[Management of nipple-areolar complex anomalies]

Nipple-areolar complex anomalies may be secondary to many etiologies from simple anatomic variations to malignant processes as Paget disease or invasive breast cancer, passing through benign locally aggressive processes as erosive adenomatosis of the nipple. Differential diagnosis is not always simple. If clinical exam and standard radiological checkup can't confirm the benignity of the lesion, a biopsy specimen will be obtained to allow an anatomopathological examination. A precise diagnosis can then be made leading to optimal management. This paper describes how to explore nipple-areolar complex anomalies through an uncommon clinical case associating independently an invasive retro-areolar cancer and a dermatological disease of the areola mimicking a Paget disease.

From modified radical mastectomy to infra-radical mastectomy: a phase I study for surgical de-escalation focusing on pathological analyses

Background

Despite that breast conservative therapy became the standard of care in breast cancer, modified radical mastectomy, a large mutilating surgery, is still required for an important number of patients. In order to improve the quality of life and the psychological aspects of a surgery involving the femininity of woman, we developed a new less invasive procedure called infra-radical mastectomy. It aims to save the neckline of patients by the maintenance of the peripheral skin-fatty flap that constitutes the base for implantation of the breast. This phase I study analyzed the feasibility of this procedure using outcome of anatomo-pathological analyses as primary endpoint.

Methods

Between March 2015 and July 2017, all women with operable breast cancer without signs of lymph node invasion were invited to participate in the study in the 2 participating institutions. After a water-assisted dissection of the peri-glandular space, an enucleation of the breast was performed by a cold knife which represents the infra-radical mastectomy. A peri-glandular re-excision (PGR) of the skin and the fat tissue surrounding the gland was then achieved to obtain an MRM. This PGR underwent a careful pathological examination (10 samples per patient). Moreover, the tissue volume and the skin surface of the PGR were quantified.

Results

A total of 53 patients (median age: 60 years) were prospectively recruited. The pathological analysis of peri-glandular biopsies revealed none residual invasive carcinoma, 1% of biopsies contained focal ductal carcinoma in situ (DCIS) and 0.4% atypical hyperplasia corresponding to 4 and 2 patients respectively. These 4 patients with residual DCIS were preoperatively diagnosed with extensive DCIS. On average after an infra-radical mastectomy, 37% of the volume and 53% of the skin surface of a complete modified radical mastectomy were sparred.

Conclusions

The evaluation of biopsies from peri-glandular tissue suggests that infra-radical mastectomy should be further evaluated except for patients diagnosed with extensive DCIS which must be excluded of this infra-radical approach. Additional work is needed to evaluate cosmetic outcome and impact on quality of life, the need of radiotherapy and the oncological long-term outcome.

[Breast cancer : individualized risk assessment for tailor-made screening]

Breast cancer is the leading cause of neoplastic death in women around the world. In the era of personalized medicine, legitimately awaited by our patients, the future of breast cancer screening will depend on an individual-based risk assessment, making it possible to better adapt the age of onset, frequency and the type of examinations useful for this screening. This article reviews the three broad categories of highest risk factors available to establish a risk score appropriate for each patient.

A Nonrandomized Comparison Study of Self-Hypnosis, Yoga, and Cognitive-Behavioral Therapy to Reduce Emotional Distress in Breast Cancer Patients

The authors asked breast cancer (BC) patients to participate in 1 of 3 mind-body interventions (cognitive-behavioral therapy (CBT), yoga, or self-hypnosis) to explore their feasibility, ease of compliance, and impact on the participants' distress, quality of life (QoL), sleep, and mental adjustment. Ninety-nine patients completed an intervention (CBT: n = 10; yoga: n = 21; and self-hypnosis: n = 68). Results showed high feasibility and high compliance. After the interventions, there was no significant effect in the CBT group but significant positive effects on distress in the yoga and self-hypnosis groups, and, also, on QoL, sleep, and mental adjustment in the self-hypnosis group. In conclusion, mind-body interventions can decrease distress in BC patients, but RCTs are needed to confirm these findings.

Multidisciplinary rehabilitation program after breast cancer: benefits on physical function, anthropometry and quality of life

BACKGROUND

Different clinical trials show beneficial effects of physical training offered during and/or after breast cancer treatment. However, given the variety of side effects that may be encountered, physical training could be combined with psychological, relational and social guidance. This kind of multidisciplinary program has been little studied so far.

AIM

The aim of this study was to determine the benefits of a three-month multidisciplinary rehabilitation program among women after breast cancer treatment.

DESIGN

Controlled no-randomized trial.

SETTING

University for outcomes, University Hospital Center for interventions.

POPULATION

Two hundred and nine outpatients who have been treated for a primary breast carcinoma.

METHODS

Patients were divided into a control group (N.=106) and an experimental group (N.=103) which has benefited from a rehabilitation program of three months including physical training and psycho-educational sessions. The assessments, performed before and after the program, included functional assessments ("Sit and Reach Test", maximal incremental exercise test and "Six-Minute Walk Test"), body composition measurements (Body Mass Index [BMI] and body fat percentage) and a questionnaire (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30).

RESULTS

After three months, flexibility, walking distance and all parameters measured during the maximal incremental exercise, except maximal heart rate, were significantly improved in the experimental group. The body fat percentage was significantly decreased and a significant improvement was observed for perceived health status (quality of life), functional role, emotional state, physical, cognitive and social functions and for most symptoms. In the control group, most of these improvements didn't appear and a significant increase in BMI and body fat percentage was observed.

CONCLUSIONS

This trial identifies the benefits of a well detailed multidisciplinary rehabilitation program, including physical re-conditioning and psycho-educational sessions, with important improvements in functional capacity, body composition and the majority of functions and symptoms among women after breast cancer treatment.

CLINICAL REHABILITATION IMPACT

Through its results, this study could contribute to the development of hospital quality standards for oncologic rehabilitation. Physiotherapists can efficiently propose this kind of multidisciplinary rehabilitation program.

Abstract P3-13-22: Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer

Background: Surgical procedures in breast cancer have become less aggressive. However, around one in three patients must undergo modified radical mastectomy (MRM). We evaluated if infraradical mastectomy (IFM), which preserves the skin and fat tissues surrounding the breast, is safe. IFM has the potential to preserve neck opening and by the way femininity of patients. Aesthetic results obtained after breast reconstruction are also expected to be improved.

Objective: The primary objective of this phase 1 trial is to evaluate the feasibility and safety of IFM.

Methods: Patients were recruited in two specialized breast clinics. We performed enucleation with a cold knife to the mammary gland after a water-assisted dissection of the periglandular space using a dedicated tool. In a second step we removed the peripheral skin and fat tissue which surrounded the gland to obtain a classical MRM. Fat tissue removed in the second step underwent a careful pathological examination (10 biopsies) in order to evaluate residual invasive or in situ breast cancer and atypical hyperplasia. We also evaluated which is the percentage of tissue and skin removed in the second step with regard to the global surgical specimen because that could be left in the future if the procedure is declared safe.

Results: A total of 35 patients (43 to 80 years old) were prospectively recruited from March 2015 to March 2016. The distribution of tumor type was: pTis 2.9%, pT1 45.7%, pT2 45.7% and pT3 5.7%. Pathological analysis of the periglandular tissue removed in the second step revealed: 0% invasive carcinoma, 1% focal ductal carcinoma in situ (DCIS), and 0% atypical hyperplasia. On average, the weight of an IFM was 37% lower compared to the weight of a MRM. Skin resection was reduced by 48% with IFM. No serious adverse event was observed.

Conclusions: Preliminary results are promising. Our phase 1 trial suggests that the procedure is safe concerning premalignant or malignant disease left after IFM. Moreover, a high quantity of skin and fat tissue is saved by IFM. We are now recruiting a second cohort of patients in order to confirm these results. In addition, we will also quantify the amount of mammary glands left around IFM compared to MRM by performing additional biopsies and quantitative evaluation by pathologists.

Presurgical selection criteria have been modified for the second cohort in order to avoid residual DCIS left after IFM. After this second cohort, we plan to begin a large prospective randomized phase 3 trial with long-term disease-free survival and aesthetic results as the primary endpoints.

Citation Format: Coibion M, Lifrange E, Jossa V, Mutijima E, Crevecoeur A, Olivier F, Di Bella J, Jerusalem G. Should modified radical mastectomy be modified? A phase 1 study to evaluate infraradical mastectomy for invasive breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-13-22.

[A new approach to breast cancer screening]

We tested, in the Province of Liege, an original approach that tends to individualize mass screening for breast cancer considering breast density and the notion of higher risk. We compared the previous recommendations (January to June 2012) in the age ranges of 40-49 years (n = 1.730) and 70-74 years (n = 286) to the new recommendations (June 2012 - December 2014) in the age ranges of 40-49 years (n = 11.123) and 70-74 years (n = 2.008). With the new recommendations, 38 % of women aged 40 to 49 years will benefit from a biennial invitation to screening due to a mainly greasy nature of their breasts (BI-RADS 1 and 2), while 11 % are classified BI-RADS 3 and 1 % BI-RADS 4 and are invited to perform an ultrasound to increase the screening sensitivity. A complete breast screening is offered to 6 % of women aged 40-49 years in view of a positive family history, and to 0.3 % of women aged 40-49 years and 8 % of women 70-74 years with a higher risk personal history. This individualized approach of mass screening is easily feasible from a practical viewpoint and the detection rate of breast cancers is increased.

Circulating microRNA-based screening tool for breast cancer

Circulating microRNAs (miRNAs) are increasingly recognized as powerful biomarkers in several pathologies, including breast cancer. Here, their plasmatic levels were measured to be used as an alternative screening procedure to mammography for breast cancer diagnosis.

A plasma miRNA profile was determined by RT-qPCR in a cohort of 378 women. A diagnostic model was designed based on the expression of 8 miRNAs measured first in a profiling cohort composed of 41 primary breast cancers and 45 controls, and further validated in diverse cohorts composed of 108 primary breast cancers, 88 controls, 35 breast cancers in remission, 31 metastatic breast cancers and 30 gynecologic tumors.

A receiver operating characteristic curve derived from the 8-miRNA random forest based diagnostic tool exhibited an area under the curve of 0.81. The accuracy of the diagnostic tool remained unchanged considering age and tumor stage. The miRNA signature correctly identified patients with metastatic breast cancer. The use of the classification model on cohorts of patients with breast cancers in remission and with gynecologic cancers yielded prediction distributions similar to that of the control group.

Using a multivariate supervised learning method and a set of 8 circulating miRNAs, we designed an accurate, minimally invasive screening tool for breast cancer.

Asporin Is a Fibroblast-Derived TGF-β1 Inhibitor and a Tumor Suppressor Associated with Good Prognosis in Breast Cancer

BACKGROUND

Breast cancer is a leading malignancy affecting the female population worldwide. Most morbidity is caused by metastases that remain incurable to date. TGF-β1 has been identified as a key driving force behind metastatic breast cancer, with promising therapeutic implications.

METHODS AND FINDINGS

Employing immunohistochemistry (IHC) analysis, we report, to our knowledge for the first time, that asporin is overexpressed in the stroma of most human breast cancers and is not expressed in normal breast tissue. In vitro, asporin is secreted by breast fibroblasts upon exposure to conditioned medium from some but not all human breast cancer cells. While hormone receptor (HR) positive cells cause strong asporin expression, triple-negative breast cancer (TNBC) cells suppress it. Further, our findings show that soluble IL-1β, secreted by TNBC cells, is responsible for inhibiting asporin in normal and cancer-associated fibroblasts. Using recombinant protein, as well as a synthetic peptide fragment, we demonstrate the ability of asporin to inhibit TGF-β1-mediated SMAD2 phosphorylation, epithelial to mesenchymal transition, and stemness in breast cancer cells. In two in vivo murine models of TNBC, we observed that tumors expressing asporin exhibit significantly reduced growth (2-fold; p = 0.01) and metastatic properties (3-fold; p = 0.045). A retrospective IHC study performed on human breast carcinoma (n = 180) demonstrates that asporin expression is lowest in TNBC and HER2+ tumors, while HR+ tumors have significantly higher asporin expression (4-fold; p = 0.001). Assessment of asporin expression and patient outcome (n = 60; 10-y follow-up) shows that low protein levels in the primary breast lesion significantly delineate patients with bad outcome regardless of the tumor HR status (area under the curve = 0.87; 95% CI 0.78-0.96; p = 0.0001). Survival analysis, based on gene expression (n = 375; 25-y follow-up), confirmed that low asporin levels are associated with a reduced likelihood of survival (hazard ratio = 0.58; 95% CI 0.37-0.91; p = 0.017). Although these data highlight the potential of asporin to serve as a prognostic marker, confirmation of the clinical value would require a prospective study on a much larger patient cohort.

CONCLUSIONS

Our data show that asporin is a stroma-derived inhibitor of TGF-β1 and a tumor suppressor in breast cancer. High asporin expression is significantly associated with less aggressive tumors, stratifying patients according to the clinical outcome. Future pre-clinical studies should consider options for increasing asporin expression in TNBC as a promising strategy for targeted therapy.

Oncological and surgical outcome after oncoplastic breast surgery

BACKGROUND

Oncoplastic surgery combines breast-conserving treatment and plastic surgery techniques. The aim of the study was to identify breast and tumor-related characteristics that contribute to the rate of complications and recurrence.

METHODS

This retrospective study included 72 patients with a median follow-up of 32 months. For each patient, a comprehensive set of data was collected, including epidemiology, tumor characteristics, preoperative information, detailed pathology reports, radiotherapy treatment and type of surgical technique. The rate of complications, recurrence and survival were studied.

RESULTS

Complete tumor removal was performed with clear margins in all patients but in 25 of them margins were less than 2 mm. One patient had local recurrence and another developed distant metastases. The study showed that the size of the margin was not predictive of recurrence as long as not positive; the greater the resection volume, the larger the excision margin. The resection size was the only factor influencing complications and no specific tumor-related factor significantly increased the complication rate. Surgical complications did not delay the initiation of chemotherapy and radiotherapy.

CONCLUSIONS

This is the first oncoplastic study where both tumor and breast characteristics were analyzed using the most recent criteria of the literature. Oncoplastic surgery can be considered as oncologically safe. The resection size was the sole significant risk factor for postoperative complications. Complications after oncoplastic breast surgery did not differ neoadjuvant therapy. Long-term event-free survival was excellent (96% at 7 years).

[Management of breast cancer in a woman with breast implants]

The incidence of breast cancer, currently one woman on eight, also concerns patients who underwent augmentation surgery. Breast implants have already been the subject of numerous publications concerning the risk of inducing breast cancer or of delaying its diagnosis; however, no significant causal relationship has been established. The purpose of this article is to assess the diagnostic and therapeutic consequences when breast cancer is identified in a patient with breast implants.

Oncological and Surgical Outcome after Oncoplastic Breast Surgery

BACKGROUND

Oncoplastic surgery combines breast-conserving treatment and plastic surgery techniques. The aim of the study was to identify breast and tumor-related characteristics that contribute to the rate of complications and recurrence.

MATERIAL & METHODS

This retrospective study included 72 patients with a median follow-up of 32 months. For each patient, a comprehensive set of data was collected, including epidemiology, tumor characteristics, preoperative information, detailed pathology reports, radiotherapy treatment and type of surgical technique. The rate of complications, recurrence and survival were studied.

RESULTS

Complete tumor removal was performed with clear margins in all patients but in 25 of them margins were less than 2 mm. One patient had local recurrence and another developed distant metastases. The study showed that the size of the margin was not predictive of recurrence as long as not positive; the greater the resection volume, the larger the excision margin. The resection size was the only factor influencing complications and no specific tumor-related factor significantly increased the complication rate. Surgical complications did not delay the initiation of chemotherapy and radiotherapy.

CONCLUSION

This is the first oncoplastic study where both tumor and breast characteristics were analyzed using the most recent criteria of the literature. Oncoplastic surgery can be considered as oncologically safe. The resection size was the sole significant risk factor for postoperative complications. Complications after oncoplastic breast surgery did not differ neoadjuvant therapy. Long-term event-free survival was excellent (96% at 7 years).

Novel comprehensive approach for accessible biomarker identification and absolute quantification from precious human tissues

The identification of specific biomarkers obtained directly from human pathological lesions remains a major challenge, because the amount of tissue available is often very limited. We have developed a novel, comprehensive, and efficient method permitting the identification and absolute quantification of potentially accessible proteins in such precious samples. This protein subclass comprises cell membrane associated and extracellular proteins, which are reachable by systemically deliverable substances and hence especially suitable for diagnosis and targeted therapy applications. To isolate such proteins, we exploited the ability of chemically modified biotin to label ex vivo accessible proteins and the fact that most of these proteins are glycosylated. This approach consists of three successive steps involving first the linkage of potentially accessible proteins to biotin molecules followed by their purification. The remaining proteins are then subjected to glycopeptide isolation. Finally, the analysis of the nonglycosylated peptides and their involvement in an in silico method increased the confident identification of glycoproteins. The value of the technique was demonstrated on human breast cancer tissue samples originating from 5 individuals. Altogether, the method delivered quantitative data on more than 400 potentially accessible proteins (per sample and replicate). In comparison to biotinylation or glycoprotein analysis alone, the sequential method significantly increased the number (≥30% and ≥50% respectively) of potentially therapeutically and diagnostically valuable proteins. The sequential method led to the identification of 93 differentially modulated proteins, among which several were not reported to be associated with the breast cancer. One of these novel potential biomarkers was CD276, a cell membrane-associated glycoprotein. The immunohistochemistry analysis showed that CD276 is significantly differentially expressed in a series of breast cancer lesions. Due to the fact that our technology is applicable to any type of tissue biopsy, it bears the ability to accelerate the discovery of new relevant biomarkers in a broad spectrum of pathologies.

[Primary and secondary prevention for women at high risk for breast cancer]

Many factors determine a woman's risk of breast cancer; some genetic are related to family history, others are based on personal factors such reproductive and medical history. A high-risk woman must benefit of a specific screening regimen including breast examination, mammography, ultrasonography and contrast material-enhanced magnetic resonance. But she can also benefit of chemo prevention or/and risk-reducing surgery such bilateral prophylactic salpingo-oophorectomy and bilateral prophylactic mastectomy.

[Breast cancer in Belgium: why are we the first in Europe?]

Breast cancer incidence in Belgium is on the top of European countries, with 9.697 new cases in 2008 and 106/100.000 women/year. The explanation of this high incidence in our country is probably the accumulation of risk factors (many of them are linked to lifestyle), and the impact of screening and registration of cases. The relative impact of each of theses factors is less clear because we don't have powerful statistical studies. Belgium is slightly above the European mean for breast cancer mortality, with 19,4/100.000 women/year and an all stages 15-year survival of 75%. Breast cancers are responsible for around 3% of all-cause mortality in Belgian women. This article discusses the causes of this high Belgian incidence and of current decrease of incidence in western countries, and reviews known and less known risk factors of breast cancers, with a special focus on menopause hormonal treatments.

[Cytological sampling techniques in breast pathology]

Mammary cytology is part of the breast cancer test. Its accuracy depends on both the sample quality and the cyto-pathologist's competence. Extracting cells in a liquid environment allows obtaining smears in less hemorrhagic thin layers, containing more cells and with less interference with the fixation artefact. This technique keeps materiel for further immunocytochemistry and cell biology studies if needed. It will be especially useful in automated analysis.

[Breast cancer in young women]

The outcome of very young patients with early breast cancer is worser compared to older patients with a similar clinical presentation. The triple negative, luminal B, HER2+ subtypes are more frequent in this population. Adequate local treatment (breast-conserving surgery or total mastectomy) must be discussed with the patient. The role of radiotherapy is very important in these patients with high risk of local recurrence. The progress in adjuvant treatment of very young patients requires studies of tailored treatments.

[Hormone therapy for breast cancer]

Following Beatson's publications in 1896, various modalities of endocrine therapy applied to breast cancer have been developed. Endocrine treatment has greatly contributed to the improvement of the disease's prognosis. Tamoxifen has established itself as a first choice adjuvant therapy for patients with tumors expressing hormone receptors. Over the last decade, third generation aromatase inhibitors have demonstrated their efficacy amongst menopausal patients, alone or in combination with tamoxifen. Efficacy of these medications is dependent on patient's compliance. This article proposes a synthesis of the main knowledges available in the field of breast cancer endocrine therapy.

[Breast oncoplastic surgery]

Oncoplastic surgery combines large lumpectomy and defect remodeling by different plastic surgery methods. These procedures improve the cosmetic result after partial mastectomy and widens the possibilities for conservative treatment. Different techniques are used from simple glandular remodeling to more difficult techniques for breast plasties with or without simultaneous controlateral symetrisation procedure. The surgical option depends especially on the ratio between the volume of the tumor and the volume of the breast and the position of the tumor. This more effective conservative treatment facilitates also postoperative radiotherapy, reduces the sequellae and the psychological impact of breast cancer treatment.

[Management of estrogen deficiency after breast cancer]

The prevention and the treatment of oestrogen deficiency induced by breast cancer treatments are crucial in the management of patients. The impacts of this deficiency must not be neglected: quality of life impairments inducing eventually premature withdrawal of hormonotherapies, and excess of bone and cardio-vascular morbidities and mortalities, especially in good prognosis young women. Management strategies of short and long term effects of this deficiency are reviewed and discussed here.

[Targeted therapies in breast cancer]

The better understanding of the biology of breast cancer has allowed the identification of new targets for anticancer therapy. Trastuzumab, a monoclonal antibody binding the HER2 receptor, is used since several years in the treatment of HER2 overexpressing breast cancer, including in the adjuvant setting. Lapatinib, a tyrosine kinase inhibitor, was introduced more recently into the clinic. New treatment options under evaluation in HER2 overexpressing breast cancer include combinations of anti-HER2 treatments, drugs targeting the downstream signaling pathway and new anti-HER2 agents such as pertuzumab and T-DM1. This article also reviews other targeted treatments of interest in the field of breast cancer including antiangiogenic agents and drugs targeting the PI3K-AKT-mTOR pathway.

[Bilateral prophylactic mastectomy for women at very high risk for breast cancer: beyond the technique]

Bilateral prophylactic mastectomy is the most efficient risk management strategy for women at very high risk for breast cancer. Different methods can be used. The implementation of such a strategy must respond to the request of a well informed patient.

[Systemic chemotherapy and breast cancer]

Breast cancer mortality is decreasing, partly due to better adjuvant treatments with new drugs and new schedules. In Belgium, the overall survival is 76%. Chemotherapy is still an important treatment option. We need to better select patients who really will benefit from treatment in order to decrease toxicity and improve long term outcome.Targeting the specific population is now a priority. Prognostic and predictive factors will enable us to better define the sub-population of patients most benefiting from treatment. We will also discuss the knowledge of systemic treatment. When we have to decide wether chemotherapy is indicated, we need to well balance the treatment risks and benefits because gain in survival is important but reducing short and long term toxicity is also a challenge.

[Sentinel lymph node biopsy and axillary reverse mapping: a tailoring axillary staging in breast cancer]

The status of the axillary lymph nodes is one of the most important prognostic factors in women with early stage breast cancer. Histologic examination of removed lymph nodes is the most accurate method for assessing spread of disease to these nodes. Axillary lymph node dissection (ALND) remains the standard approach for women who have clinically palpable axillary nodes. The benefits of ALND include its impact on disease control (axillary recurrence and survival), its prognostic value, and its role in treatment selection. However, the anatomic disruption caused by ALND may result in lymphedema, nerve injury, and shoulder dysfunction, which compromise functionality and quality of life. For patients who have clinically negative axillary lymph nodes, sentinel lymph node (SLN) biopsy offers a less morbid method to determine if there are positive nodes, in which case axillary node dissection would be necessary. Patients who are SLN-positive should undergo complete ALND. Axillary reverse mapping (ARM) is a recent improvement of ALND which, like the biopsy of the GS, would reduce morbidity.

[Management and follow-up of a consecutive series of 411 surgically treated breast cancer patients]

This study reports a consecutive serie of 427 breast neoplasms (411 patients) diagnosed and treated in our department between 1994 and 2004. Patients' records were prospectively collected including personnal medical history and the major elements of the diagnostic and the therapeutic protocol applied. 12 patients (3%) had to be excluded due to incomplete follow-up data. With a median follow-up of 8 years, a 4.5% loco-regional relapse rate is noted while 11% of patients recurred at distant sites and 9% died of their disease progression. These statistics are comparable to those published by prominant breast cancer centers. Amongst the 16% of deaths (67/411 Pts), 54% are due to breast cancer progression. The results are discussed with the aim to upgrade the diagnostic and the therapeutic protocols offered to our patients.

[Immediate breast reconstruction and postoperative radiotherapy: an overview]

Breast reconstruction is nowadays integral part of the treatment of breast cancer. When it is proposed as an immediate reconstruction, the plastic surgeon has to deal with several constraints. The coverage of the patients that must benefit from a mastectomy is complicated by additional treatments of radiotherapy. We propose, in this work, a multidisciplinary splitting of the patients into specific subgroups. An immediate reconstruction will be proposed to certain patients considering the adjuvant radiotherapy. The choices of orientation are complex and a scarce literature on this subject does not allow us to guide in a systematic way all the patients. More studies, with a prospective design, are necessary to guide the patients wishing an immediate reconstruction associated with a radiotherapy after mastectomy.

[Breast cancer in the elderly patient]

There is no standard of care for breast cancer treatment in the elderly patient. Given the heterogeneity of this population, the treatment of both localized and metastatic disease, requires to take into account not only the characteristics of this cancer but also factors related to the patient such as co-morbidities, life expectancy and the social environment.

[Adherence to long-term medication: the particular case of the adjuvant endocrine therapy for breast cancer]

The aim of adjuvant hormone therapy for breast cancer is to reach, in daily practice, an efficacy similar to that obtained in clinical trials. In spite of the demonstrated efficacy of hormone therapy, compliance represents a major challenge and a multidimensional problem. A better understanding of the reasons underlying non-compliance would help identify the patients at higher risk and would permit the implementation of strategies to improve compliance to adjuvant hormone therapy. With this in mind, we undertook a review of the recent literature on the topic (Pub Med 2003-2009).

[Monoclonal antibodies and breast cancer. Current therapeutic progress]

About 9,500 new breast cancers are diagnosed in Belgium every year. Improvement of our knowledge of altered molecular events leading to the proliferation of tumor cells has resulted in the development of targeted therapies in subgroups of cancers. One of the first validation of targeted therapy is the anti-HER-2 monoclonal antibody trastuzumab (Herceptin) in patients with overexpression of human epidermal growth factor receptor type 2 (HER2) occurring in 20 to 25% of invasive breast carcinoma. Trastuzumab binds the extracellular juxtamembrane domain and is only active in tumor with HER2 gene amplification detected by fluorescence in situ hybridization (FISH). The results from randomized trials have rapidly lead to the approvement of the drug in the metastatic and then in the adjuvant setting. Another targeted therapy, also approved in the treatment of breast cancer, is the monoclonal antibody bevacizumab with an anti-VEGF (Vascular Endothelial Growth Factor) activity. We will review the benefit of these targeted therapies in breast cancer and their role in the treatment of breast cancer.

[Validation of the sentinel lymph node biopsy in breast cancer]

PURPOSE

Assessment of our experience and validation of the sentinel lymph node biopsy technique in breast cancer stage T0-T2N0M0 surgery.

METHODS

Identification and biopsy of the sentinel lymph node by the radio colloid method in a consecutive series of 205 patients undergoing surgery for breast cancer stage T0-T2N0M0 between October 1998 and January 2007, initially in association with a complete axillary lymph node dissection (learning curve), later in an elective way. Prospective recording of the data and analysis with an average follow-up of 50 months (3 to 102 months).

RESULTS

Biopsy rate of the sentinel lymph node of 90%, false negative rate of the method 2.5%, axillary recurrence rate 0%.

CONCLUSION

We confirm in this series that the sentinel lymph node biopsy technique is a reliable approach in our experience for the evaluation of the axillary lymph node status in breast cancer stage T0-T2N0M0.

[Therapeutic progress in gynecology: organic diseases]

Over the last ten years, progress in evidence-based medicine coupled with technological and surgical breakthroughs have deeply changed the management of our patients. Uterine bleeding is the first cause of gynaecological consultation and the intrauterine progestin delivery system as well as new hysteroscopic procedures have optimized the therapeutic approach to this problem. Introduction of magnetic resonance imaging and interventional procedures have improved breast disease diagnosis and management; likewise sentinel node localization, introduction of aromatase and growth factors inhibitors, new radiotherapy procedures and pharmacogenomics, have helped to ameliorate breast cancer treatment. Pelvic surgery has been switching more and more towards laparoscopic procedures not only in the field of benign lesions (eg endometriosis), of surgery of prolapse and incontinence with new prosthetic materials, but also for an improved management of gynaecological cancers.

Percutaneous stereotactic en bloc excision of nonpalpable breast carcinoma: a step in the direction of supraconservative surgery

Recently, the advanced breast biopsy instrumentation (ABBI) system has been introduced as an alternative to conventional breast biopsy techniques. This study was prospectively conducted to evaluate the potential of the ABBI method in locoregional management of a consecutive series of patients with nonpalpable mammographically detected breast carcinomas. Sixty-one consecutive patients underwent an ABBI procedure as a first step before possible surgery for nonpalpable breast lesions that would in any case require complete excision. For the 27 patients in whom the ABBI biopsy revealed malignancy further surgery was recommended, including re-excision of the biopsy site and axillary dissection in cases of infiltrating carcinoma. We calculated the probabilities that the ABBI specimen would have tumor-free margins and that a definitely complete excision had been achieved as a function of the mammographic or pathological diameter of the cancer. For cancer with a pathological diameter less than 10 mm measured on the ABBI specimen, the probability (92%) of obtaining complete resection was significantly better than for larger lesions (P=0.01, Fisher's exact test). Although the therapeutic perspectives for the ABBI method are limited at present, we suggest that this approach is a first step in the direction of a surgical strategy that is better adapted to the pathological characteristics peculiar to these small tumors, whose incidence is increasing.

[Benefits and limitations of mammography]

The literature on screening mammography provides ample opportunity for doubt (the sceptics) and dogma (the screening zealots), and can be interpreted to prove both benefit and harm. The benefit of mammography screening, if any, is modest and the balance between beneficial (potentially, a 20% relative reduction in breast cancer mortality with no significant benefit on all-cause mortality) and harmful (physical and psychological morbidity related to the 15-40% missed cancers and the 80-90% false-positive diagnoses) effects is still delicate. The mammogram alone is a modest weapon. Concurrent clinical breast examination is mandatory. Women that are concerned about breast cancer should be fully informed of the potential benefits and risks of screening mammography. These women should benefit from mammography with concurrent clinical breast examination, and possible whole-breast ultrasound in heterogeneously dense and extremely dense breast patterns.

[Postmenopausal hormone replacement therapy and breast cancer risk: an update]

Numerous studies have examined the risk of breast cancer in patients with postmenopausal hormone substitution. Most of these studies are retrospective, and a few recent studies are prospective. The observed results present with weak variations from baseline and major heterogeneity. Some studies highlight a slightly increased relative risk of breast cancer. A reanalysis of 51 studies demonstrates a relative risk of 1.35 for developing breast cancer during hormone substitution, with a 2.3% increased risk per year of use. Recently, the results of the WHI study have shown a slight increase of some risks of disease, including breast cancer (relative risk, 1.26). These results have induced the interruption of one of the 3 arms of the study (that of the patients treated with an estrogen-progestin combination), and have provoked a new discussion about the benefits and risks associated with hormone substitution. These facts have been largely related and commented in the general press. In this article, we review the important studies concerning this topic.

[Hormone replacement therapy after breast cancer. Yes...or no?]

Clinical and experimental studies indicate that combined unique conjugated estrogens and medroxyprogesterone acetate moderately increase the risk of breast cancer in postmenopausal women. Classically, hormone replacement therapy is contra-indicated in women with a past history of breast cancer due to the fear of recurrence. However, these postmenopausal patients complain about hot flushes and adjuvant hormonal therapies (such as aromatase inhibitors, SERMs and Tamoxifen...) aggravate their symptoms. Observational studies and their meta-analyses do not show a deleterious effect but rather a beneficial impact of hormone replacement therapy among women with a past history of breast cancer. We summarise all these studies and their biological, clinical and epidemiological interpretations. We conclude that short term hormone replacement therapy is safe among those women requesting a replacement therapy after complete information. It is however advisable to conclude definitely only when prospective randomised trials with estradiol or tibolone (a promising alternative) will be available. Such ongoing studies will allow to conclude definitely the possible benefits and risks of hormone replacement therapy among patients with a past history of breast cancer.

Stereotactic breast biopsy with an 8-gauge, directional, vacuum-assisted probe: initial experience

This study was prospectively conducted to assess the feasibility, safety and accuracy of an 8-G directional vacuum-assisted biopsy (DVAB) probe in the diagnostic management of nonpalpable breast lesions (NPBL). Of 170 planned procedures which were indicated for investigation of BI-RADS category-3 to category-5 lesions, 153 were performed in 138 consecutive patients. The probe was targeted by the stereotactic unit of a prone table (United States Surgical Corporation, Norwalk, Conn.; and Lorad, Danbury, Conn.). Four to 18 (mean 8) core specimens were obtained for each lesion. In case of complete removal of the lesion, a localizing clip was deployed at the biopsy site. Adequate material for histopathologic examination was obtained in all cases (100%). Four of 138 (3%) patients experienced mild hematomas. We observed 15 of 39 failures (38%) to place the localizing clips. Thirteen of 153 (8%) procedures were inconclusive and required reintervention. Following DVAB, 42 of 138 (30%) patients underwent surgery. Subject to incomplete follow-up of the entire cohort, we observed no false-positive and one false-negative diagnosis. These preliminary results suggest that DVAB using an 8-G probe are feasible, safe and accurate. In our experience, clip placement was problematic. It is probable that increasing the dimensions of DVAB will only be relevant in a limited number of clinical situations, primarily the desire to obtain complete radiologic resections of the target abnormality.

En bloc excision of nonpalpable breast lesions using the advanced breast biopsy instrumentation system: an alternative to needle guided surgery?

This study was prospectively conducted to evaluate the clinical potential of the advanced breast biopsy instrumentation (ABBI) system as an alternative to needle localization and open surgery in the management of nonpalpable breast lesions (NPBL). One hundred and eighty-six consecutive patients were referred for management of NPBL. Thirty-six underwent an ABBI procedure, offered as a first step before possible surgery for lesions which would in any case have required complete excision. The 18 patients with a malignant ABBI biopsy underwent re-excision of the biopsy site and axillary dissection was carried out in cases of infiltrating carcinoma. The other 150 patients underwent image-guided needle biopsy. Following these procedures, 60/150 (40%) patients underwent needle-guided surgery. Finally, 96/186 (51%) patients required complete excision. A total of 43 benign lesions and 53 carcinomas were confirmed. Thirty-six out of 96 (38%) excisions were obtained with the ABBI system; 17/43 (40%) benign lesions and 11/53 (21%) carcinomas were completely removed with the ABBI system. Out of 9 malignant specimens with a pathological size less than 10 mm, 5/9 (55%) had tumor-free margins and in 8/9 (89%) no residual disease was found at re-excision. The preliminary results of this study suggest that, in selected cases, en bloc excision using the ABBI procedure could be an alternative to conventional surgery.

[Supraconservative breast surgery]

Currently, 30% of the breast biopsies are performed for patients with nonpalpable lesions. The surgical management of these lesions had to evolve to a better three-dimensional targeting and a reduction of the tissue traumatism. The ABBI procedure allows the percutaneous one bloc excision of suspicious mammographically detected lesions with a diameter of less than 2cm. We prospectively evaluated this procedure as a therapeutic tool. Of the 10 malignant lesions with a pathologic size <10mm, 9 (90%) were completely resected with the ABBI device (no residual disease at re-excision of the biopsy site). The results of this preliminary study suggest a potential therapeutic role of the ABBI procedure in the therapeutic arsenal against mammary lesions.

[Hidden factors of breast cancer: recommended follow-up for hyperplasia or carcinoma in situ]

After the diagnosis of breast epithelial hyperplasia or carcinoma in situ, the clinical follow-up must take into account several parameters. First, the adequacy of the diagnostic and the therapeutic approach is to be evaluated. Second, the patient must be informed of her risk of subsequent breast cancer. In such a protocol, one can recommend a program of close follow-up in an attempt at early detection. An annual clinical examination combined with a mammographic and a sonographic exam is considered as the method of choice. In between annual check-ups, clinical exam is encouraged. The potential benefits of magnetic-resonance imaging in these circumstances is currently evaluated. In rare instances, the absolute risk of breast cancer is so high that a prophylactic mastectomy can be considered.