A multi-institutional analysis of intraoperative radiotherapy for early breast cancer: Does age matter?

BACKGROUND

Single-session intraoperative radiation therapy (IORT) minimizes treatment demands associated with traditional whole breast radiation therapy (WBRT) but outcomes on local disease control and morbidity among the elderly is limited.

METHODS

A multi-institutional retrospective registry was established from 19 centers utilizing IORT from 2007 to 2013. Patient, tumor, and treatment variables were analyzed for ages <70 and ≥70.

RESULTS

We evaluated 686 patients (<70 = 424; ≥70 = 262) who were margin and lymph node negative. Patients <70 were more likely to have longer operative time, oncoplastic closure, higher rates of IORT used as planned boost, and receive chemotherapy and post-operative WBRT. Wound complication rates were low and not significantly different between age groups. Median follow-up was 1.06 (range 0.51-1.9) years for < 70 and 1.01 (range 0.5-1.68) years for ≥ 70. There were 5 (0.73%) breast recurrences (4 in <70 and 1 ≥ 70, p = 0.65) and no axillary recurrences during follow-up.

CONCLUSIONS

IORT was associated with a low rate of wound complication and local recurrence on short-term follow-up in this cohort.

Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study

BACKGROUND

Breast-conserving surgery (BCS) is considered the standard treatment for early-stage breast cancer. However, fair to poor cosmetic outcomes following conventional BCS have been observed in as many as one-third of cases. The aim of this study was to determine the critical tumor-to-breast volume ratio for each quadrant of the breast beyond which conventional BCS would no longer offer acceptable cosmetic and functional results or satisfactory quality of life for the patient.

METHODS

A prospective cohort study was performed between December 2011 and December 2013 involving 350 patients younger than 70 years with early-stage unifocal (T ≤ 30 mm) breast cancer who underwent wide excision and axillary sentinel lymph node biopsy followed by whole-breast irradiation. Using validated panels and software (the Breast Cancer Treatment Outcome Scale [BCTOS], EORTC Cancer Quality of Life Questionnaire number C30-BR23, and Breast Cancer Conservative Treatment - cosmetic results [BCCT.core] software), quality of life and aesthetic and functional parameters and their changes in correlation to the percentage of breast volume excised were statistically analyzed.

RESULTS

The maximum percentages of breast volume that were resectable by conventional BCS without resulting in unacceptable aesthetic and functional outcomes or decreased quality of life were 18-19% in the upper-outer quadrant (p < 0.0001), 14-15% in the lower-outer quadrant (p < 0.0001), 8-9% in the upper-inner quadrant (p < 0.0001), and 9-10% in the lower-inner quadrant (p < 0.0001).

CONCLUSION

Aided by the calculated cut-off values for each breast quadrant, breast surgeons might render more objective decisions regarding performing conventional BCS, using oncoplastic techniques or choosing mastectomy with immediate reconstruction.

Does breast screening offer a survival benefit? A retrospective comparative study of oncological outcomes of screen-detected and symptomatic early stage breast cancer cases

INTRODUCTION

Mammography screening reduces breast cancer mortality by up to 32%. However, some recent studies have questioned the impact of non-palpable breast cancer detection on mortality reduction. The aim of this study was to analyse the clinicopathological and long-term follow-up data of early stage screened and symptomatic breast cancer patients.

PATIENTS AND METHOD

The institutional prospectively led database was systematically analysed for breast cancer cases diagnosed via the mammography screening program from 2002 to 2009. As a control group, symptomatic early stage breast cancer patients were collected randomly from the same database and matched for age and follow-up period. All medical records were reviewed retrospectively.

RESULTS

Data from 298 breast cancer patients were collected from 47,718 mammography screenings. In addition, 331 symptomatic breast cancer patients were randomly selected. The screened group presented a significantly lower median tumour size (P < 0.00001). The incidence of negative regional lymph nodes was significantly higher in the screened group (P < 0.0006). The incidence of chemotherapy was 17% higher in the symptomatic group (P = 4*10^-5). At the median follow-up of 65 and 80 months, the screened group did not exhibit better overall (P = 0.717) or disease-free survival (P = 0.081) compared to the symptomatic group.

CONCLUSION

Our results do not suggest that mammography screening does not reduce breast cancer mortality but the mammography screening did not bring any significant improvement in patient overall or disease-free survival for the early stage breast cancer patients compared to the symptomatic group. The drawback of symptomatic early stage tumours compared to non-palpable tumours could be equalized by modern multimodality oncology treatments.

Association of CETP polymorphisms with the risk of vascular dementia and white matter lesions

Cholesteryl ester transfer protein (CETP), a component of the high density lipoprotein (HDL), plays a central role in reverse cholesterol transport. We investigated the association of two putative functional CETP polymorphisms (C-629A and I405V) with the risk of vascular dementia (VD) and tested if this association is influenced by the presence of APOE4 allele. Our study included 163 VD patients (mean age: 74.25 +/- 7.9 years) and 452 cognitively healthy probands (mean age: 70.81 +/- 7.9 years). As a biological correlate, the association of CETP gene variants with white matter lesion (WML) load was investigated. Neither the C-629A (P = 0.169) nor the I405V (P = 0.840) polymorphism was associated with VD risk in the whole sample. However, in non-carriers of the APOE4 allele, homozygote carriers of the CETP C-629A A allele presented with an increased risk of VD (P = 0.01). Whereas in APOE4 carriers, no association of CETP polymorphisms with VD risk was detected. In addition, carriers of the CETP C-629A AA genotype presented with decreased WML load in the frontal brain (P = 0.009). Our results suggest that CETP gene polymorphisms might influence WML load and the risk of VD, the latter in non-carriers of the APOE4 allele.

Gene variations in GSTM3 are a risk factor for Alzheimer's disease

Oxidative stress is a relevant pathomechanism in Alzheimer's disease (AD) and gene variations in the glutathione S-transferase M3 gene (GSTM3), involved in the detoxification of oxygen radicals, might influence the risk of AD. We investigated the effect of three polymorphisms in GSTM3: rs1332018 (C/A); rs1799735 (del/AGG); rs7483 (G/A), on the risk of AD in 363 AD patients and 358 healthy controls. Single marker association analyses revealed that the AGG/AGG genotype of the GSTM3 rs1799735 (del/AGG) polymorphism was associated with an increased risk of AD (p=0.05), especially in the group of APOE4-allele non-carriers (p=0.004; OR=2.07). Examination of the haplotypes identified a two-marker haplotype (C/AGG) consisting of rs1332018 (C/A) and rs1799735 (del/AGG) to increase the risk of AD (p=0.029), this effect was also most prevalent in APOE4-allele non-carriers (p=0.009; OR=1.95). The population attributable risk of this haplotype in APOE4-allele non-carriers was 32.2%. Our results suggest that there is a group of AD patients in which variations in metabolism of oxidative stress play an important role.

Cowden Syndrome as an indication for bilateral prophyllactic mastectomy: A series of two cases

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Background: Multiple hamartoma syndrome, or Cowden Syndrome, is an autosomal dominant disorder which predisposes toward neoplasms in the thyroid, colon, and breast. Chemoprevention in women with a genetic predisposition toward breast cancer has not yet been shown to be beneficial in prospective data. Bilateral prophylactic mastectomy (BMP) has emerged as a viable option for women with suspected genetic predispositions toward breast cancer, with an estimated risk reduction of around 90 percent. Our search of the literature has not detected any case series of BMP in the Cowden Syndrome patients. Methods: We present two women presenting with historical and physical evidence for this Cowden Syndrome with desire to undergoing PBM. Results: Both women successfully underwent subcutaneous bilateral mastectomy with immediate reconstruction. (See table ) They are both alive without evidence of breast cancer to date. Conclusions: Cowden Syndrome can be added to other genetic syndromes with clear predispositions toward breast cancer, and presents an option for prophylactic bilateral mastectomy in women who desire a risk reduction for breast cancer.

[Table: see text]

No significant financial relationships to disclose.

Modified tensor fascia lata musculofasciocutaneous flap for the coverage of trochanteric pressure sores

The method most frequently used for the coverage of trochanteric pressure sores is the tensor fascia lata (TFL) flap. The authors introduce a new, hatchet-shaped incision strategy for the TFL flap, which preserves the safe blood supply of the flap and keeps the flap mobile enough. The part of the flap including the muscle is adapted to the greater trochanter. This provides a good aesthetic result without dog-ear formation at the rotation point of the flap. The donor site is closed in a V-Y fashion, and the closure does not require any skin grafting or designing a local flap. The TFL hatchet flap was used nine times on eight patients to cover trochanteric pressure sores. With one exception all patients healed. No recurrence was observed during the follow-up period, and no contour difference developed on the lateral aspect of the thigh.

[The Hungarian translation of the "Dental Fear Survey" based on the Hungarian population]

Authors translated the "Dental Fear Survey" (DFS) into Hungarian. 196 persons have been investigated and the DFS values have been compared to DAS, STAI-S, STAI-T values. Mean values were: DFS: 46.27; DAS: 12.24; STAI-S: 41.58; STAI-T: 42.68. Authors found all values higher in the case of women comparing to men. Positive correlation has been found between DAS and DFS, but STAI-S and STAI-T increased only moderately comparing to the DAS and DFS values.

Universal application of intraoperative lymphatic mapping and sentinel lymphadenectomy in solid neoplasms

PURPOSE

Regional lymph node involvement is the most important prognostic indicator in patients with solid tumors. Conventional lymph node dissection has not been shown to affect survival and is often associated with considerable morbidity. Intraoperative lymphatic mapping and sentinel lymph node dissection were therefore designed as a minimally invasive alternative to routine elective lymph node dissection in patients with primary cutaneous melanoma. This study examined whether introperative lymphatic mapping and sentinel lymph node dissection were accurate in staging patients with other solid malignancies.

PATIENTS AND METHODS

Between 1985 and 1998, 107 patients with breast cancer, 17 with thyroid tumors, 14 with gastrointestinal/gynecologic cancers, six with Merkel cell cancers, and five with squamous cell carcinomas of the head and neck have undergone mapping and sentinel lymph node dissection at the John Wayne Cancer Institute.

RESULTS

The sentinel node was identified in 96% of patients (98% melanoma). In 36% of patients the sentinel node was the only tumor-positive node (71% melanoma). Eighteen percent of sentinel nodes were negative by hematoxylin and eosin staining but were positive by immunohistochemical staining (15% melanoma).

CONCLUSION

These data suggest that many solid neoplasms have a primary lymphatic channel and lymph node to which it drains. Although sentinel lymph node dissection has been popularized in melanoma therapy, we have found it feasible for treatment of other solid malignancies. This technique may ultimately replace conventional dissection with more accurate staging.

[Introduction of the concept of Dental Anxiety Scale in Hungary. Epidemiologic studies on the Hungarian population]

Authors translated the Corah's "Dental Anxiety Scale" (DAS) into Hungarian. 143 dental patients, and 74 dental student's, were investigated and the DAS values were compared to the State-Trait Anxiety Invertory (STAI-S and STAI-T) values. Mean values were: DAS: 9.92, STAI-S: 39.17, STAI-T: 41.34. Authors found lower scores in the case of dental students comparing to patients (p < 0.001), and women comparing to men (p < 0.001). DAS values increased slowly with age, and decreased at 60 years old, or older patients. Married patients had higher DAS and STAI-S scores, but lower STAI-T scores comparing to the unmarried and divorced patients.

[The use of hypnosis in stomatology]

It follows from the fore going that hypnosis itself can not cure, but it is a great possibility to use it as a supplementary method and a curing means in our practice. The treatment is applicable for stomatological interventions, and somatic diseases of psychic origin which have connections on our field. Thus hypnosis can effect out therapeutic-work very favourable.