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Falade I, Switalla K, Quirarte A, Baxter M, Soroudi D, Rothschild H, Abe SE, Goodwin K, Piper M, Wong J, Foster R, Mukhtar RA. Oncologic Safety of Immediate Oncoplastic Surgery Compared with Standard Breast-Conserving Surgery for Patients with Invasive Lobular Carcinoma. Ann Surg Oncol 2024:10.1245/s10434-024-15326-5. [PMID: 38713388 DOI: 10.1245/s10434-024-15326-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/01/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND Invasive lobular carcinoma (ILC) of the breast grows in a diffuse pattern, resulting in a high risk of positive margins at surgical resection. Oncoplastic approaches have been shown to reduce this risk, but concerns persist around the safety of immediate oncoplastic surgery for those with ILC. This study evaluated the short- and long-term oncologic outcomes of immediate oncoplastic surgery for patients with ILC. METHODS This study retrospectively analyzed an institutional database of stages I to III ILC patients who underwent breast-conserving surgery (BCS) with or without immediate oncoplastic surgery (oncoplastic closure or oncoplastic reduction mammoplasty [ORM]). The study compared positive margin rates, rates of successful BCS, and recurrence-free survival (RFS) by type of surgery. RESULTS For 494 patients the findings showed that the use of immediate ORM was associated with significantly lower odds of positive margins (odds ratio [OR], 0.34; 95 % confidence interval [CI], 0.17-0.66; p = 0.002). Both lumpectomy with oncoplastic closure and ORM were significantly associated with higher rates of successful BCS than standard lumpectomy (94.2 %, 87.8 %, and 73.9 %, respectively; p < 0.001). No difference in RFS was observed between those undergoing immediate oncoplastic surgery and those undergoing standard lumpectomy alone. CONCLUSIONS The patients with stages I to III ILC who underwent immediate oncoplastic surgery had significant benefits including lower odds of positive margins and higher rates of successful BCS, with both types of immediate oncoplastic surgery showing similar RFS compared with lumpectomy alone. This supports the oncologic safety of immediate oncoplastic surgery for diffusely growing tumors such as ILC, providing it an ideal option for patients desiring BCS.
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Affiliation(s)
- Israel Falade
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA.
| | - Kayla Switalla
- University of Minnesota Medical School, Minneapolis, MN, USA
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Astrid Quirarte
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Molly Baxter
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Daniel Soroudi
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Harriet Rothschild
- School of Medicine, University of California-San Francisco, San Francisco, CA, USA
| | - Shoko Emily Abe
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Karen Goodwin
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Merisa Piper
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Jasmine Wong
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Robert Foster
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
| | - Rita A Mukhtar
- Division of Surgical Oncology, Department of Surgery, University of California-San Francisco, San Francisco, CA, USA
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Diagnostic Value of Intraoperative Frozen Section in Breast-Conserving Surgery: A Systematic Review and Meta-analysis. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.114082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Context: According to previous studies, using the frozen section procedure during breast surgery reduces the rate of error and the need for re-surgery. We aimed at performing a comprehensive systematic review and meta-analysis to provide reliable evidence on the diagnostic value of frozen section procedures in breast-conserving surgery (BCS). Data Sources: A thorough search was performed in PubMed, Embase, Cochrane Library, and Web of Science databases for human diagnostic studies that used the frozen section in BCS. Meta-analyses were done to find the sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Study Selection: Human diagnostic studies used the frozen section in breast-conserving surgery and studies that reported the sensitivity and specificity of the frozen section in BCS or contained data that could be calculated the desired parameters were selected for this meta-analysis. Data Extraction: Assessment of studies quality was done and data was extracted from included papers. Then, the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to assess the quality of included papers. Results: Thirty-five papers were entered into our study. The meta-analysis indicated the high sensitivity (83.47, 95%CI 79.61 - 87.32) and specificity (99.29, 95%CI 98.89 - 99.68) for the frozen section in BCS, which resulted in an accuracy of 93.77 (95%CI 92.45 - 95.10). We also found a significant PPV (93.26, 95%CI 91.25 - 95.27), NPV (92.17, 95%CI 90.22 - 94.11), PLR (7.99, 95%CI 6.01 - 9.96), and NLR (0.18, 95%CI 0.14 - 0.23). Conclusions: The findings showed that intraoperative frozen section analysis has high sensitivity and specificity for evaluating lumpectomy margins in patients with early-stage breast cancer and significantly reduces the need for re-operation. Accordingly, re-operation costs are not imposed on the patient and reduce the anxiety of the patients.
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Wj H, As E, Js R, C P, Dh B. Rates of margin positive resection with breast conservation for invasive breast cancer using the NCDB. Breast 2021; 60:86-89. [PMID: 34520952 PMCID: PMC8441089 DOI: 10.1016/j.breast.2021.08.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/20/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022] Open
Abstract
Background Previous studies suggest the rate of positive surgical margin (PSM) after lumpectomy for breast cancer is approximately 20 %. The risk of PSM at time of resection is often a source of fear for patients, driving some to elect to undergo mastectomy. This study describes rates and predictors of positive margins for invasive breast cancers in the National Cancer Database (NCDB). Materials and methods From 2004 to 2013, patients with non-metastatic invasive breast cancers who underwent breast conservation surgery were identified from the NCDB. Patients’ demographic, clinical, and facility of treatment characteristics were collected and compared. Per SSO-ASTRO-ASCO criteria, margin negative is defined as no gross or microscopic disease (i.e. no tumor on ink). Bivariate tests and multivariate logistic regression were conducted to identify independent predictors of patients with PSM at the time of resection. Results A total of 707,798 patients were identified with non-metastatic invasive breast tumors who underwent lumpectomy. Rate of PSM across the entire cohort was 5.02 %. Over time, the rate of PSM decreased significantly from 6.54 % in 2004 to 3.91 % in 2013 (p < 0.001). Pure lobular histology predicted for the highest rate of PSM compared with IDC (8.63 vs 4.55 %; p < 0.001). In adjusted analysis, high grade, non-ductal histology and HER2 amplification were significantly associated with PSM with breast conservation while estrogen and progesterone status were not. Conclusion This study demonstrates a 5 % risk of PSM at time of breast conservation surgery using a large, modern national database. Patients with invasive lobular and mixed histology have a nearly two-fold risk of PSM compared to invasive ductal cancers. These results provide important data points to help appropriately counsel patients regarding the risk of PSM. Using the National Cancer Database (NCDB), trends in positive surgical margin (PSM) at time of lumpectomy for early stage invasive breast cancer are decreasing over time. Observed rates of PSM in this analysis are approximately 5 % for the entire cohort. Predictors of PSM are lobular histology, increasing T and N stage, grade, and Her2+ histology.
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Affiliation(s)
- Hotsinpiller Wj
- University of Alabama at Birmingham, Department of Radiation Oncology, USA
| | - Everett As
- Alliance Cancer Care in Huntsville, Alabama, USA
| | - Richman Js
- University of Alabama at Birmingham, Division of Gastrointestinal Surgery, USA
| | - Parker C
- University of Alabama at Birmingham, Division of Surgical Oncology, USA
| | - Boggs Dh
- University of Alabama at Birmingham, Department of Radiation Oncology, USA.
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4
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Gommers JJJ, Duijm LEM, Bult P, Strobbe LJA, Kuipers TP, Hooijen MJH, Mann RM, Voogd AC. The Impact of Preoperative Breast MRI on Surgical Margin Status in Breast Cancer Patients Recalled at Biennial Screening Mammography: An Observational Cohort Study. Ann Surg Oncol 2021; 28:5929-5938. [PMID: 33796997 PMCID: PMC8460561 DOI: 10.1245/s10434-021-09868-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/02/2021] [Indexed: 01/10/2023]
Abstract
Background This study aimed to examine the association between preoperative magnetic resonance imaging (MRI) and surgical margin involvement, as well as to determine the factors associated with positive resection margins in screen-detected breast cancer patients undergoing breast-conserving surgery (BCS). Methods Breast cancer patients eligible for BCS and diagnosed after biennial screening mammography in the south of The Netherlands (2008–2017) were retrospectively included. Missing values were imputed and multivariable regression analyses were performed to analyze whether preoperative MRI was related to margin involvement after BCS, as well as to examine what factors were associated with positive resection margins, defined as more than focally (>4 mm) involved. Results Overall, 2483 patients with invasive breast cancer were enrolled, of whom 123 (5.0%) had more than focally involved resection margins. In multivariable regression analyses, preoperative MRI was associated with a reduced risk of positive resection margins after BCS (adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.33–0.96). Lobular histology (adjusted OR 2.86, 95% CI 1.68–4.87), large tumor size (per millimeter increase, adjusted OR 1.05, 95% CI 1.03–1.07), high (>75%) mammographic density (adjusted OR 3.61, 95% CI 1.07–12.12), and the presence of microcalcifications (adjusted OR 4.45, 95% CI 2.69–7.37) and architectural distortions (adjusted OR 1.85, 95% CI 1.01–3.40) were independently associated with positive resection margins after BCS. Conclusions Preoperative MRI was associated with lower risk of positive resection margins in patients with invasive breast cancer eligible for BCS using multivariable analysis. Furthermore, specific mammographic characteristics and tumor characteristics were independently associated with positive resection margins after BCS.
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Affiliation(s)
- Jessie J J Gommers
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Lucien E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Bult
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Luc J A Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Toon P Kuipers
- Department of Radiology, Bernhoven Hospital, Uden, The Netherlands
| | | | - Ritse M Mann
- Department of Medical Imaging, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
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Wanis ML, Wong JA, Rodriguez S, Wong JM, Jabo B, Ashok A, Lum SSJ, Solomon NL, Reeves ME, Garberoglio CA, Senthil M. Rate of Re-excision after Breast-conserving Surgery for Invasive Lobular Carcinoma. Am Surg 2020. [DOI: 10.1177/000313481307901034] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Invasive lobular carcinoma (ILC) accounts for approximately 5 to 20 per cent of all breast cancers and is often multicentric. Despite pre- and intraoperative assessments to achieve negative margins, ILC is reported to be associated with higher rates of positive margin. This cross-sectional study examined patients with breast cancer treated at our institution from 2000 to 2010. The objective was to investigate the rate of re-excision resulting from positive or close margin (1 mm or less) in patients who underwent breast-conserving surgery (BCS) for ILC compared with invasive ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS). Of the 836 patients treated, 416 patients underwent BCS. The rate of re-excision after BCS for ILC was 35.1 versus 17.7 per cent for IDC and 20.0 per cent for DCIS ( P = 0.04). Re-excisions were more often performed for positive margin in patients with ILC (11 of 37 [29.7%]) versus IDC (36 of 334 [10.8%]) and DCIS (five of 45 [11.1%];( P = 0.004). In this single-institution review, BCS for ILC had significantly higher rates of re-excision as a result of positive margins when compared with IDC and DCIS. Tumor size greater than 2 cm and lymph node involvement were identified as factors associated with positive surgical margin in ILC. The higher possibility of positive margins and the need for additional procedures should be discussed with patients undergoing BCS for ILC.
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Affiliation(s)
- Morcos L. Wanis
- From Loma Linda University Medical Center, Loma Linda, California
| | - Jennifer A. Wong
- From Loma Linda University Medical Center, Loma Linda, California
| | - Samuel Rodriguez
- From Loma Linda University Medical Center, Loma Linda, California
| | - Jasmine M. Wong
- From Loma Linda University Medical Center, Loma Linda, California
| | - Brice Jabo
- From Loma Linda University Medical Center, Loma Linda, California
| | - Arjun Ashok
- From Loma Linda University Medical Center, Loma Linda, California
| | - Sharon S. J. Lum
- From Loma Linda University Medical Center, Loma Linda, California
| | | | - Mark E. Reeves
- From Loma Linda University Medical Center, Loma Linda, California
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Piper ML, Wong J, Fahrner-Scott K, Ewing C, Alvarado M, Esserman LJ, Mukhtar RA. Success rates of re-excision after positive margins for invasive lobular carcinoma of the breast. NPJ Breast Cancer 2019; 5:29. [PMID: 31508489 PMCID: PMC6731236 DOI: 10.1038/s41523-019-0125-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/19/2019] [Indexed: 11/09/2022] Open
Abstract
Rates of positive margins after surgical resection of invasive lobular carcinoma (ILC) are high (ranging from 18 to 60%), yet the efficacy of re-excision lumpReceptor subtypeectomy for clearing positive margins is unknown. Concerns about the diffuse nature of ILC may drive increased rates of completion mastectomy to treat positive margins, thus lowering breast conservation rates. We therefore determined the success rate of re-excision lumpectomy in women with ILC and positive margins after surgical resection. We identified 314 cases of stage I-III ILC treated with breast conserving surgery (BCS) at the University of California, San Francisco. Surgical procedures, pathology reports, and outcomes were analyzed using univariate and multivariate statistics and Cox-proportional hazards models. We evaluated outcomes before and after the year 2014, when new margin management consensus guidelines were published. Positive initial margins occurred in 118 (37.6%) cases. Of these, 62 (52.5%) underwent re-excision lumpectomy, which cleared the margin in 74.2%. On multivariate analysis, node negativity was significantly associated with successful re-excision (odds ratio [OR] 3.99, 95% CI 1.15-13.81, p = 0.029). After 2014, we saw fewer initial positive margins (42.7% versus 25.5%, p = 0.009), second surgeries (54.6% versus 20.2%, p < 0.001), and completion mastectomies (27.7% versus 4.5%, p < 0.001). In this large cohort of women with ILC, re-excision lumpectomy was highly successful at clearing positive margins. Additionally, positive margins and completion mastectomy rates significantly decreased over time. These findings highlight improvements in management of ILC, and suggest that completion mastectomy may not be required for those with positive margins after initial BCS.
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Affiliation(s)
- Merisa L. Piper
- Division of Plastic Surgery, Department of Surgery, University of California, San Francisco, CA USA
| | - Jasmine Wong
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Kelly Fahrner-Scott
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Cheryl Ewing
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Michael Alvarado
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Laura J. Esserman
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
| | - Rita A. Mukhtar
- Division of General Surgery, Department of Surgery, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA USA
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Mamtani A, Zabor EC, Rosenberger LH, Stempel M, Gemignani ML, Morrow M. Was Reexcision Less Frequent for Patients with Lobular Breast Cancer After Publication of the SSO-ASTRO Margin Guidelines? Ann Surg Oncol 2019; 26:3856-3862. [PMID: 31456094 DOI: 10.1245/s10434-019-07751-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Society of Surgical Oncology and American Society for Radiation Oncology consensus guidelines defined a negative margin for breast-conserving surgery (BCS) as no ink on tumor, and implementation has reduced rates of additional surgery for patients with invasive ductal cancer (IDC). The outcomes for invasive lobular cancer (ILC) patients are uncertain. METHODS This study identified patients who had stage 1 or 2 ILC treated with BCS from January 2010 to February 2018. The guidelines were adopted 1 January 2014. Clinicopathologic characteristics, margin status, and reexcisions were compared before and after adoption of the guidelines and with those of IDC patients treated from May 2013 to February 2015. RESULTS Among 745 early-stage ILC patients undergoing BCT, 312 (42%) were treated before the guidelines and 433 (58%) after the guidelines. Most clinicopathologic characteristics were similar between the two groups, with differences in lobular carcinoma in situ, lymphovascular invasion, and node-positivity rates. The overall rates of additional surgery declined significantly after the guidelines (31.4 to 23.1%; p = 0.01), but the difference did not reach significance for reexcisions (19.9 to 15.2%; p = 0.12) or conversions to mastectomy (11.5 to 7.9%; p = 0.099) individually. Between eras, no difference in incidence or number of tumor on ink or ≤ 2 mm margins was observed (all p = 0.2). Larger tumors, younger age, and pre-guideline era were independently associated with additional surgery. Only younger age was predictive of mastectomy. Among 431 pre-guideline and 601 post-guideline IDC patients, reexcisions declined from 21.3 to 14.8% (p = 0.008), and conversion to mastectomy was rare (0.6%). The magnitude of reduction in any additional surgery (interaction, p = 0.92) and reexcisions (interaction, p = 0.56) was similar between ILC and IDC. CONCLUSIONS Despite differences in growth pattern and conspicuity, guideline adoption significantly reduced additional surgery among ILC patients, with a magnitude of benefit similar to that among IDC patients.
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Affiliation(s)
- Anita Mamtani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Emily C Zabor
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Lai HW, Huang RH, Wu YT, Chen CJ, Chen ST, Lin YJ, Chen DR, Lee CW, Wu HK, Lin HY, Kuo SJ. Clinicopathologic factors related to surgical margin involvement, reoperation, and residual cancer in primary operable breast cancer – An analysis of 2050 patients. Eur J Surg Oncol 2018; 44:1725-1735. [DOI: 10.1016/j.ejso.2018.07.056] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 07/04/2018] [Accepted: 07/23/2018] [Indexed: 12/23/2022] Open
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Maloney BW, McClatchy DM, Pogue BW, Paulsen KD, Wells WA, Barth RJ. Review of methods for intraoperative margin detection for breast conserving surgery. JOURNAL OF BIOMEDICAL OPTICS 2018; 23:1-19. [PMID: 30369108 PMCID: PMC6210801 DOI: 10.1117/1.jbo.23.10.100901] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/03/2018] [Indexed: 05/18/2023]
Abstract
Breast conserving surgery (BCS) is an effective treatment for early-stage cancers as long as the margins of the resected tissue are free of disease according to consensus guidelines for patient management. However, 15% to 35% of patients undergo a second surgery since malignant cells are found close to or at the margins of the original resection specimen. This review highlights imaging approaches being investigated to reduce the rate of positive margins, and they are reviewed with the assumption that a new system would need high sensitivity near 95% and specificity near 85%. The problem appears to be twofold. The first is for complete, fast surface scanning for cellular, structural, and/or molecular features of cancer, in a lumpectomy volume, which is variable in size, but can be large, irregular, and amorphous. A second is for full, volumetric imaging of the specimen at high spatial resolution, to better guide internal radiologic decision-making about the spiculations and duct tracks, which may inform that surfaces are involved. These two demands are not easily solved by a single tool. Optical methods that scan large surfaces quickly are needed with cellular/molecular sensitivity to solve the first problem, but volumetric imaging with high spatial resolution for soft tissues is largely outside of the optical realm and requires x-ray, micro-CT, or magnetic resonance imaging if they can be achieved efficiently. In summary, it appears that a combination of systems into hybrid platforms may be the optimal solution for these two very different problems. This concept must be cost-effective, image specimens within minutes and be coupled to decision-making tools that help a surgeon without adding to the procedure. The potential for optical systems to be involved in this problem is emerging and clinical trials are underway in several of these technologies to see if they could reduce positive margin rates in BCS.
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Affiliation(s)
- Benjamin W. Maloney
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - David M. McClatchy
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Brian W. Pogue
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
- Geisel School of Medicine, Department of Surgery, Hanover, New Hampshire, United States
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Keith D. Paulsen
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
- Geisel School of Medicine, Department of Surgery, Hanover, New Hampshire, United States
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Wendy A. Wells
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Geisel School of Medicine, Department of Pathology and Laboratory Medicine, Hanover, New Hampshire, United States
| | - Richard J. Barth
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
- Geisel School of Medicine, Department of Surgery, Hanover, New Hampshire, United States
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Geisel School of Medicine, Department of Pathology and Laboratory Medicine, Hanover, New Hampshire, United States
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Abstract
Invasive lobular carcinoma (ILC) is the second most common type of breast cancer, with a unique pathogenesis and distinct clinical biology. ILCs display a characteristic loss of E-cadherin, are largely estrogen receptor positive, HER2 negative, and low to intermediate grade. These features portend a favorable prognosis, but there is a tendency for late recurrences and atypical metastases. ILCs tend to be insidious and infiltrative, which can pose a challenge for diagnosis, and emerging data suggest they may have a propensity for a differing response to standard therapies.
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Affiliation(s)
- Anita Mamtani
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tari A King
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston MA 02215, USA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, 450 Brookline Avenue, Boston, MA 02215, USA.
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11
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van Deurzen CHM. Predictors of Surgical Margin Following Breast-Conserving Surgery: A Large Population-Based Cohort Study. Ann Surg Oncol 2016; 23:627-633. [PMID: 27590331 PMCID: PMC5149558 DOI: 10.1245/s10434-016-5532-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Indexed: 12/04/2022]
Abstract
Background The purpose of this retrospective, population-based, cohort study was to identify patient and tumor characteristics that are associated with a high risk of tumor-positive margins after breast-conserving surgery (BCS) to optimize preoperative counseling. Methods All patients with invasive breast cancer (IBC) reported according to the synoptic reporting module in the Dutch Pathology Registry between 2009 and 2015 were included (n = 42.048 cases). Data extraction included age, type of surgery, several tumor characteristics, and resection margin status according to the Dutch indications for re-excision (free, focally positive, or more than focally positive). Univariate and multivariate tests were used to determine the association between clinicopathological features and margin status, restricted to patients with BCS. Results Of 42,048 cases, a total of 25,315 cases (60.2 %) with IBC underwent BCS. Of these patients, 2578 patients (10.2 %) had focally positive resection margins and 1665 (6.6 %) had more than focally positive resection margins. By univariate analysis, the following features were significantly associated with involved margins: age < 60 years, multifocality, lobular subtype, tumor size >2 cm, intermediate- and high-grade, positive ER status, positive Her2 status, angio-invasion, and the presence/extent of a ductal carcinoma in situ (DCIS) component. In multivariate logistic regression, the variables with the strongest association with involved margins (OR > 2) were multifocality, lobular subtype, large tumor size, and the presence of DCIS. Conclusions Several clinicopathologic features are associated with involved resection margins after BCS for IBC. Assessment of these features preoperatively could be used to optimize preoperative counseling.
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12
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Ultrasound-guided breast-conserving surgery for early-stage palpable and nonpalpable invasive breast cancer: decreased excision volume at unchanged tumor-free resection margin. Breast Cancer Res Treat 2016; 158:535-41. [PMID: 27444926 DOI: 10.1007/s10549-016-3914-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 07/14/2016] [Indexed: 01/08/2023]
Abstract
Ultrasound guidance (USG) during breast-conserving surgery improves tumor-free surgical resection margins. The objective of this study was to evaluate whether USG reduces resection volumes without compromising margin status. 134 patients with palpable or nonpalpable T1-2N0-1 invasive breast cancer were treated with USG and compared with a historical reference control group (CON) consisting of palpation-guided (PAG) or wire-guided localization (WIG) breast-conserving surgery. Primary outcomes were excess resection volume and clear margin status, and secondary outcome was re-excision rate. 66 patients underwent USG. In the CON group (n = 68), PAG was performed in 24 (35 %) and WIG in 44 (64 %) patients. Median excision volume [39 (IQR 20-66) vs 56 (38-94) cm(3); p = 0.001] and median calculated resection ratio [1.7 (1.0-2.9) vs 2.8 (1.4-4.6) (p = 0.005)] were significantly smaller in the USG than in the CON group. Median minimal distance to the resection margin [4 mm (IQR 2-5 mm) vs 2 mm (1-4 mm), p = 0.004] was significantly larger. Clear resection margins were achieved in 58 of the USG patients (88 %) and in 58 of the CON patients (86 %) (p = 0.91); this was true in patients with palpable as well as nonpalpable lesions. Reexcision was needed in 6.1 and 7.2 % respectively. Relative risk for re-excision in the USG group was 0.82 (95 % CI 0.23-2.93). In patients with palpable and nonpalpable breast cancers, USG allows for lower excision volume and reduced resection of healthy breast tissue, without increased re-excision rate.
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Brkljačić B, Divjak E, Tomasović-Lončarić Č, Tešić V, Ivanac G. Shear-wave sonoelastographic features of invasive lobular breast cancers. Croat Med J 2016; 57:42-50. [PMID: 26935613 PMCID: PMC4800323 DOI: 10.3325/cmj.2016.57.42] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim To evaluate shear-wave elastographic (SWE) and related gray-scale features of pure invasive lobular breast carcinoma (ILC) and compare them with invasive ductal breast cancers (IDC). Methods Quantitative SWE features of mean (El-mean), maximum (El-max), minimum (El-min) elasticity values of the stiffest portion of the mass, and lesion-to-fat elasticity ratio (E-ratio) were measured in 40 patients with pure ILC and compared with 75 patients with IDC. Qualitative gray-scale features of lesion size, echogenicity, orientation, and presence of distal shadowing were determined and compared between the groups. Results ILC were significantly larger than IDC (P = 0.008) and exhibited significantly higher El-max (P = 0.015) and higher El-mean (P = 0.008) than IDC. ILC were significantly more often horizontally oriented, while IDC were significantly more often vertically oriented (P < 0.001); ILC were significantly more often hyperechoic than IDC (P < 0.001). Differences in stiffness between ILC and IDC determined by quantitative SWE parameters were present only in small tumors (≤1.5 cm in size), ie, small ILC had significantly higher El-max (P = 0.030), El-mean (P = 0.014), and El-min (P = 0.045) than small IDC, while tumors larger than 1.5 cm had almost equal stiffness, without significant differences between the groups. Conclusion Specific histopathologic features of ILC are translated into their qualitative sonographic and quantitative sonoelastographic appearance, with higher stiffness of small ILC compared to small IDC. Gray-scale and sonoelastographic features may help in diagnosing ILC.
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Affiliation(s)
| | | | | | | | - Gordana Ivanac
- Gordana Ivanac, Department of Diagnostic and Interventional Radiology, Breast Unit, University Hospital Dubrava, University of Zagreb School of Medicine, Avenija G.Šuška 6, 10000 Zagreb, Croatia,
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Sledge GW, Chagpar A, Perou C. Collective Wisdom: Lobular Carcinoma of the Breast. Am Soc Clin Oncol Educ Book 2016; 35:18-21. [PMID: 27249682 DOI: 10.1200/edbk_100002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- George W Sledge
- From the Division of Oncology, Stanford University School of Medicine, Stanford, CA; Yale University, New Haven, CT; The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anees Chagpar
- From the Division of Oncology, Stanford University School of Medicine, Stanford, CA; Yale University, New Haven, CT; The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Charles Perou
- From the Division of Oncology, Stanford University School of Medicine, Stanford, CA; Yale University, New Haven, CT; The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Al-Azhri J, Koru-Sengul T, Miao F, Saclarides C, Byrne MM, Avisar E. Predictors of Surgery Types after Neoadjuvant Therapy for Advanced Stage Breast Cancer: Analysis from Florida Population-Based Cancer Registry (1996-2009). BREAST CANCER-BASIC AND CLINICAL RESEARCH 2015; 9:99-108. [PMID: 26691964 PMCID: PMC4677798 DOI: 10.4137/bcbcr.s31503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 08/18/2015] [Accepted: 08/19/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE Despite the established guidelines for breast cancer treatment, there is still variability in surgical treatment after neoadjuvant therapy (NT) for women with large breast tumors. Our objective was to identify predictors of the type of surgical treatment: mastectomy versus breast-conserving surgery (BCS) in women with T3/T4 breast cancer who received NT. METHODS Population-based Florida Cancer Data System Registry, Florida’s Agency for Health Care Administration, and US census from 1996 to 2009 were linked for women diagnosed with T3/T4 breast cancer and received NT followed by either BCS or mastectomy. Analysis of multiple variables, such as sociodemographic characteristics (race, ethnicity, socioeconomic status, age, marital status, and urban/rural residency), tumor’s characteristics (estrogen/progesterone receptor status, histology, grade, SEER stage, and regional nodes positivity), treatment facilities (hospital volume and teaching status), patients’ comorbidities, and type of NT, was performed. RESULTS Of 1,056 patients treated with NT for T3/T4 breast cancer, 107 (10%) had BCS and 949 (90%) had mastectomy. After adjusting with extensive covariables, Hispanic patients (adjusted odds ratio (aOR) = [3.50], 95% confidence interval (CI): 1.38–8.84, P = 0.008) were more likely to have mastectomy than BCS. Compared to localized SEER stage, regional stage with direct extension (aOR = [3.24], 95% CI: 1.60–6.54, P = 0.001), regional stage with direct extension and nodes (aOR = [4.35], 95% CI: 1.72–11.03, P = 0.002), and distant stage (aOR = [4.44], 95% CI: 1.81–10.88, P = 0.001) were significantly more likely to have mastectomy than BCS. Compared to patients who received both chemotherapy and hormonal therapy, patients who received hormonal NT only (aOR = [0.29], 95% CI: 0.12–0.68, P = 0.004) were less likely to receive mastectomy. CONCLUSION Our study suggests that Hispanic ethnicity, advanced SEER stage, and type of NT are significant predictors of receiving mastectomy after NT.
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Affiliation(s)
- Jamila Al-Azhri
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. ; Department of Surgery, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Feng Miao
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Constantine Saclarides
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Margaret M Byrne
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eli Avisar
- Division of Surgical Oncology, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA. ; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Karanlik H, Ozgur I, Cabioglu N, Sen F, Erturk K, Kilic B, Onder S, Deniz M, Yavuz E, Aydiner A. Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome. Eur J Surg Oncol 2015; 41:1226-33. [PMID: 26141784 DOI: 10.1016/j.ejso.2015.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 06/02/2015] [Accepted: 06/03/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival. MATERIALS AND METHODS 251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery. RESULTS The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups. CONCLUSIONS Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.
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Affiliation(s)
- H Karanlik
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey.
| | - I Ozgur
- Department of Surgery, Acibadem International Hospital, Istanbul, Turkey
| | - N Cabioglu
- Department of Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - F Sen
- Medical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - K Erturk
- Medical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - B Kilic
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - S Onder
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - M Deniz
- Surgical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - E Yavuz
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - A Aydiner
- Medical Oncology Unit, Institute of Oncology, Istanbul University, Istanbul, Turkey
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Sagara Y, Barry WT, Mallory MA, Vaz-Luis I, Aydogan F, Brock JE, Winer EP, Golshan M, Metzger-Filho O. Surgical Options and Locoregional Recurrence in Patients Diagnosed with Invasive Lobular Carcinoma of the Breast. Ann Surg Oncol 2015; 22:4280-6. [PMID: 25893416 DOI: 10.1245/s10434-015-4570-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE Recent consensus guidelines on margins for breast-conserving surgery (BCS) recommend the use of "no ink on tumor" as the standard for an adequate margin. The recommendations extend to invasive lobular carcinoma (ILC), but the data on this subset are limited. We reviewed our modern dataset on margin status with outcomes of ILC. METHODS We performed a retrospective cohort study on 736 patients with a diagnosis of stage I-III ILC treated at our cancer center between May 1997 and December 2007. Clinicopathologic data were extracted from the Clinical Research Information Systems Database. Margin status was defined using the latest ASCO/ASTRO/SSO consensus guideline criteria. RESULTS The initial surgery performed was mastectomy in 352 patients (48 %) and BCS in 384 patients (52 %). In multivariate analysis, tumor size and multifocality were significantly associated with high rates of mastectomy and positive surgical margins at initial BCS. After initial BCS, additional surgery was performed in 92 patients (24 %). During a 72-month median follow-up period, 12 (3.1 %) ipsilateral breast tumor recurrences (IBTR) and 5 (1.3 %) other locoregional recurrences (LRR) were observed. Patients with margins with ink on tumor who did not receive further surgery were found to have significantly increased LRR [odds ratio (OR) 5.5; p = 0.02] and IBTR (OR 8.5; p = 0.006), whereas patients with close margins (1-3 mm) and margins within 1 mm were not. CONCLUSIONS Our study supports the validity of using "no ink on tumor" as the standard for a negative margin for pure and mixed ILC treated with multimodality therapy.
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Affiliation(s)
- Yasuaki Sagara
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - William T Barry
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Ines Vaz-Luis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Fatih Aydogan
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jane E Brock
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Eric P Winer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mehra Golshan
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Otto Metzger-Filho
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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18
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Eterno V, Zambelli A, Pavesi L, Villani L, Zanini V, Petrolo G, Manera S, Tuscano A, Amato A. Adipose-derived Mesenchymal Stem Cells (ASCs) may favour breast cancer recurrence via HGF/c-Met signaling. Oncotarget 2015; 5:613-33. [PMID: 24327602 PMCID: PMC3996669 DOI: 10.18632/oncotarget.1359] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Adipose tissue is a reservoir of Mesenchymal Stem Cells (Adipose-derived Mesenchymal Stem Cells, ASCs), endowed with regenerative properties. Fat graft was proposed for breast reconstruction in post-surgery cancer patients achieving good aesthetic results and tissues regeneration. However, recent findings highlight a potential tumorigenic role that ASCs may have in cancer recurrence, raising some concerns about their safety in clinical application. To address this issue, we established a model where autologous ASCs were combined with primary normal or cancer cells from breast of human donors, in order to evaluate potential effects of their interactions, in vitro and in vivo. Surprisingly, we found that ASCs are not tumorigenic per sè, as they are not able to induce a neoplastic transformation of normal mammary cells, however they could exhacerbate tumorigenic behaviour of c-Met-expressing breast cancer cells, creating an inflammatory microenvironment which sustained tumor growth and angiogenesis. Pharmacological c-Met inhibition showed that a HGF/c-Met crosstalk between ASCs and breast cancer cells enhanced tumor cells migration, acquiring a metastatic signature, and sustained tumor self-renewal. The master role of HGF/c-Met pathway in cancer recurrence was further confirmed by c-Met immunostaining in primary breast cancer from human donors, revealing a strong positivity in patients displaying a recurrent pathology after fat grafts and a weak/moderate staining in patients without signs of recurrence. Altogether our findings, for the first time, suggest c-Met expression, as predictive to evaluate risk of cancer recurrence after autologous fat graft in post-surgery breast cancer patients, increasing the safety of fat graft in clinical application.
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Barentsz M, Postma E, van Dalen T, van den Bosch M, Miao H, Gobardhan P, van den Hout L, Pijnappel R, Witkamp A, van Diest P, van Hillegersberg R, Verkooijen H. Prediction of positive resection margins in patients with non-palpable breast cancer. Eur J Surg Oncol 2015; 41:106-12. [DOI: 10.1016/j.ejso.2014.08.474] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 08/13/2014] [Accepted: 08/24/2014] [Indexed: 10/24/2022] Open
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20
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Kikuyama M, Akashi-Tanaka S, Hojo T, Kinoshita T, Ogawa T, Seto Y, Tsuda H. Utility of intraoperative frozen section examinations of surgical margins: implication of margin-exposed tumor component features on further surgical treatment. Jpn J Clin Oncol 2014; 45:19-25. [DOI: 10.1093/jjco/hyu158] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Arps DP, Jorns JM, Zhao L, Bensenhaver J, Kleer CG, Pang JC. Re-excision rates of invasive ductal carcinoma with lobular features compared with invasive ductal carcinomas and invasive lobular carcinomas of the breast. Ann Surg Oncol 2014; 21:4152-8. [PMID: 24980090 DOI: 10.1245/s10434-014-3871-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Invasive ductal carcinoma (IDC) with lobular features (IDC-L) is not recognized as a subtype of breast cancer. We previously showed that IDC-L may be a variant of IDC with clinicopathological characteristics more similar to invasive lobular carcinoma (ILC). We sought to determine the re-excision rates of IDC-L compared with ILC and IDC, and the feasibility of diagnosing IDC-L on core biopsies. METHODS Surgical procedure, multiple tumor foci, tumor size, and residual invasive carcinoma on re-excision were recorded for IDC-L (n = 178), IDC (n = 636), and ILC (n = 251). Re-excision rates were calculated by excluding mastectomy as first procedure cases and including only re-excisions for invasive carcinoma. Slides of correlating core biopsies for IDC-L cases initially diagnosed as IDC were re-reviewed. RESULTS For T2 tumors (2.1-5.0 cm), re-excision rates for IDC-L (76 %) and ILC (88 %) were higher than that for IDC (42 %) (p = 0.003). Multiple tumor foci were more common in IDC-L (31 %) and ILC (26 %) than IDC (7 %) (p < 0.0001), which was a significant factor in higher re-excision rates when compared with a single tumor focus (p < 0.001). Ninety-two of 149 patients (62 %) with IDC-L were diagnosed on core biopsies. Of the 44 patients initially diagnosed as IDC, 30 were re-reviewed, of which 24 (80 %) were re-classified as IDC-L. CONCLUSIONS Similar to ILC, re-excision rates for IDC-L are higher than IDC for larger tumors. Patients may need to be counseled about the higher likelihood of additional procedures to achieve negative margins. This underscores the importance of distinguishing IDC-L from IDC on core biopsies.
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Affiliation(s)
- David P Arps
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
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22
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Adams A, van Brussel ASA, Vermeulen JF, Mali WPTM, van der Wall E, van Diest PJ, Elias SG. The potential of hypoxia markers as target for breast molecular imaging--a systematic review and meta-analysis of human marker expression. BMC Cancer 2013; 13:538. [PMID: 24206539 PMCID: PMC3903452 DOI: 10.1186/1471-2407-13-538] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 10/23/2013] [Indexed: 02/07/2023] Open
Abstract
Background Molecular imaging of breast cancer is a promising emerging technology, potentially able to improve clinical care. Valid imaging targets for molecular imaging tracer development are membrane-bound hypoxia-related proteins, expressed when tumor growth outpaces neo-angiogenesis. We performed a systematic literature review and meta-analysis of such hypoxia marker expression rates in human breast cancer to evaluate their potential as clinically relevant molecular imaging targets. Methods We searched MEDLINE and EMBASE for articles describing membrane-bound proteins that are related to hypoxia inducible factor 1α (HIF-1α), the key regulator of the hypoxia response. We extracted expression rates of carbonic anhydrase-IX (CAIX), glucose transporter-1 (GLUT1), C-X-C chemokine receptor type-4 (CXCR4), or insulin-like growth factor-1 receptor (IGF1R) in human breast disease, evaluated by immunohistochemistry. We pooled study results using random-effects models and applied meta-regression to identify associations with clinicopathological variables. Results Of 1,705 identified articles, 117 matched our selection criteria, totaling 30,216 immunohistochemistry results. We found substantial between-study variability in expression rates. Invasive cancer showed pooled expression rates of 35% for CAIX (95% confidence interval (CI): 26-46%), 51% for GLUT1 (CI: 40-61%), 46% for CXCR4 (CI: 33-59%), and 46% for IGF1R (CI: 35-70%). Expression rates increased with tumor grade for GLUT1, CAIX, and CXCR4 (all p < 0.001), but decreased for IGF1R (p < 0.001). GLUT1 showed the highest expression rate in grade III cancers with 58% (45-69%). CXCR4 showed the highest expression rate in small T1 tumors with 48% (CI: 28-69%), but associations with size were only significant for CAIX (p < 0.001; positive association) and IGF1R (p = 0.047; negative association). Although based on few studies, CAIX, GLUT1, and CXCR4 showed profound lower expression rates in normal breast tissue and benign breast disease (p < 0.001), and high rates in carcinoma in situ. Invasive lobular carcinoma consistently showed lower expression rates (p < 0.001). Conclusions Our results support the potential of hypoxia-related markers as breast cancer molecular imaging targets. Although specificity is promising, combining targets would be necessary for optimal sensitivity. These data could help guide the choice of imaging targets for tracer development depending on the envisioned clinical application.
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Affiliation(s)
- Arthur Adams
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Arps DP, Healy P, Zhao L, Kleer CG, Pang JC. Invasive ductal carcinoma with lobular features: a comparison study to invasive ductal and invasive lobular carcinomas of the breast. Breast Cancer Res Treat 2013; 138:719-26. [PMID: 23535842 DOI: 10.1007/s10549-013-2493-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 03/19/2013] [Indexed: 10/27/2022]
Abstract
Invasive ductal carcinoma with lobular features (IDC-L) is not recognized as a distinct subtype of breast cancer, and its clinicopathologic features and outcomes are unknown. In this retrospective study, we focused on characterization of clinicopathologic features and outcomes of IDC-L and compared them to invasive ductal carcinoma (IDC) and invasive lobular carcinoma (ILC). 183 cases of IDC-L from 1996 to 2011 were compared with 1,499 cases of IDC and 375 cases of ILC. Available slides of IDC-L (n = 150) were reviewed to quantify the lobular component (≤ 20, 21-50, 51-80, >80 %), defined as small cells individually dispersed, arranged in linear cords, or in loose aggregates without the formation of tubules or cohesive nests. E-cadherin immunostain was performed to confirm ductal origin. Compared to IDC, IDC-L was more likely to have lower histologic grade (p < 0.001), be positive for estrogen receptor (96 vs. 70 %; p < 0.0001) and progesterone receptor (84 vs. 57 %; p < 0.0001), and less likely to overexpress HER-2/neu (12 vs. 23 %; p = 0.001). Despite these favorable prognostic features, IDC-L had a higher frequency of nodal metastases (51 vs. 34 %; p < 0.0001) and a worse 5-year disease-free survival than IDC (hazard ratio = 0.454; p = 0.0004). ILC and IDC-L had similar clinicopathologic features and outcomes. The proportion of the lobular component in IDC-L had no impact on the size, nodal status, stage, or outcome. Our data suggest that although IDC-L may be a variant of IDC, with >90 % of cases being E-cadherin positive, the clinical and biological characteristics are more similar to that of ILC.
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Affiliation(s)
- David P Arps
- Department of Pathology, University of Michigan Health System, 1500 E. Medical Center Dr., 2G340, Ann Arbor, MI 48109, USA
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Koca B, Kuru B, Yuruker S, Gokgul B, Ozen N. Factors affecting surgical margin positivity in invasive ductal breast cancer patients who underwent breast-conserving surgery after preoperative core biopsy diagnosis. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2013; 84:154-9. [PMID: 23487000 PMCID: PMC3594642 DOI: 10.4174/jkss.2013.84.3.154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 12/03/2012] [Accepted: 12/18/2012] [Indexed: 11/30/2022]
Abstract
Purpose The aim of our study is to evaluate the factors affecting surgical margin positivity among patients with invasive ductal breast cancer who underwent breast-conserving surgery (BCS) after preoperative diagnostic core biopsy. Methods Two hundred sixteen patients with stage I, II invasive ductal breast carcinoma who had histological diagnosis with preoperative tru-cut biopsy and underwent BCS were included in the present study. Potential factors that affect the positive surgical margin were analyzed. In univariate analysis, the comparisons of the factors affecting the surgical margin positivity were made by chi-square test. Logistic regression test was used to detect the independent factors affecting the surgical margin positivity. Results Positive axillary lymph node (odds ratio [OR], 8.2; 95% confidence interval [CI], 3.01 to 22.12), lymphovascular invasion (LVI; OR, 3.9; 95% CI, 1.62 to 9.24), extensive intraductal component (EIC; OR, 6.1; 95% CI, 2.30 to 16.00), presence of spiculation (OR, 5.1; 95% CI, 2.00 to 13.10) or presence of microcalcification in the mammography (OR, 13.7; 95% CI, 4.04 to 46.71) have been found to be the independent and adverse factors affecting surgical margin positivity. Conclusion Considering decision making for the extent of the excision and for achieving negative surgical margin before BCS, positive axillary lymph node, LVI, EIC, spiculation or microcalcification in mammography are related as predictor factors for positive surgical margin.
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Affiliation(s)
- Bulent Koca
- Department of General Surgery, Ondokuz Mayis University School of Medicine, Samsun, Turkey
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25
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Down SK, Jha MBBS MS MSc PK, Burger A, Hussien MI. Oncological Advantages of Oncoplastic Breast-Conserving Surgery in Treatment of Early Breast Cancer. Breast J 2013; 19:56-63. [PMID: 23301761 DOI: 10.1111/tbj.12047] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Sue K. Down
- Breast Surgery Unit; Norfolk & Norwich University Hospital; Norwich United Kingdom
| | | | - Amy Burger
- Breast Surgery Unit; Norfolk & Norwich University Hospital; Norwich United Kingdom
| | - Maged I. Hussien
- Breast Surgery Unit; Norfolk & Norwich University Hospital; Norwich United Kingdom
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Krekel NMA, Haloua MH, Lopes Cardozo AMF, de Wit RH, Bosch AM, de Widt-Levert LM, Muller S, van der Veen H, Bergers E, de Lange de Klerk ESM, Meijer S, van den Tol MP. Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial. Lancet Oncol 2012; 14:48-54. [PMID: 23218662 DOI: 10.1016/s1470-2045(12)70527-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Breast-conserving surgery for palpable breast cancer is associated with tumour-involved margins in up to 41% of cases and excessively large excision volumes. Ultrasound-guided surgery has the potential to resolve both of these problems, thereby improving surgical accuracy for palpable breast cancer. We aimed to compare ultrasound-guided surgery with the standard for palpable breast cancer-palpation-guided surgery-with respect to margin status and extent of healthy breast tissue resection. METHODS In this randomised controlled trial, patients with palpable T1-T2 invasive breast cancer were recruited from six medical centres in the Netherlands between October, 2010, and March, 2012. Eligible participants were randomly assigned to either ultrasound-guided surgery or palpation-guided surgery in a 1:1 ratio via a computer-generated random sequence and were stratified by study centre. Patients and investigators were aware of treatment assignments. Primary outcomes were surgical margin involvement, need for additional treatment, and excess healthy tissue resection (defined with a calculated resection ratio derived from excision volume and tumour diameter). Data were analysed by intention to treat. This trial is registered at http://www.TrialRegister.nl, number NTR2579. FINDINGS 134 patients were eligible for random allocation. Two (3%) of 65 patients allocated ultrasound-guided surgery had tumour-involved margins compared with 12 (17%) of 69 who were assigned palpation-guided surgery (difference 14%, 95% CI 4-25; p=0·0093). Seven (11%) patients who received ultrasound-guided surgery and 19 (28%) of those who received palpation-guided surgery required additional treatment (17%, 3-30; p=0·015). Ultrasound-guided surgery also resulted in smaller excision volumes (38 [SD 26] vs 57 [41] cm(3); difference 19 cm(3), 95% CI 7-31; p=0·002) and a reduced calculated resection ratio (1·0 [SD 0·5] vs 1·7 [1·2]; difference 0·7, 95% CI 0·4-1·0; p=0·0001) compared with palpation-guided surgery. INTERPRETATION Compared with palpation-guided surgery, ultrasound-guided surgery can significantly lower the proportion of tumour-involved resection margins, thus reducing the need for re-excision, mastectomy, and radiotherapy boost. By achieving optimum resection volumes, ultrasound-guided surgery reduces unnecessary resection of healthy breast tissue and could contribute to improved cosmetic results and quality of life. FUNDING Dutch Pink Ribbon Foundation, Osinga-Kluis Foundation, Toshiba Medical Systems.
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Affiliation(s)
- Nicole M A Krekel
- Department of Surgical Oncology, VU University Medical Center, Amsterdam, Netherlands
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Krekel N, Zonderhuis B, Muller S, Bril H, van Slooten HJ, de Lange de Klerk E, van den Tol P, Meijer S. Excessive resections in breast-conserving surgery: a retrospective multicentre study. Breast J 2012; 17:602-9. [PMID: 22050281 DOI: 10.1111/j.1524-4741.2011.01198.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The main determinant of cosmetic outcomes following breast-conserving surgery (BCS) for breast cancer is the volume of resection. The importance of achieving optimal oncological control may lead to an unnecessarily large resection of breast tissue. The aim of this study is to evaluate excess resection volume in BCS for cancer by determining a calculated resection ratio (CRR). This retrospective study was conducted in four affiliated institutions and involved 726 consecutive patients with T1-T2 invasive breast cancer treated by BCS between January 2006 and 2009. The pathology reports were reviewed for tumor palpability, tumor size, surgical specimen size, and oncological margin status. The optimal resection volume (ORV) was defined as the spherical tumor volume with an added 1.0 cm margin of healthy breast tissue. The total resection volume (TRV) was defined as the ellipsoid volume of the surgical specimen. CRR was determined by dividing the TRV by the ORV. Of all tumors, 72% (525/726) were palpable, and 28% (201/726) were nonpalpable. The tumor stage was T1 in 492 patients (67.8%) and T2 in 234 patients (32.2%). The median CRR was 2.5 (0.01-42.93). Margin status was positive or focally positive in 153 patients (21.1%). Lower tumor stage was associated with a higher CRR (factor 0.61 [p < 0.0001] and a lower positive margin rate [p = 0.064]). Accordingly, the median CRR of the nonpalpable lesions was higher than that of the palpable lesions (3.1 and 2.2, respectively; p < 0.01), and the involved margin rate was lower (17.4% and 22.5%, respectively; p = 0.13). Of patients with a CRR >4.0, 10.7% still had tumor involved margins. This study clearly shows that BCS is associated with excessive resection of healthy breast tissue while clear margins are not assured. Surgical factors should be modified to improve surgical accuracy.
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Affiliation(s)
- Nicole Krekel
- Surgical Oncology, VU University Medical Center, Amsterdam, The Netherlands.
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Doyle TE, Factor RE, Ellefson CL, Sorensen KM, Ambrose BJ, Goodrich JB, Hart VP, Jensen SC, Patel H, Neumayer LA. High-frequency ultrasound for intraoperative margin assessments in breast conservation surgery: a feasibility study. BMC Cancer 2011; 11:444. [PMID: 21992187 PMCID: PMC3209468 DOI: 10.1186/1471-2407-11-444] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 10/12/2011] [Indexed: 12/22/2022] Open
Abstract
Background In addition to breast imaging, ultrasound offers the potential for characterizing and distinguishing between benign and malignant breast tissues due to their different microstructures and material properties. The aim of this study was to determine if high-frequency ultrasound (20-80 MHz) can provide pathology sensitive measurements for the ex vivo detection of cancer in margins during breast conservation surgery. Methods Ultrasonic tests were performed on resected margins and other tissues obtained from 17 patients, resulting in 34 specimens that were classified into 15 pathology categories. Pulse-echo and through-transmission measurements were acquired from a total of 57 sites on the specimens using two single-element 50-MHz transducers. Ultrasonic attenuation and sound speed were obtained from time-domain waveforms. The waveforms were further processed with fast Fourier transforms to provide ultrasonic spectra and cepstra. The ultrasonic measurements and pathology types were analyzed for correlations. The specimens were additionally re-classified into five pathology types to determine specificity and sensitivity values. Results The density of peaks in the ultrasonic spectra, a measure of spectral structure, showed significantly higher values for carcinomas and precancerous pathologies such as atypical ductal hyperplasia than for normal tissue. The slopes of the cepstra for non-malignant pathologies displayed significantly greater values that differentiated them from the normal and malignant tissues. The attenuation coefficients were sensitive to fat necrosis, fibroadenoma, and invasive lobular carcinoma. Specificities and sensitivities for differentiating pathologies from normal tissue were 100% and 86% for lobular carcinomas, 100% and 74% for ductal carcinomas, 80% and 82% for benign pathologies, and 80% and 100% for fat necrosis and adenomas. Specificities and sensitivities were also determined for differentiating each pathology type from the other four using a multivariate analysis. The results yielded specificities and sensitivities of 85% and 86% for lobular carcinomas, 85% and 74% for ductal carcinomas, 100% and 61% for benign pathologies, 84% and 100% for fat necrosis and adenomas, and 98% and 80% for normal tissue. Conclusions Results from high-frequency ultrasonic measurements of human breast tissue specimens indicate that characteristics in the ultrasonic attenuation, spectra, and cepstra can be used to differentiate between normal, benign, and malignant breast pathologies.
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Affiliation(s)
- Timothy E Doyle
- Department of Physics, Utah Valley University, Orem, UT 84058, USA.
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Dixon JM, Renshaw L, Dixon J, Thomas J. Invasive lobular carcinoma: response to neoadjuvant letrozole therapy. Breast Cancer Res Treat 2011; 130:871-7. [DOI: 10.1007/s10549-011-1735-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 08/03/2011] [Indexed: 11/24/2022]
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Fodor J, Major T, Tóth J, Sulyok Z, Polgár C. Comparison of mastectomy with breast-conserving surgery in invasive lobular carcinoma: 15-Year results. Rep Pract Oncol Radiother 2011; 16:227-31. [PMID: 24376985 DOI: 10.1016/j.rpor.2011.06.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Accepted: 06/22/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Invasive lobular cancer (ILC) is biologically distinct from invasive ductal cancer and there is disagreement regarding appropriate local management of this disease. AIM The current study reports long term results comparing mastectomy with breast-conserving surgery (BCS) in the treatment of ILC. MATERIAL AND METHODS Study includes 235 women with ILC treated between 1983 and 1987. All of them underwent axillary dissection and either mastectomy (n = 163) or BCS (n = 72). 50 Gy adjuvant radiotherapy (RT) was given for 53 BCS and 81 mastectomy patients. The BCS group was compared with the mastectomy group. RESULTS Patients treated with mastectomy or BCS had a similar outcome at 15 years with regard to distant metastasis-free (62% vs. 70%; p, 0.2017) and breast cancer-specific (62% vs. 70%; p, 0.1728) survival. In the BCS group the actuarial rate of ipsilateral in breast recurrences was 10% with and 53% without RT at 15 years (relative risk [RR], 0.10; p < 0.0001). In the mastectomy group the actuarial rate of chest wall recurrences was 16% with and 13% without RT at 15 years (RR, 1.45; p, 0.3965). Isolated ipsilateral in breast recurrence did not (RR, 1.73; p, 0.2767) but isolated chest-wall recurrence did (RR, 2.65; p, 0.0089) adversely affect cause-specific survival. CONCLUSION Breast cancer specific survival is not affected by the type of surgical treatment. BCS and RT is a safe option to control local disease in patients with ILC.
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Affiliation(s)
- János Fodor
- Department of Radiotherapy, National Institute of Oncology, Ráth Gy. u. 7-9, Budapest H-1122, Hungary
| | - Tibor Major
- Department of Radiotherapy, National Institute of Oncology, Ráth Gy. u. 7-9, Budapest H-1122, Hungary
| | - József Tóth
- Department of Pathology, National Institute of Oncology, Budapest, Hungary
| | - Zoltán Sulyok
- Department of Surgery, National Institute of Oncology, Budapest, Hungary
| | - Csaba Polgár
- Department of Radiotherapy, National Institute of Oncology, Ráth Gy. u. 7-9, Budapest H-1122, Hungary
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Influence of margin status on outcomes in lobular carcinoma: experience of the European Institute of Oncology. Ann Surg 2011; 253:580-4. [PMID: 21248632 DOI: 10.1097/sla.0b013e31820d9a81] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We analyzed 382 patients with pure lobular carcinoma treated up to 2002 with sufficient follow-up to draw prognostic conclusions, all treated by conservative surgery. Our aim was to evaluate the influence of margin status on outcomes with a view assessing the appropriateness of conservative surgery in this breast cancer subtype. METHODS We assessed locoregional relapse, distant metastasis, contralateral breast cancer, breast cancer-related event free survival, disease-free survival and overall survival according to margin status categorized as at least 10 mm versus less than 10 mm (usually considered negative). RESULTS The proportions of patients with less than 10 mm margins varied significantly with age (P = 0.02), menopausal status (P = 0.006), and tumor size (P = 0.02) but no other characteristic was significantly related to margin status. As regards unfavorable events during follow-up, none differed significantly between at least 10 mm and less than 10 mm margin groups. In particular, there were 11 (3.7%) local relapses in the same quadrant in at least 10 mm margin group compared to 4 (4.6%) in the less than 10 mm margin group, and 7 (2.4%) ipsilateral breast cancers in the 10 mm or more margin group but none in the less than 10 mm group. These findings indicate that minimal residual disease as evidenced by margins less than 10 mm is eradicated by radiotherapy (backed up in selected cases by reexcision, which in this series was always conservative). The rate of contralateral breast cancer was low at 2.9% indicating that prophylactic contralateral mastectomy is not justified. CONCLUSIONS We conclude that the surgical approach and criteria for adjuvant hormonal and systemic treatment in lobular carcinoma should be the same as for ductal carcinoma, provided that adequate preoperative investigations exclude extensive multifocal and contralateral disease.
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Sakr R, Poulet B, Kaufman G, Nos C, Clough K. Clear margins for invasive lobular carcinoma: A surgical challenge. Eur J Surg Oncol 2011; 37:350-6. [DOI: 10.1016/j.ejso.2011.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 12/29/2010] [Accepted: 01/06/2011] [Indexed: 11/27/2022] Open
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Ward ST, Jones BG, Jewkes AJ. A two-millimetre free margin from invasive tumour minimises residual disease in breast-conserving surgery. Int J Clin Pract 2010; 64:1675-80. [PMID: 20946273 DOI: 10.1111/j.1742-1241.2010.02508.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS In breast-conserving surgery, the width of free margin around a tumour to ensure adequate excision is controversial. The aim of this study was first to evaluate the frequency of residual disease in wider excision specimens in patients who undergo further surgery because of close margins of < 5 mm. Secondly, the ability of demographic and tumour-related factors to predict the close margins was appraised. PATIENTS AND METHODS Three-hundred-and-three patients were included in the study. Patients undergoing wider excision were assessed for the presence of residual disease, and this was tested for association with the width of the initial free margin. Various factors were studied for association with close or involved margins by univariate analysis. RESULTS Fifty-three per cent of patients were eligible for re-excision based on the need for a 5-mm clearance. With a free margin of 2 mm or more from invasive tumour, the probability of finding residual disease was 2.4%. The probability of residual disease was higher for ductal carcinoma in situ (DCIS) and did not decline with increasing the free margin width. Tumour size, lobular cancer type, vascular invasion and nodal involvement were associated with close margins. CONCLUSIONS We suggest that a free margin of 2 mm from invasive tumour is adequate to minimise residual disease, whereas the equivalent free margin for DCIS remains unclear. Patients with large tumours and lobular cancer type should be counselled at the time of first surgery concerning the higher risk of further excision and mastectomy.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm, Residual
- Reoperation
- Risk Factors
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Affiliation(s)
- S T Ward
- Department of Breast Surgery, Good Hope Hospital, Sutton Coldfield, West Midlands, UK.
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Arora N, King TA, Jacks LM, Stempel MM, Patil S, Morris E, Morrow M. Impact of Breast Density on the Presenting Features of Malignancy. Ann Surg Oncol 2010; 17 Suppl 3:211-8. [DOI: 10.1245/s10434-010-1237-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Indexed: 01/02/2023]
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Preoperative cytological and histological diagnosis of breast lesions: A critical review. Eur J Surg Oncol 2010; 36:934-40. [PMID: 20709485 DOI: 10.1016/j.ejso.2010.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 05/20/2010] [Accepted: 06/07/2010] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Non-operative pathology diagnoses constitute an essential part of the work-up of breast lesions. With fine needle aspiration (FNA) and core needle biopsy (CNB) both having unique advantages, there is an increasing acceptance of CNB. This paper aims to outline the scientific basis of this trend. Additionally, we provide an update on novel techniques that derive cytological specimens from CNB (i.e., touch imprint (TI) and core wash (CW) cytology) in an attempt to get the best of both worlds. METHODS In addition to using the authors' experience, we performed a search of the Medline database combining the search terms "breast cancer diagnosis", "core needle biopsy", "fine needle aspiration", "touch imprint cytology", "core wash cytology" and "complications". We defined a conclusive non-operative diagnosis as "malignant" in lesions that were malignant on follow-up and "benign" in lesions that were benign on follow-up. RESULTS CNB was more often conclusive than FNA in benign and malignant lesions in 4 prospective studies. Although the more rapid diagnoses by FNA result in less patient anxiety during diagnostic work-up, CNB allows for fairly reliable estimation of invasion, histological type, grade, and receptor expression. CW and TI cytology seem promising techniques with conclusiveness rates that are roughly comparable to that of FNA. CONCLUSIONS All new suspicious breast lesions require careful non-operative investigation by CNB. However, additional cytological assessment by FNA can still be useful as a same-day diagnosis decreases patient anxiety and facilitates surgical treatment planning. TI and CW cytology techniques are promising same-day diagnosis modalities.
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Khan SA, Eladoumikdachi F. Optimal surgical treatment of breast cancer: Implications for local control and survival. J Surg Oncol 2010; 101:677-86. [DOI: 10.1002/jso.21502] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hodi Z, Ellis IO, Elston CW, Pinder SE, Donovan G, Macmillan RD, Lee AHS. Comparison of margin assessment by radial and shave sections in wide local excision specimens for invasive carcinoma of the breast. Histopathology 2010; 56:573-80. [DOI: 10.1111/j.1365-2559.2010.03518.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Silberfein EJ, Hunt KK, Broglio K, Shen J, Sahin A, Le-Petross H, Oh J, Litton J, Hwang RF, Mittendorf EA. Clinicopathologic factors associated with involved margins after breast-conserving surgery for invasive lobular carcinoma. Clin Breast Cancer 2010; 10:52-8. [PMID: 20133259 DOI: 10.3816/cbc.2010.n.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Obtaining negative margins for patients undergoing breast-conserving surgery (BCS) for invasive lobular carcinoma (ILC) can be difficult because of the unique histologic pattern of ILC. Our goal was to determine whether any specific patient- or disease-related factors influenced margin status. PATIENTS AND METHODS We retrospectively reviewed 211 patients with ILC treated from 1994 through 2004 to determine if specific clinical and pathologic factors influenced the ability to obtain negative margins. RESULTS We identified 110 patients (52%) who underwent total mastectomy and 101 (48%) who underwent BCS. Among patients who underwent BCS, 50 (50%) had close or positive margins. Patients with close or positive margins were more likely to have architectural distortion on ultrasonography (vs. mass or calcifications; P = .049), to have undergone excisional biopsy (vs. core or fine-needle aspiration; P = .008), and to have associated ductal carcinoma in situ (P = .021). On multivariate analysis, only biopsy method retained significance (P = .006). CONCLUSION Core needle biopsy is the preferred method of diagnostic biopsy before surgical intervention. With appropriate patient selection, most patients with early-stage ILC can undergo successful BCS.
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Affiliation(s)
- Eric J Silberfein
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA
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Jobsen J, Riemersma S, van der Palen J, Ong F, Jonkman A, Struikmans H. The impact of margin status in breast-conserving therapy for lobular carcinoma is age related. Eur J Surg Oncol 2010; 36:176-81. [DOI: 10.1016/j.ejso.2009.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Revised: 05/26/2009] [Accepted: 06/02/2009] [Indexed: 11/25/2022] Open
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Moran MS, Yang Q, Haffty BG. The Yale University Experience of Early-Stage Invasive Lobular Carcinoma (ILC) and Invasive Ductal Carcinoma (IDC) Treated with Breast Conservation Treatment (BCT): Analysis of Clinical-Pathologic Features, Long-Term Outcomes, and Molecular Expression of COX-2, Bcl-2, and p53 as a Function of Histology. Breast J 2009; 15:571-8. [DOI: 10.1111/j.1524-4741.2009.00833.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McGuire KP, Santillan AA, Kaur P, Meade T, Parbhoo J, Mathias M, Shamehdi C, Davis M, Ramos D, Cox CE. Are Mastectomies on the Rise? A 13-Year Trend Analysis of the Selection of Mastectomy Versus Breast Conservation Therapy in 5865 Patients. Ann Surg Oncol 2009; 16:2682-90. [PMID: 19653046 DOI: 10.1245/s10434-009-0635-x] [Citation(s) in RCA: 255] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Revised: 05/06/2009] [Accepted: 05/07/2009] [Indexed: 02/06/2023]
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/secondary
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/secondary
- Carcinoma, Lobular/surgery
- Female
- Humans
- Mastectomy, Segmental/statistics & numerical data
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Staging
- Patient Preference
- Prognosis
- Prospective Studies
- Retrospective Studies
- Time Factors
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Wagner J, Boughey JC, Garrett B, Babiera G, Kuerer H, Meric-Bernstam F, Singletary E, Hunt KK, Middleton LP, Bedrosian I. Margin assessment after neoadjuvant chemotherapy in invasive lobular cancer. Am J Surg 2009; 198:387-91. [PMID: 19362281 DOI: 10.1016/j.amjsurg.2009.01.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 01/07/2009] [Accepted: 01/15/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND Optimal surgical management of patients with invasive lobular carcinoma (ILC) who undergo neoadjuvant chemotherapy (NAC) is unknown. We evaluated optimal margin distance and local recurrence (LR) rates for these patients. METHODS Ninety-three (30%) of 311 patients with ILC received NAC. We examined margin status, residual disease after re-excision, and clinical outcomes. RESULTS Margin positivity rates after the final operative procedure were similar between the NAC and surgery-first group (P > .05). The proportion of patients, stratified by margin status, who were taken back for re-excision was not different between the 2 groups, and, similarly, there were no differences in frequency of residual disease (all P > .05). At a median follow-up of 3.1 years, 1 patient in the NAC group and 2 in the surgery-first group developed LR (P = 1.0). CONCLUSIONS Patients with ILC who have undergone NAC and have margins >1 mm have a low probability of residual disease and LR.
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Affiliation(s)
- Jamie Wagner
- Department of Surgical Oncology, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030, USA
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Diepenmaat LA, van der Sangen MJC, van de Poll-Franse LV, van Beek MWPM, van Berlo CLH, Luiten EJT, Nieuwenhuijzen GAP, Voogd AC. The impact of postmastectomy radiotherapy on local control in patients with invasive lobular breast cancer. Radiother Oncol 2008; 91:49-53. [PMID: 18950883 DOI: 10.1016/j.radonc.2008.09.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 09/10/2008] [Accepted: 09/23/2008] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of this population-based study was to examine the impact of postmastectomy radiotherapy on the risk of local recurrence in patients with invasive lobular breast cancer (ILC). METHODS The population-based Eindhoven Cancer Registry was used to select all patients with ILC, who underwent mastectomy in five general hospitals in the southern part of the Netherlands between 1995 and 2002. Of the 499 patients 383 patients fulfilled the eligibility criteria. Of these patients, 170 (44.4%) had received postmastectomy radiotherapy. The median follow-up was 7.2 years. Fourteen patients (3.7%) were lost to follow-up. RESULTS During follow-up 22 patients developed a local recurrence, of whom 4 had received postmastectomy radiotherapy. The 5-year actuarial risk of local recurrence was 2.1% for the patients with and 8.7% for the patients without postmastectomy radiotherapy. After adjustment for age at diagnosis, tumour stage and adjuvant systemic treatment, the patients who underwent postmastectomy radiotherapy were found to have a more than 3 times lower risk of local recurrence compared to the patients without (Hazard Ratio 0.30; 95% Confidence Interval: 0.10-0.89). CONCLUSION Local control is excellent for patients with ILC who undergo postmastectomy radiotherapy and significantly better than for patients not receiving radiotherapy.
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Affiliation(s)
- Lindy A Diepenmaat
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Kurniawan ED, Wong MH, Windle I, Rose A, Mou A, Buchanan M, Collins JP, Miller JA, Gruen RL, Mann GB. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol 2008; 15:2542-9. [PMID: 18618180 DOI: 10.1245/s10434-008-0054-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Revised: 05/24/2008] [Accepted: 05/24/2008] [Indexed: 01/29/2023]
Abstract
BACKGROUND Breast-conserving surgery (BCS) requires clear surgical margins to minimize local recurrence. We sought to identify groups of patients at higher risk of involved margins who might benefit from preoperative counselling and/or more generous excision at the first operation. METHODS We reviewed demographic, clinical, radiological and pathological records of all women diagnosed with ductal carcinoma in situ (DCIS) or invasive cancer (IC) through a population-based breast screening program in Melbourne, Australia between 1994 and 2005. RESULTS A total of 2,160 women were diagnosed with DCIS or IC. We excluded 199 who had mastectomy (TM) as initial procedure or had missing data. Three hundred and thirteen had a diagnostic biopsy. Of 1,648 women who had BCS after a preoperative diagnosis of DCIS or IC, 13.5% had involved margins, 16.6% had close (</=1 mm), and 69.8% clear (>1 mm) margins. Of the patients, 281/1,648 (17.1%) underwent re-excision, of whom 93 (33.1%) had residual disease identified. Mammographic microcalcifications (P < 0.0001), absence of a mammographic mass (P = 0.002), presence of DCIS (P < 0.0001), high tumour grade (P < 0.0001), large size (P < 0.0001), multifocal disease (P < 0.0001) and lobular histology (P = 0.005) were associated with involved margins. Microcalcifications (odds ratio [OR] 1.97), large size (OR 4.22) and multifocal disease (OR 2.85) were independently associated with involved margins. Residual disease was associated with involved margins (P < 0.0001), presence of DCIS (P = 0.05) and large tumour size (P = 0.01). CONCLUSION After BCS, patients with mammographic microcalcifications, larger tumour size and multifocal tumours are more likely to have involved margins. Patients with involved margins, large tumour size and/or a DCIS component are more likely to have residual disease on re-excision.
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Affiliation(s)
- Emil D Kurniawan
- Department of Surgery, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, 3050, Australia
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Surgical Margins in Breast-Conservation Operations for Invasive Carcinoma: Does Neoadjuvant Chemotherapy Have an Impact? J Am Coll Surg 2008; 206:1116-21. [DOI: 10.1016/j.jamcollsurg.2007.12.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Revised: 12/21/2007] [Accepted: 12/26/2007] [Indexed: 11/20/2022]
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O’Donnell M, Salem A, Badger S, Sharif M, Lioe T, Spence R. Completion mastectomy after breast conserving surgery. Breast 2008; 17:199-204. [DOI: 10.1016/j.breast.2007.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Revised: 09/12/2007] [Accepted: 10/08/2007] [Indexed: 11/26/2022] Open
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