomes of healthy control subjects. Receiver operating characteristic curve analysis indicated that the combination of plasma exosome miR-1246 and miR-21 is a better indicator of breast cancer than their individual levels.

CONCLUSIONS

Our results demonstrate that certain microRNA species, such as miR-21 and miR-1246, are selectively enriched in human breast cancer exosomes and significantly elevated in the plasma of patients with breast cancer. These findings indicate a potential new strategy to selectively analyze plasma breast cancer microRNAs indicative of the presence of breast cancer.

Exosome-mediated microRNA signaling from breast cancer cells is altered by the anti-angiogenesis agent docosahexaenoic acid (DHA)

BACKGROUND

Docosahexaenoic acid (DHA) is a natural compound with anticancer and anti-angiogenesis activity that is currently under investigation as both a preventative agent and an adjuvant to breast cancer therapy. However, the precise mechanisms of DHA's anticancer activities are unclear. It is understood that the intercommunication between cancer cells and their microenvironment is essential to tumor angiogenesis. Exosomes are extracellular vesicles that are important mediators of intercellular communication and play a role in promoting angiogenesis. However, very little is known about the contribution of breast cancer exosomes to tumor angiogenesis or whether exosomes can mediate DHA's anticancer action.

RESULTS

Exosomes were collected from MCF7 and MDA-MB-231 breast cancer cells after treatment with DHA. We observed an increase in exosome secretion and exosome microRNA contents from the DHA-treated cells. The expression of 83 microRNAs in the MCF7 exosomes was altered by DHA (>2-fold). The most abundant exosome microRNAs (let-7a, miR-23b, miR-27a/b, miR-21, let-7, and miR-320b) are known to have anti-cancer and/or anti-angiogenic activity. These microRNAs were also increased by DHA treatment in the exosomes from other breast cancer lines (MDA-MB-231, ZR751 and BT20), but not in exosomes from normal breast cells (MCF10A). When DHA-treated MCF7 cells were co-cultured with or their exosomes were directly applied to endothelial cell cultures, we observed an increase in the expression of these microRNAs in the endothelial cells. Furthermore, overexpression of miR-23b and miR-320b in endothelial cells decreased the expression of their pro-angiogenic target genes (PLAU, AMOTL1, NRP1 and ETS2) and significantly inhibited tube formation by endothelial cells, suggesting that the microRNAs transferred by exosomes mediate DHA's anti-angiogenic action. These effects could be reversed by knockdown of the Rab GTPase, Rab27A, which controls exosome release.

CONCLUSIONS

We conclude that DHA alters breast cancer exosome secretion and microRNA contents, which leads to the inhibition of angiogenesis. Our data demonstrate that breast cancer exosome signaling can be targeted to inhibit tumor angiogenesis and provide new insight into DHA's anticancer action, further supporting its use in cancer therapy.

Blocking the adhesion cascade at the premetastatic niche for prevention of breast cancer metastasis

Shear-resistant adhesion and extravasation of disseminated cancer cells at the target organ is a crucial step in hematogenous metastasis. We found that the vascular adhesion molecule E-selectin preferentially promoted the shear-resistant adhesion and transendothelial migration of the estrogen receptor (ER)(-)/CD44(+) hormone-independent breast cancer cells, but not of the ER(+)/CD44(-/low) hormone-dependent breast cancer cells. Coincidentally, CD44(+) breast cancer cells were abundant in metastatic lung and brain lesions in ER(-) breast cancer, suggesting that E-selectin supports hematogenous metastasis of ER(-)/CD44(+) breast cancer. In an attempt to prevent hematogenous metastasis through the inhibition of a shear-resistant adhesion of CD44(+) cancer cells to E-selectin-expressing blood vessels on the premetastatic niche, an E-selectin targeted aptamer (ESTA) was developed. We demonstrated that a single intravenous injection of ESTA reduced metastases to a baseline level in both syngeneic and xenogeneic forced breast cancer metastasis models without relocating the site of metastasis. The effect of ESTA was absent in E-selectin knockout mice, suggesting that E-selectin is a molecular target of ESTA. Our data highlight the potential application of an E-selectin antagonist for the prevention of hematogenous metastasis of ER(-)/CD44(+) breast cancer.

Do the CMS proposed breast cancer quality measures actually predict improved outcomes?

BACKGROUND

In 2007, professional collaborations developed a unified set of quality standards for breast cancer care.

METHODS

This was an Institutional Review Board-approved, retrospective review of all breast cancer patients treated initially at University of Oklahoma Medical Center from 2000 to 2008. All tumor registry data were reviewed to test compliance with the Center for Medicare and Medicaid Services (CMS) (Medicare) quality standards.

RESULTS

Overall and disease-free survival was better for patients meeting the radiation for breast conservation standard (P < .02). Whether estrogen receptor positive (ER+) or estrogen receptor negative, there were similar statistically significant benefits of combination chemotherapy in overall and disease-free survival rates for all patients with tumors greater than 1 cm in size (P < .05). Hormonal therapy was associated with an overall survival benefit (P < .005) but only a trend toward improvement in disease-free survival (P = .076).

CONCLUSIONS

We believe the current CMS standards are a reasonable first step at monitoring breast cancer quality of care. Our data suggest that these may be improved by including combination chemotherapy in ER+ disease when data show a net survival benefit over hormonal therapy alone.

Tamoxifen downregulates ets oncogene family members ETV4 and ETV5 in benign breast tissue: implications for durable risk reduction

Five years of tamoxifen reduces breast cancer risk by nearly 50% but is associated with significant side effects and toxicities. A better understanding of the direct and indirect effects of tamoxifen in benign breast tissue could elucidate new mechanisms of breast carcinogenesis, suggest novel chemoprevention targets, and provide relevant early response biomarkers for phase II prevention trials. Seventy-three women at increased risk for breast cancer were randomized to tamoxifen (20 mg daily) or placebo for 3 months. Blood and breast tissue samples were collected at baseline and posttreatment. Sixty-nine women completed all study activities (37 tamoxifen and 32 placebo). The selected biomarkers focused on estradiol and IGFs in the blood; DNA methylation and cytology in random periareolar fine-needle aspirates; and tissue morphometry, proliferation, apoptosis, and gene expression (microarray and reverse transcriptase PCR) in the tissue core samples. Tamoxifen downregulated Ets oncogene transcription factor family members ETV4 and ETV5 and reduced breast epithelial cell proliferation independent of CYP2D6 genotypes or effects on estradiol, ESR1, or IGFs. Reduction in proliferation was correlated with downregulation of ETV4 and DNAJC12. Tamoxifen reduced the expression of ETV4- and ETV5-regulated genes implicated in epithelial-stromal interaction and tissue remodeling. Three months of tamoxifen did not affect breast tissue composition, cytologic atypia, preneoplasia, or apoptosis. A plausible mechanism for the chemopreventive effects of tamoxifen is restriction of lobular expansion into stroma through downregulation of ETV4 and ETV5. The human equivalent of murine multipotential progenitor cap cells of terminal end buds may be the primary target.

Mechanisms of improved outcomes for breast cancer between surgical oncologists and general surgeons

BACKGROUND

Prior multi-institutional studies have reported a survival benefit of breast cancer treatment by surgical oncologists (SO) over general surgeons (GS).

METHODS

Retrospective review tumor registry data of all breast cancer patients receiving primary treatment at a single institution from January 1, 1995, to December 31, 2008.

RESULTS

During the time period, there were 2192 patients who received primary breast cancer treatment at this institution. The mean age was 57 years and the mean follow-up was >55 months. Stage distribution was similar between GS and SO. Overall survival (SO 83.8% vs. GS 75.6%) and disease-free survival (SO 80.7% vs. GS 72.0%) was highly statistically significant (P<0.0001). For stages 1, 2a, 2b, 3a, and 3b there were statistically significant (P<0.05) differences for overall and disease-free survival. Overall, the use of breast conservation was more likely by SO-52.6 vs. 38.3% all stages and 65.8 vs. 54.0% for stage 0-2. The compliance with all systemic therapies (chemotherapy and hormone therapy) was more likely if being treated by SO-77.3 vs. 68.5% (P<0.02). The use of radiotherapy for breast conservation and in stage 3 mastectomy patients was higher for SO (P<0.001). Participation in clinical trials was far higher for SO patients-56.2 vs. GS 7.0% (P<0.001).

CONCLUSIONS

The value added by having primary breast cancer treatment by a SO seems to arise from the more successful completion of multidisciplinary care in a timely fashion and higher rates of clinical trial involvement.

An HLA-presented fragment of macrophage migration inhibitory factor is a therapeutic target for invasive breast cancer

This report describes a novel HLA/peptide complex with potential prognostic and therapeutic roles for invasive breast cancer. Macrophage migration inhibitory factor (MIF) mediates inflammation and immunity, and MIF overexpression is observed in breast cancer. We hypothesized that the HLA class I of cancerous breast epithelial cells would present MIF-derived peptides. Consistent with this hypothesis, the peptide FLSELTQQL (MIF(19-27)) was eluted from the HLA-A*0201 (HLA-A2) of breast cancer cell lines. We posited that if this MIF(19-27)/HLA-A2 complex was exclusively found in invasive breast cancer, it could be a useful prognostic indicator. To assess the presentation of MIF peptides by the HLA of various cells and tissues, mice were immunized with the MIF(19-27)/HLA-A2 complex. The resulting mAb (RL21A) stained invasive ductal carcinoma (IDC) but not ductal carcinoma in situ, fibroadenoma, or normal breast tissues. RL21A did not stain WBCs (total WBCs) or normal tissues from deceased HLA-A2 donors, substantiating the tumor-specific nature of this MIF/HLA complex. As this MIF/HLA complex appeared specific to the surface of IDC, RL21A was tested as an immunotherapeutic for breast cancer in vitro and in vivo. In vitro, RL21A killed the MDA-MB-231 cell line via complement and induction of apoptosis. In an in vivo orthotopic mouse model, administration of RL21A reduced MDA-MB-231 and BT-20 tumor burden by 5-fold and by >2-fold, respectively. In summary, HLA-presented MIF peptides show promise as prognostic cell surface indicators for IDC and as targets for immunotherapeutic intervention.

Surgical perspectives from a prospective, nonrandomized, multicenter study of breast conserving surgery and adjuvant electronic brachytherapy for the treatment of breast cancer

BACKGROUND

Accelerated partial breast irradiation (APBI) may be used to deliver radiation to the tumor bed post-lumpectomy in eligible patients with breast cancer. Patient and tumor characteristics as well as the lumpectomy technique can influence patient eligibility for APBI. This report describes a lumpectomy procedure and examines patient, tumor, and surgical characteristics from a prospective, multicenter study of electronic brachytherapy.

METHODS

The study enrolled 65 patients of age 45-84 years with ductal carcinoma or ductal carcinoma in situ, and 44 patients, who met the inclusion and exclusion criteria, were treated with APBI using the Axxent® electronic brachytherapy system following lumpectomy. The prescription dose was 34 Gy in 10 fractions over 5 days.

RESULTS

The lumpectomy technique as described herein varied by site and patient characteristics. The balloon applicator was implanted by the surgeon (91%) or a radiation oncologist (9%) during or up to 61 days post-lumpectomy (mean 22 days). A lateral approach was most commonly used (59%) for insertion of the applicator followed by an incision site approach in 27% of cases, a medial approach in 5%, and an inferior approach in 7%. A trocar was used during applicator insertion in 27% of cases. Local anesthetic, sedation, both or neither were administered in 45%, 2%, 41% and 11% of cases, respectively, during applicator placement. The prescription dose was delivered in 42 of 44 treated patients.

CONCLUSIONS

Early stage breast cancer can be treated with breast conserving surgery and APBI using electronic brachytherapy. Treatment was well tolerated, and these early outcomes were similar to the early outcomes with iridium-based balloon brachytherapy.

Electronic brachytherapy as adjuvant therapy for early stage breast cancer: a retrospective analysis

PURPOSE

This multicenter, retrospective study evaluated treatment and clinical outcomes of patients with early stage breast cancer who received adjuvant high-dose rate (HDR) electronic brachytherapy (EBT) treatment post-lumpectomy using the Axxent(®) EBT system. Dosimetric data from the EBT treatment plans were compared with those based on iridium-192 HDR brachytherapy.

MATERIAL AND METHODS

Medical records of 63 patients with early stage breast cancer (Tis, T1a, T1b, T1c, and T2) who were treated post-lumpectomy with EBT alone or in combination with external beam radiation therapy were reviewed. The prescribed EBT dose was 34 Gy (10 fractions over 5 days, 3.4 Gy each) to 1 cm from the balloon surface. Dosimetry data from 12 patients were compared with these of treatment plans using an iridium-192 source prepared for the same 12 patients.

RESULTS

The majority of patients (90.5%) were older than 50 years and had one or more risk factors for breast cancer (80.6%). Tumor sizes were 0.1 cm to 3.5 cm (mean 1.3 cm). Median follow-up was 7 months (1 to 18 months) post-EBT. Balloon applicators were implanted 0 to 85 days (mean 13.4 days) post-lumpectomy/re-excision. The most common adverse events were erythema, rash dermatitis, and pain or breast tenderness. No recurrences were reported. Dosimetric analyses demonstrated comparable target coverage, increased high-dose regions, and a significantly reduced dose to the ipsilateral breast and lungs as well as the heart with EBT as compared with the iridium-192 treatment plans.

CONCLUSION

This retrospective, multicenter study showed that postsurgical adjuvant radiation therapy for early stage breast cancer can be administered using the EBT system with similar toxicity outcomes to those reported with iridium-192 brachytherapy. EBT offers a convenient, portable, nonisotope alternative to HDR brachytherapy using iridium-192.

Clinical series of oncoplastic mastopexy to optimize cosmesis of large-volume resections for breast conservation

BACKGROUND

Oncoplastic mastopexy has been popularized as a method to hide the cosmetic effects of central or large-volume resections associated with breast conservation surgery for breast cancer.

MATERIALS AND METHODS

This review was undertaken to study the uses and limitations of these techniques in providing adequate breast conservation lumpectomy for breast cancer of any stage in a single surgeon's practice. A review of breast cancer cases March 2004 through December 2009 were analyzed for the use of oncoplastic reconstruction in breast conservation surgery.

RESULTS

A total of 167 patients had lumpectomies during this period associated with oncoplastic mastopexy reconstruction. The average age was 55.6 years with a range of 33-85 years. Stage 0 breast cancer accounted for 33 cases (19.8%), and 134 cases were invasive cancers stages 1-3 (stage 1, 34.1%; stage 2, 30.6%; and stage 3, 15.6%). The most common oncoplastic techniques used were, in order of frequency: batwing mastopexy, parallelogram mastopexy, and Modified Wise pattern mastopexy. Positive or close margins (≤ 2 mm) were present in 37 of 167 cases (22%). Positive margins were most associated with higher stage, positive nodes, positive lymphovascular invasion (LVI), use of neoadjuvant chemotherapy, and larger initial T stage, positive estrogen receptor (ER), and younger age. Of these higher stage, node positive, and use of neoadjuvant chemotherapy were statistically significant in this small series (P values = 0.034, 0.016, and 0.022, respectively). Ki-67 and HER2 status were not associated with positive margins. Positive margins were manageable by local re-excision of a solitary face of the prior resection wall in more than 2/3 of cases to achieve negative pathologic margins. Only 11 of 167 required mastectomy because of failure to achieve adequate margins for oncologic control.

CONCLUSIONS

Oncoplastic mastopexy allows the surgeon to address large tumors or tumors in cosmetically difficult sites adequately for breast conservation. Careful margin marking and re-excision of close or positive margins is still often feasible to achieve adequate negative margin with acceptable cosmesis in spite of the large initial volumes of resection.

Use of electronic brachytherapy to deliver postsurgical adjuvant radiation therapy for endometrial cancer: a retrospective multicenter study

BACKGROUND

This retrospective, multicenter study evaluated the feasibility and safety of high-dose rate electronic brachytherapy (EBT) as a postsurgical adjuvant radiation therapy for endometrial cancer.

METHODS

Medical records were reviewed from 41 patients (age 40-89 years) with endometrial cancer (Federation of International Gynecology and Obstetrics stages IA-IIIC) treated at nine centers between April 2008 and October 2009. Treatment included intracavitary vaginal EBT alone (n = l6) at doses of 18.0-24.0 Gy in 3-4 fractions and EBT in combination with external beam radiation therapy (EBRT, n = 25) at a total radiation dose range of 40.0-80.4 Gy. Doses were prescribed to a depth of 5 mm from the applicator surface and to the upper third (n = 15) and the upper half (n = 26) of the vagina.

RESULTS

Median follow-up was 3.8 (range 0.5-12.0) months. All 41 patients received the intended dose of radiation as prescribed. Adverse events occurred in 13 of 41 patients and were mild to moderate (Grade 1-2), consisting primarily of vaginal mucositis, rectal mucosal irritation and discomfort, and temporary dysuria and diarrhea. There were no Grade 3 adverse events in the EBT-only treatment group. One patient, who was being treated with the combination of EBT and EBRT for recurrent endometrial cancer, had a Grade 3 adverse event. No recurrences have been reported to date.

CONCLUSION

Electronic brachytherapy provides a feasible treatment option for postoperative adjuvant vaginal brachytherapy as sole radiation therapy and in combination with EBRT for primary endometrial cancer. Early and late toxicities were mild to moderate.

Focused microwave thermotherapy for preoperative treatment of invasive breast cancer: a review of clinical studies

BACKGROUND

Preoperative focused microwave thermotherapy (FMT) is a promising method for targeted treatment of breast cancer cells. Results of four multi-institutional clinical studies of preoperative FMT for treating invasive carcinomas in the intact breast are reviewed.

METHODS

Externally applied wide-field adaptive phased-array FMT has been investigated both as a preoperative heat-alone ablation treatment and as a combination treatment with preoperative anthracycline-based chemotherapy for breast tumors ranging in ultrasound-measured size from 0.8 to 7.8 cm.

RESULTS

In phase I, eight of ten (80%) patients receiving a single low dose of FMT prior to receiving mastectomy had a partial tumor response quantified by either ultrasound measurements of tumor volume reduction or by pathologic cell kill. In phase II, the FMT thermal dose was increased to establish a threshold dose to induce 100% pathologic tumor cell kill for invasive carcinomas prior to breast-conserving surgery (BCS). In a randomized study for patients with early-stage invasive breast cancer, of those patients receiving preoperative FMT at ablative temperatures, 0 of 34 (0%) patients had positive tumor margins, whereas positive margins occurred in 4 of 41 (9.8%) of patients receiving BCS alone (P = 0.13). In a randomized study for patients with large tumors, based on ultrasound measurements the median tumor volume reduction was 88.4% (n = 14) for patients receiving FMT and neoadjuvant chemotherapy, compared with 58.8% (n = 10) reduction in the neoadjuvant chemotherapy-alone arm (P = 0.048).

CONCLUSIONS

Wide-field adaptive phased-array FMT can be safely administered in a preoperative setting, and data from randomized studies suggest both a reduction in positive tumor margins as a heat-alone treatment for early-stage breast cancer and a reduction in tumor volume when used in combination with anthracycline-based chemotherapy for patients with large breast cancer tumors. Larger randomized studies are required to verify these conclusions.

Breast ductoscopy and the evolution of the intra-ductal approach to breast cancer

Interest in breast endoscopy came from Oriental investigators in the early 1990s where bloody nipple discharge is a more common presentation of breast cancer. The early techniques using a single microfiber scope without ductal distension was successful in navigating only the first 1-3 cm of the ducts and fraught with technical problems such as scope breakage and poor image quality. In spite of these barriers there has been increasing use of this technology in Japan and more widespread acceptance as the technology of scope design improved. Dooley and others tested a new method of obtaining a rich cytologic specimen from the ducts of high-risk women known as ductal lavage recently. The success of this procedure was that it detected severe cytologic and malignant atypia in clinically and radiographically normal breasts. Reproducibly, the same breast duct could be cannulated and severely atypical cytology obtained. The problem arose in identifying the lesion within the breast, which was the source for the atypia. New American multi-fiber microendoscopes were applied to solve this problem in an initial series of patients with abnormal cytology to identify the lesions. Success of that series lead to wider application of the imaging technology and eventual adoption of this imaging modality help to guide during all non-mastectomy breast surgery where fluid could be elicited from the nipple to identify the duct connecting to the lesion for which surgery was being performed. Initial reports have demonstrated the types of operative findings in certain sub-populations early in the use of this technology.

Local recurrence after mastectomy in patients with T3pN0 breast carcinoma treated without postoperative radiation therapy

OBJECTIVE

The need for comprehensive adjuvant radiotherapy in patients with T3pN0 breast cancer is controversial. This retrospective analysis was performed to assess the frequency of local and distant recurrence in patients treated with mastectomy without postoperative radiation.

MATERIALS AND METHODS

A single institution database of 2362 patients with breast carcinoma treated from 1974 to 1994 yielded 101 patients who had T3pN0 disease and did not receive chest wall or nodal irradiation. The median follow-up time was 93 months (range, 10-256 months). Sites of first failure were categorized as isolated chest wall (CWF), regional lymph nodes (RNF, which in this case were considered to be either axillary or supraclavicular), or distant sites (DF). CWF and/or RNF were considered local recurrences. Patients with simultaneous CWF and DF or RNF and DF were scored as DF. A comparison was made to 286 T2pN0 patients, also treated between 1974 and 1994.

RESULTS

Twenty-two T3N0 patients developed recurrent disease. Site of first recurrence was isolated local recurrence in 11 patients and distant in 11 patients. Four patients had simultaneous local and distant recurrences. Site of isolated local recurrence was CWF in 5 patients and RNF in 6 patients. Median tumor size was 6 cm (range, 5-10.5 cm). There was no difference in local recurrence for tumor sizes < or =7 cm versus >7 cm (P = 0.07). The crude recurrence rate for T3pN0 patients treated by mastectomy was similar to T2pN0 patients treated in similar fashion (P = 0.3).

CONCLUSION

The risk of isolated local recurrence in patients with T3pN0 breast cancer and negative margins is moderately low and similar to T2pN0 patients. These results suggest that routine use of postoperative chest wall and nodal irradiation in all T3pN0 patients may not be required.

Activity of combination chemotherapy, docetaxel and epirubicin as neoadjuvant therapy for women with breast cancer

BACKGROUND

This study assesses the efficacy of epirubicin and docetaxel as neoadjuvant therapy for women with breast cancer.

PATIENTS AND METHODS

This is a single institution, single arm, phase II study of epirubicin given at 75 mg/m(2) and docetaxel at 75 mg/m(2) every three weeks for four cycles prior to surgical excision in women with large breast cancers. Pegfilgrastim was routinely administered as primary prophylaxis against febrile neutropenia.

RESULTS

Out of the 18 patients enrolled on the study, 12 (66.7%) had a clinical response and 13 (72.2%) had a pathologic response, with a pathologic complete response of 5.6%. Pre-menopausal women and patients with estrogen receptor positive tumors had a higher response rate. One patient died due to sepsis and febrile neutropenia.

CONCLUSION

Combination chemotherapy with epirubicin and docetaxel is highly active against breast cancer. With close monitoring for toxicity, this combination can be safely administered with mild side-effects.

Hot flash therapies in breast cancer survivors

More than 86% of those diagnosed with invasive breast cancer are expected to survive for >/= 5 years after their diagnosis. Approximately 75% of postmenopausal women who had breast cancer report experiencing hot flashes. More than 90% of young survivors also experience hot flashes, which can be more severe and long lasting, with iatrogenic ovarian ablation or antiestrogen therapy. There are numerous options for the treatment of hot flashes. Not one treatment fits all. Some treatments are generally more effective than others, and each has different side effects. This review is meant to provide the basic information needed to make a decision about the best treatment for a breast survivor experiencing hot flashes.

Fifteen-year series of skin-sparing mastectomy for stage 0 to 2 breast cancer

BACKGROUND

In 1989, skin-sparing mastectomy started at a number of breast centers in the United States because of an increasing demand for immediate reconstruction and a desire for better cosmetic outcomes.

METHODS

To ensure the safety of this new approach, we have reviewed the personal series of a single surgeon using a standardized skin-sparing technique during 1989 to 2004.

RESULTS

Skin-sparing mastectomy with immediate reconstruction was performed on 225 patients, and standard mastectomy was performed on 1,022 patients. The age distribution was 8 years younger on average in the reconstructed group. The average follow-up for each group was 49 months. The local recurrence for each group was 1.7% and 1.5% (P > .80). The regional recurrence was 3.8% and 3.9% (P > .80). The average time to local recurrence was similar in each group (33.1 and 32.6 months, P > .80).

CONCLUSIONS

A skin-sparing mastectomy does not change the local, regional, or systemic risk to breast cancer patients.

The future prospect: ductoscopy-directed brushing and biopsy

The intraductal approach to breast cancer and premalignant lesions has now developed to yield substantial cytologic samples of exfoliated cells. Standard cytology is still inadequate in sensitivity and specificity to accurately interpret the majority of samples. As techniques evolve using ductoscopic biopsy and molecular marker panels to increase accuracy of cytologic interpretation, these tools will be able to unravel the breast carcinogenesis pathways. They will also offer considerable benefit in screening for premalignant changes and developing effective chemoprevention strategies.

Understanding the mechanisms creating false positive lumpectomy margins

OBJECTIVE

All breast surgeons deal with the frustration of initial pathologic close or positive margins that have no residual cancer upon re-excision. To understand the mechanisms that create false positive margins, specimen handling was standardized in a single surgeon's practice and margin issues were tracked.

METHODS

Prospectively over a 3.5-year period, needle-localized lumpectomies for the management of early-stage breast cancer were standardized in all aspects of specimen handling, including surgeon inking and specimen compression for specimen radiography for quality assurance. The current study reviews 220 such cases where the original lumpectomy included a small piece of overlying skin from over the target lesion. All specimen radiography was performed with compression at the skin to deep level to bias the "pancaking" effect of pushing tumor to specimen surface to the deep margin.

RESULTS

Of the 220 therapeutic lumpectomies performed for clinical stage 0-2 breast cancer in this fashion, 175 (79.5%) had negative margins by a distance of 10 mm or more. Margins less than 10 mm were classified as close and were present in 20 (9.1%) of cases. These were heavily biased toward margins closer than 2 mm. Positive initial margins accounted for 25 (11.4%) of cases. Of the 45 close or positive margin cases, 12 involved the deep margin only, and on re-excision none was found to have residual tumor. When other single margins were involved, re-excision found tumor in 5 of 14 cases (35.7%). When multiple margins were close or positive, 9 of 19 cases (47.3%) were found to have residual tumor at re-excision.

CONCLUSIONS

Specimen compression increases the incidence of false margin positivity. The best predictors of true margin positivity are multiple close or positive margins or margin positivity in a direction not associated with specimen ex vivo compression.

Nonsurgical ablation of primary breast cancer

The potential for these therapies is overwhelming when one considers that as many as 90,000 patients may be candidates annually in the United States. The ideal therapy should be safe, as painless as possible, accessible, and effective in reducing local recurrence. Because of the novelty of these techniques, no therapy has met all of these goals. Even if these ideals are attained, questions remain about how to follow these patients with regard to frequency and imaging modality for local recurrence. As these technologies are refined, and they mature; it is conceivable that the future treatment of breast cancer may be less morbid than the open breast biopsies now being used for just the diagnosis of the disease.

Office-based breast ductoscopy for diagnosis

OBJECTIVE

Ductoscopy is an evolving technology that has been used primarily and historically in conjunction with open surgical procedures. New technical improvements allow intraductal biopsy and therefore its application in the clinical setting for diagnostic evaluations of the breast. This study looks at the initial use of intraductal biopsy in a variety of settings from an academic university practice to a private single-surgeon office.

METHODS

This is a multicenter retrospective series of 88 patients undergoing ductoscopy of > or =1 duct for the diagnostic workup of common breast problems. The procedures were done with the patient under local anesthesia, and intraductal biopsy specimens were taken and analyzed as breast cytology samples.

RESULTS

Of the 88 patients undergoing office ductoscopy, nipple discharge was the most common indication (n = 83 patients; 94% to 66% spontaneous and 34% elicited). Fifty-five percent were high risk for breast cancer by history. The majority of patients had normal previous mammograms: 48 Breast Imaging-Reporting and Data System (BIRADS) 1, 24 BIRADS 2, and 7 BIRADS 3 to 5. The most common finding was papilloma present in 29 (32%) patients by endoscopy. Only 31% of patients had a history of brown or bloody nipple discharge. A wide variety of other endoscopic abnormalities were seen and biopsied. The average number of biopsies per patient was 2 with 18 (20.5%) having severe or malignant atypia. Further follow-up and management of these more concerning abnormalities is currently ongoing.

CONCLUSIONS

These results indicate that office ductoscopy with biopsy is both feasible and does identify suspicious or malignant atypia in patients with expressed or spontaneous nipple fluid.

Focused microwave phased array thermotherapy for ablation of early-stage breast cancer: results of thermal dose escalation

BACKGROUND

Tumor ablation as a means of treating breast cancer is being investigated. Microwave energy is promising because it can preferentially heat high-water-content breast carcinomas, compared to adipose and glandular tissues.

METHODS

This is a prospective, multicenter, nonrandomized dose-escalation study of microwave treatment. Thermal dose was measured as (1) thermal equivalent minutes (cumulative equivalent minutes; CEM) of treatment relative to a temperature of 43 degrees C and (2) peak tumor temperature. Microwaves were guided by an antenna-temperature sensor placed percutaneously into the tumor. Outcomes measured were pathologic response (tumor necrosis) side effects.

RESULTS

Twenty-five patients (mean age, 57 years) were enrolled. The mean tumor diameter was 1.8 cm. Tumoricidal temperatures (>43 degrees C) were reached in 23 patients (92%). Tumor size was unchanged after thermotherapy (P = not significant). Pathologic necrosis was achieved in 17 (68%) patients. Complete necrosis of the invasive component was achieved in two patients. One hundred forty CEM is predictive of a 50% tumor response, and 210 CEM is predictive of a 100% tumor response (P =.003). Univariate linear regression predicts that peak tumor temperatures of 47.4 degrees C and 49.7 degrees C cause a 50% tumor response and a 100% tumor response, respectively.

CONCLUSIONS

Thermotherapy causes tumor necrosis and can be performed safely with minimal morbidity. The degree of tumor necrosis is a function of the thermal dose. Future studies will evaluate the impact of high doses of thermotherapy on margin status and complete tumor ablation.

Success of sentinel lymph node mapping after breast cancer ablation with focused microwave phased array thermotherapy

BACKGROUND

Breast cancer tumor ablation as part of a multimodality approach in the treatment of breast cancer is the subject of recent interest. This study was conducted to determine if the ability to perform sentinel node biopsy was impaired after thermal-induced ablation of breast cancer.

METHODS

We studied patients who had sentinel node biopsy after preoperative focused microwave phased array for breast cancer ablation.

RESULTS

Twenty-one patients with T1-T2 breast cancer and clinically negative axilla underwent wide local excision and sentinel node biopsy guided by blue dye and sulfur colloid. Surgery was done an average of 17 days after microwave ablation. Fifteen of 22 patients (68%) had histologic evidence of tumor necrosis. Sentinel lymph node mapping was successful in 19 of 21 patients (91%). Axillary metastases were detected in 42% of cases.

CONCLUSIONS

This study documents successful sentinel lymph node mapping for patients treated with antecedent local tumor ablation using focused microwave phased array ablation.

Association of maspin expression with the high histological grade and lymphocyte-rich stroma in early-stage breast cancer

AIMS

Maspin is a recently described member of the serpin family or protease inhibitors that is known to be a tumour suppressor gene product. Loss of maspin expression has been found in most breast cancer cases and is correlated with cell motility and tumour invasiveness. However, its precise role in human breast cancer remains to be discovered. We aimed to evaluate the role of maspin in early-stage breast cancer.

METHODS AND RESULTS

We analysed the expression of maspin in 192 stage I and II primary breast cancers by immunohistochemistry. Of these cases, 34.4% showed maspin expression. Maspin expression was more frequently found in invasive ductal carcinoma (36.4%) than in invasive lobular carcinoma (7.1%). High maspin expression was demonstrated in breast cancers showing high histological grade or lymphocyte-rich stroma (P < 0.05). Maspin expression was not associated with overall and disease-free survival rate of breast cancer.

CONCLUSIONS

The results indicate that different biological mechanisms may be responsible for maspin expression in histologically distinct types of breast cancer. Our survey suggests that maspin expression in breast cancer might have a compensatory role rather than prognostic one.

Routine operative breast endoscopy during lumpectomy

BACKGROUND

Lumpectomy for the management of breast cancer is commonly directed by mammography or ultrasound. We hypothesized that fluid-producing ducts would likely connect to the site of the known cancerous or precancerous lesion and that endoscopic evaluation might reveal unsuspected additional disease.

METHODS

All women undergoing lumpectomy in a single surgeon's practice from January 2000 to August 2001 were evaluated for fluid production from the nipple at the time of lumpectomy. All fluid-producing ducts were cannulated and endoscoped with a 0.9-mm Acueity microendoscope.

RESULTS

Of the 201 patients (16 with atypical ductal hyperplasia, 52 with ductal carcinoma-in-situ, and 133 with stage 1 or 2 breast cancers), 150 (74.6%) could be successfully dilated and scoped. Additional lesions outside the anticipated lumpectomy were identified in 41% (n = 83) of cases. If successful, the chances for a positive margin for cancer decreased from 23.5% to only 5.0%. Endoscopy proved to be a useful adjunct in this series of patients because it identified all cases of extensive intraductal component in early-stage breast cancer.

CONCLUSIONS

Routine operative breast endoscopy can reduce the need for re-excision lumpectomy. It also finds substantially more cancerous and precancerous disease than anticipated by routine preoperative mammography and ultrasound.

Ductal lavage, nipple aspiration, and ductoscopy for breast cancer diagnosis

The intraductal approach to breast cancer has been invigorated this year by a series of papers exploring ductal-based screening through nipple aspiration and lavage and ductal exploration through endoscopy. The merging of these efforts to define the earliest biologic changes in the progression toward breast cancer is opening new fields for both bench-translational and clinical research. These techniques have already begun to show value in defining the presence and extent of proliferative disease in high-risk patients, allowing for more informed therapeutic decision making.

Ambulatory mastectomy

BACKGROUND

Ambulatory mastectomy has been a topic of heated political debate with little analysis of clinical data.

METHODS

Based on extensive satisfaction surveys, an ideal surgical treatment experience was developed that decreased nausea, increased preoperative education, and reduced perioperative narcotic usage. Using this new algorithm, patients treated by a single surgeon were given the choice of overnight stay versus discharge to home with visiting nurse care.

RESULTS

From March 1 to October 31, 2001, 92 mastectomies or lumpectomy/axillary dissections were performed in 87 patients. One patient chose to remain in the center overnight. All others were discharged in less than 2.5 hours postoperatively. Perioperative complications fell to 20% of those of the prior year. Hospital charges fell 79.5%.

CONCLUSIONS

Despite lay reservations about ambulatory mastectomy, a detailed approach can result in markedly reduced health care costs without incurring additional morbidity or mortality.

Routine operative breast endoscopy for bloody nipple discharge

BACKGROUND

Submillimeter endoscopes are now available and have been described to assist surgeons in the evaluation and management of symptomatic nipple discharge.

METHODS

To evaluate its potential use, a microendoscope (0.9 mm Acueity) was used on all patients in a single surgeon's practice who were undergoing nipple exploration for spontaneous hemoccult positive nipple discharge. This procedure was performed at the surgical resection of the symptomatic retro-areolar duct, and 27 patients underwent the endoscopy during the period from January 2000 to August 2001.

RESULTS

In 96% (26 of 27) of the patients, the endoscope was successfully introduced into the lactiferous sinus, and the proximal breast ducts were successfully visualized. A lesion accounting for the bleeding was seen in all 26 patients, with 70% (n = 19) having multiple intraluminal defects. Cancers were identified in two cases (7.4%), and in both cases, there was a more proximal papilloma in the same ductal system. Similarly, in 33% of the benign cases, both papillomas and usual or atypical ductal hyperplasia were present. Lesions were identified that extended up to 7.5 cm deep to the nipple. The deepest lesion was one of the endoscopically identified cancers in a patient with normal mammogram and breast ultrasound. Surgical resection could be directed by simple transillumination of the skin during endoscopy.

CONCLUSIONS

This series demonstrates the clinical feasibility of routine operative breast endoscopy in the management of bloody nipple discharge. The high incidence of multiple lesion identification suggests that the classic blind resection of a limited distance of duct in the retroareolar space may significantly underestimate the true extent of proliferative disease accounting for pathologic nipple discharge.

Breast enhanced scintigraphy testing distinguishes between normal, inflammatory breast changes, and breast cancer: a prospective analysis and comparison with mammography

The detection of breast cancer has primarily focused on anatomic findings, whereas assessment of physiologic information using nuclear imaging has been used for the detection of heart disease. Using this approach, the authors developed a method (breast enhanced scintigraphy test [BEST]) for differentiation of breast tissue by enhancing the delivery of isotope. To determine if this technique could distinguish between normal (Nl), inflammatory changes of the breast (ICB), and breast cancer (CA), 100 women were prospectively studied using BEST imaging, and results were compared with mammography and pathology findings using either biopsy or ductoscopy approaches. Mammography demonstrated a sensitivity and specificity of 69% and 84%, respectively. Using BEST imaging, maximal count activity (MCA) was able to distinguish between Nl, ICB, and CA. The results of 2-tailed t test analysis demonstrated statistically significant differences between Nl and ICB MCA (P </=.001); ICB and CA MCA(P </=.001); and N1 and CA MCA(P </=.001). Using MCA results obtained via BEST imaging, breast tissue was able to be differentiated, whereas mammography was able to detect breast cancer in only 69% of cases and incorrectly identified cancer in 16% of cases.

Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation

The purpose of the present study was to determine whether contour abnormalities of the abdomen after breast reconstruction with abdominal flaps are related to the harvest of the rectus abdominis muscle. Abdominal contour was analyzed in 155 women who had breast reconstruction with abdominal flaps; 108 women had free transverse rectus abdominis muscle (TRAM) flaps, 37 had pedicled TRAM flaps, and 10 had deep inferior epigastric perforator (DIEP) flaps. The reconstruction was unilateral in 110 women and bilateral in 45 women. Three methods of muscle-sparing were used; they are classified as preservation of the lateral muscle, preservation of the medial and lateral muscle, or preservation of the entire muscle. One of these three methods of muscle-sparing was used in 91 women (59 percent) and no muscle-sparing was used in 64 women (41 percent). Postoperative contour abnormalities occurred in 15 woman and included epigastric fullness in five, upper bulge in three, and lower bulge in 10. One woman experienced two abnormalities, one woman experienced three, and no woman developed a hernia. Of these abnormalities, 11 occurred after the free TRAM flap, seven after the pedicled TRAM flap, and none after the DIEP flap. Bilateral reconstruction resulted in 11 abnormalities in nine women, and unilateral reconstruction resulted in seven abnormalities in six women. chi2 analysis of the free and pedicled TRAM flaps demonstrates that muscle-sparing explains the observed differences in upper bulge and upper fullness (p = 0.02), with a trend toward significance for lower bulge (p = 0.06). chi2 analysis of the free TRAM and DIEP flaps does not explain the observed difference in abnormal abdominal contour. Analysis of muscle-sparing and non-muscle-sparing methods demonstrates that the observed difference between the techniques is only explained for a lower bulge after the bilateral free TRAM flap (p = 0.04).