New lumps in the breast following conservation treatment for early breast cancer

Necrose gordurosa multinodular mamária: Diagnóstico diferencial com o carcinoma da mama através da citologia por punção aspirativa

A necrose gordurosa da mama é um processo de desintegração de células adiposas, acompanhado de uma reação granulomatosa de intensidade variável. E decorrente do reconhecimento de lipídios extravasados do citoplasma de adipócitos como substâncias estranhas ao meio extracelular. O quadro clínico-radiológico pode ocasionar dificuldades no diagnóstico diferencial com neoplasias mamárias. Neste relato é descrito um caso de necrose gordurosa multinodular mamária sendo enfatizada a importância da citologia por punção aspirativa com agulha fina para a confirmação do diagnóstico.

Fat necrosis of the breast in the accelerated partial breast irradiation era: the need for a universal grading system

Fat necrosis of the breast is increasingly reported and used as a trial endpoint in the treatment of breast cancer with accelerated partial breast irradiation (APBI). Yet, there is no universal toxicity scoring system within the latest version of the Common Terminology Criteria for Adverse Events (CTCAE v4.0). This requires investigators to adopt their own scoring system or improperly use those that exist, and limits accurate reporting of this entity. Fat necrosis of the breast also creates diagnostic uncertainty among clinicians and concern of recurrence among patients. In this review, we address the question of increasing incidence of fat necrosis through the comparison of recent APBI trials and literature. The pathogenesis, symptoms, clinical and radiologic diagnosis, clinical predictors of developing fat necrosis, management and follow-up are also discussed.Lastly, we propose a simplified and universal scoring system for the reporting of fat necrosis.

Fat necrosis after partial-breast irradiation with brachytherapy or electron irradiation versus standard whole-breast radiotherapy--4-year results of a randomized trial

PURPOSE

To examine the incidence and clinical relevance of fat necrosis after accelerated partial-breast irradiation (PBI) using interstitial high-dose-rate brachytherapy (HDR-BT) in comparison with partial-breast electron irradiation (ELE) and whole-breast irradiation (WBI).

METHODS AND MATERIALS

Between 1998 and 2004, 258 early-stage breast cancer patients were randomized to receive 50 Gy WBI (n = 130) or PBI (n = 128). The latter consisted of either 7 x 5.2 Gy HDR-BT (n = 88) or 50 Gy ELE (n = 40). The incidence of fat necrosis, its impact on cosmetic outcome, accompanying radiologic features, and clinical symptoms were evaluated.

RESULTS

The 4-year actuarial rate of fat necrosis was 31.1% for all patients, and 31.9%, 36.5%, and 17.7% after WBI, HDR-BT and ELE, respectively (p(WBI/HDR-BT) = 0.26; p(WBI/ELE) = 0.11; p(ELE/HDR-BT) = 0.025). The respective rate of asymptomatic fat necrosis was 20.2%, 25.3%, and 10% of patients. The incidence of symptomatic fat necrosis was not significantly different after WBI (8.5%), HDR-BT (11.4%), and ELE (7.5%). Symptomatic fat necrosis was significantly associated with a worse cosmetic outcome, whereas asymptomatic fat necrosis was not. Fat necrosis was detectable with mammography and/or ultrasound in each case. Additional imaging examinations were required in 21% of cases and aspiration cytology in 42%.

CONCLUSIONS

Asymptomatic fat necrosis is a common adverse event of breast-conserving therapy, having no significant clinical relevance in the majority of the cases. The incidence of both symptomatic and asymptomatic fat necrosis is similar after conventional WBI and accelerated partial-breast HDR-BT.

Surgical considerations in the treatment of early stage breast cancer with accelerated partial breast irradiation (APBI) in breast conserving therapy via intersitial brachytherapy

OBJECTIVE

To examine early and late toxicities, evaluate cosmetic results, and determine the need for reoperation or additional diagnostic procedures in patients treated with accelerated partial breast irradiation (APBI) delivered by way of an interstitial implant in breast-conserving therapy.

METHODS

A total of 199 patients with stage I or II breast cancer were managed with lumpectomy followed by radiation restricted to the tumor bed using an interstitial implant (APBI). Retrospective analyses were performed for early and late toxicities (infection, fat necrosis, breast pain, edema, erythema, fibrosis, pigmentation changes, and telangiectasias), need for reoperation or additional diagnostic procedures, cosmetic results, and local control. Patient selection criteria by the surgeon for referral to RT for APBI included age, tumor size, histology, nodal status, margin status, and absence of extensive intraductal component. Treatment was delivered with either a low-dose or high-dose rate implant. Median follow-up was 5.7 years, and 54% of the patients were followed-up for >7 years.

RESULTS

Infections developed in 22 of 199 (11%) patients: 7% early (</=1 month after implant removal) and 4% late (>1 month after implant removal). Five of the 22 patients (2% of all patients) required operative intervention for the infection, either incision and drainage or debridement. There was a statistically significant difference between infection rates with open (8.5%) versus closed (2.5%) cavity placement of the interstitial needles (P = 0.005). There was no statistically significant difference between low-dose rate (inpatient) and high-dose rate (outpatient) treatment (P = 0.207). Forty-five patients (23%) had an additional diagnostic procedure to evaluate a suspicious or uncertain finding on physical examination or mammogram. Fibrosis and fat necrosis were found in 26 of the 45 patients. The incidence of fat necrosis increased with time. More patients were found to have fat necrosis after 5 years. One patient had fat necrosis diagnosed at <6 months; 8 patients (4% of total) at >/=6 months to <2 years; 10 patients (5% of total) at >/=2 years to <5 years; and 22 patients (11% of total) at >/=5 years. The majority of fat necrosis was detected on mammogram (80%) and was asymptomatic (78%). Cosmesis and toxicities were assessed at 3 defined time points: </=6 months, 2 years, and >/=5 years of follow-up. Using Harvard criteria, good to excellent cosmetic results were observed in >90% of patients. Breast pain, edema, and erythema diminished with time. Of the 199 cases, there were only 5 ipsilateral breast failures, yielding a 5-year actuarial local recurrence rate of 1.2%. Of these 5 failures, 2 were true recurrences/marginal misses, yielding a 5-year actuarial true recurrence/marginal miss rate of 0.5%. The 5-year actuarial cause-specific survival rate was 99% for APBI patients.

CONCLUSIONS

In selected patients with early-stage breast cancer, APBI with targeted interstitial brachytherapy offers 5-year results comparable with conventional breast-conserving therapy employing whole-breast radiation therapy. Minimal long-term toxicities were noted, most of which demonstrated continued resolution over time. Acceptable acute (7%) and delayed (4%) infection rates were observed. Fat necrosis was identified with increasing frequency with time, but the majority was asymptomatic. Cosmetic results are good to excellent (>90%). Continued follow-up by the surgeon will be required to determine the long-term efficacy of this alternative treatment approach.

An analysis of breast cancer in Hungary: experience of the National Institute of Oncology, Budapest

Breast cancer is the most common type of cancer in women throughout the world (18%), with a yearly morbidity that is already over half a million. Its incidence in Hungary is increasing in each age group, and the mortality is strikingly high. This study was conducted to assess the effectiveness of breast-conserving surgery in comparison to more radical surgery on a large group of patients. During the 15 years between 1980 and 1994, a total of 6,358 patients with primary breast cancer underwent surgery at the National Institute of Oncology in Budapest, Hungary, as breast-conserving surgery in 2,026 patients (31.8%). Breast-conserving surgery is being performed in an ever-increasing number of patients, followed by adjuvant radiochemotherapy in premenopausal patients, or radiohormone therapy in menopausal patients. During follow-up, recurrence was found in only 5.9% of the patients who underwent breast-conserving treatment. Thus, according to our experience, breast conservation therapy for the management of breast cancer offers favourable results, provided that the preconditions to this treatment are adequately met.

Techniques for obtaining the diagnosis of malignant breast lesions

Although fine needle aspiration is an efficacious method for diagnosing the palpable breast cancer, a negative aspirate does not exclude the presence of a malignancy. Open breast biopsy remains the standard of care in diagnosing a malignant breast lesion. All breast biopsies should be planned as if the scar were to be excised by a definitive surgical procedure (either mastectomy or tylectomy). New lesions in the treated breast require immediate biopsy because of the high likelihood of recurrent disease. Preferably, definitive surgery for malignancy should not be delayed more than 2 weeks after biopsy.

Mammography in the pre-operative assessment and post-operative surveillance of patients treated by excision and radiotherapy for primary breast cancer

To evaluate the place of mammography in the selection of patients for excision and radiotherapy for primary breast cancer a detailed analysis of pre-operative mammograms was performed in (i) a study group of 37 patients who developed local recurrence; (ii) a matched control group with a median local recurrence free survival of 57 months. There were significantly more multifocal tumours in the study group. Tumours were significantly larger (P = 0.02) and closer to the nipple (P = 0.008) in the study group compared to the control group. Regular follow-up mammograms were available in 26 of the study group. Twenty-one patients had mammographic evidence of either residual or recurrent tumour. We conclude that pre-operative mammography is essential in the selection of patients for excision and radiotherapy. Following treatment, mammography is useful in detecting residual or recurrent disease.

Radiation and other pathological changes in breast tissue after conservation treatment for carcinoma

Histological changes in breast tissue after radiotherapy were evaluated. Changes in tissue from 17 patients previously treated for breast cancer by surgery and radiotherapy were compared with those seen in a control group treated with surgery alone. Vascular and epithelial changes were seen only in tissue from patients who had received radiotherapy and, therefore, seemed to be relatively specific; stromal changes were seen in both groups and seemed, therefore, to be non-specific. Epithelial atypia is of particular importance as it may be severe and be confused with recurrent malignancy. The presence of other changes associated with radiotherapy, particularly those in vessels, should help to avoid such misdiagnosis.