Risk Factors for Positive Margins in Breast-Conserving Surgery.

Introduction Breast-conserving surgery (BCS) followed by adjuvant radiotherapy has similar overall survival compared to mastectomy but is associated with higher rates of local recurrence. Positive surgical margins in BCS are the most important predictor of local recurrence. The aim of our study was to assess the risk factors associated with positive margins in women undergoing BCS for breast cancer in order to inform our clinical practice and minimize re-operation rates. Methods Patients with a diagnosis of breast cancer who underwent BCS from January 2013 to January 2021 were identified from our pathology database and included in the study. All patients underwent a lumpectomy with the removal of additional shaved cavity margins. Statistical analysis was used to assess the effect of patient clinical and pathological risk factors on the rate of positive margins. Results One hundred and twenty patients underwent BCS for breast cancer. Twenty-four percent of patients had positive margins. Of the 29 patients that underwent subsequent re-excisions, only 13 (45%) had residual disease in the re-excision specimen. In younger patients, tumors localized in lower quadrants and the presence of extensive intraductal component within invasive breast cancer increased the risk of positive margins. In addition, positive margins were encountered more significantly in patients with ductal carcinoma in situ (DCIS) compared to invasive tumors. Multivariate analysis showed that DCIS and young age were the only factors independently associated with positive margins. Conclusion DCIS and younger patients have a higher rate of positive margins during BCS than invasive breast cancer. For such patients at higher risk of positive margins, excision of cavity shave margins and intraoperative inking may be done to lower positive margin rates. Preoperative review of breast imaging, core biopsies, and counseling of patients about the likelihood of positive margins is important.

Prevalence of BRCA1 and BRCA2 Mutations Among High-risk Bahraini Patients with Breast Cancer.

OBJECTIVE: The purpose is to study the prevalence of BRCA1 and BRCA2 mutations in high-risk Bahraini patients diagnosed with breast cancer, its relation to family history, and to determine the clinicopathologic features of breast cancer associated with these genetic mutations, over a period of 7 years. BACKGROUND: Breast cancer is the most common type of cancer occurring in women and the second most common type generally. Approximately 12% of women worldwide will develop carcinoma of the breast sometime during their life. Additionally, 72% of women with an inherited BRCA1 mutation and 69% of those with a mutated BRCA2 will develop breast cancer by 80 years of age. The incidence of breast cancer in Bahraini women have increased over the last decade. Still, the data on BRCA1 & BRCA2 mutations in relation to breast cancer patients is limited in the Arab region, not omitting Bahrain as a country with deficient BRCA prevalence data. METHODS: This retrospective study was carried out in Salmaniya Medical Complex, Bahrain, to determine the prevalence of BRCA1 and BRCA2 mutations and to observe the breast cancer's histopathologic features that are associated with these mutations. RESULTS: 271 patients underwent the BRCA gene testing between 2013 and 2019. Out of 271 patients, 35 were excluded. Out of the 236 breast cancer patients, 219 (93%) did not have the mutation. The BRCA gene was carried by a total of 17 (7%) patients; 13 (5%) BRCA1 and 4 (2%) BRCA2. Thirteen BRCA carrier patients had invasive ductal carcinoma (IDC) (76%), 2 had ductal carcinoma in situ (DCIS) (12%), while 2 patients' histopathology was not available. Molecular subtypes showed 4 triple negative basal sub-type (TNBC), 10 positive ER and PR hormonal status, 1 positive HER-2, while 2 patients' hormonal receptor status was not available. Two BRCA1 carriers had both breast and ovarian cancers. A total of 5 (2%) breast cancer male patients were among the tested population, out of which, 1 (0.4% of the total and 20% of the male patients) was a BRCA2 carrier. Out of the 236 patients, 76 (32%) were younger than 40 years of age at the time of diagnosis. Then again, out of the 17 BRCA carrier patients, 7 (41%) were younger than 40 years. CONCLUSION: The prevalence of BRCA mutation in high risk Bahraini breast cancer patients is 7%. Among those patients, BRCA1 mutation is the most prevalent (5%) and invasive ductal carcinoma (IDC) is the most common histopathological subtype. However, there was not enough data to conclude the most prevalent molecular subtype of breast cancer in BRCA carriers due to deficiency of overseas pathology reports for patients operated outside Bahrain. When developing treatment plans for younger patients with breast cancer, inherited syndromes and precisely BRCA mutations need to be considered. Bahrain is implementing genetic testing for breast cancer patients ≤ 50 years of age since 2018, according to NCCN guidelines. We will continue to build our database to better characterize breast cancer subtypes and determine their hereditary pattern for identification of high risk families in Bahrain and for future development of more specific therapeutic approaches. KEY WORDS: Breast cancer, BRCA1, BRCA2, BRCA mutation, Bahrain, Arab region.

Contralateral axillary metastasis: a diagnostic and therapeutic clinical dilemma.

We report a 61-year-old woman with primary right breast cancer and metastatic lymphadenopathy in the contralateral axilla. This case represents a clinical dilemma because primary breast cancer, occult contralateral breast cancer and extra-mammary primary lesion can all be the source of the contralateral axillary metastasis. The patient underwent bilateral modified radical mastectomy. Immunohistochemistry revealed that the right breast was positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for human epidermal growth factor receptor-2 (HER2). In contrast, the right and left axillary lymph nodes were positive for ER, but negative for PR and HER2. There was no evidence of occult primary cancers or extra-mammary tumours.

Synchronous breast and colon cancer: the importance of multidisciplinary team cancer meetings.

A 58-year-old female patient presented with left breast lump. Mammography and ultrasonography were performed, which reported lesions suspicious of malignancy in the left breast and axilla. Core biopsy of the lesions revealed invasive ductal carcinoma with axillary lymph node metastasis. Staging CT scan (thorax, abdomen and pelvis) identified a coexisting neoplasm in the ascending colon. Colonoscopy was performed and the tumour in the ascending colon was biopsied. Histopathological examination revealed adenocarcinoma. In the multidisciplinary team cancer meeting, it was decided to treat the breast cancer first and then the colon cancer, followed by adjuvant chemotherapy. In the first operation, left modified radical mastectomy was performed. Two weeks after her initial operation, the patient underwent laparoscopic right hemicolectomy. Postoperatively, the patient did not develop any complications and was referred to oncology for chemotherapy.

Surgical treatment of granulomatous mastitis: Our experience in Bahrain.

Granulomatous mastitis (GM) is a rare, benign inflammatory disease of the breast with unknown etiology. There is no universally accepted treatment for GM. The aim of this study was to show our experience with surgical treatment of GM. A retrospective review was performed for 29 cases that were surgically treated at Salmaniya Medical Complex (SMC) in Bahrain between 2010 and 2017. All patients underwent surgical excision with debridement and removal of retroareolar ductal system. None of these patients experienced recurrence in the follow-up period. Complete surgical excision of the whole inflammatory mass is the treatment of choice.

Accuracy of intraoperative frozen section evaluation of sentinel lymph node biopsy in breast cancer: Our experience in Bahrain.

INTRODUCTION: Intraoperative frozen section of sentinel lymph nodes (SLN) in clinically node-negative breast cancer patients is performed to stage the axilla and allows axillary lymph node dissection (ALND) to be avoided in the same operative setting. The aim of this study was to evaluate our institutional experience on the accuracy of intraoperative frozen section of sentinel lymph node biopsy (SLNB) in breast cancer patients. METHODS: Clinicopathological data from patients who underwent surgery for breast cancer with SLNB from January 2013 to May 2017 at Salmaniya Medical Complex (SMC) in Bahrain were collected retrospectively. Results of intraoperative frozen section were compared to paraffin section to determine accuracy, sensitivity, specificity, positive-predictive value (PPV), negativepredictive value (NPV) and false-negative rate (FNR). RESULTS: A total of 104 patients with breast cancer underwent breast surgery with SLNB and intraoperative frozen section evaluation of SLNB. Frozen section correctly identified a positive or negative result in 97 cases (accuracy 93.2%). The sensitivity was 77.7%. The specificity was 98.7%. The PPV was 95.4%. The NPV was 92.6%. The overall FNR was 22.3%. CONCLUSION: Our results show that intraoperative frozen section can reliably evaluate the status of SLNB in patients with breast cancer, allowing us to avoid second stage surgery in most women.