Lung cancer in pregnancy.

In the 26th week of gestation, a 29-year-old pregnant office employee was referred to the pulmonary department of Linz General Hospital (AKH) under the suspicion of tuberculosis. She complained of a cough with intermittent hemoptysis and pain in the thoracic spine from which she had been suffering the past 9 weeks. A plain chest X-ray showed a dense infiltrate on the right side and multiple smaller shadows in both lungs. Laboratory testing revealed anemia, leukocytosis, and an increase of C-reactive protein. All tests for tuberculosis were negative.A bronchoscopy was performed and biopsies were taken from the right upper and middle lobe. The histopathological examination found cells of an adenocarcinoma. A magnetic resonance imaging (MRI) revealed a large tumor and surrounding atelectasis were seen in the right upper and middle lobe, as well as multiple intrapulmonary metastases in both lungs. In addition, not only metastases in the thoracic spine (level Th2/3) but also at other osseous locations and multiple cerebral metastases were detected. The patient received one cycle of chemotherapy consisting of docetaxel and carboplatin (AUC5) in the 27th week of gestation. Additional radiotherapy was applied to the involved thoracic spine. Due to positive epidermal growth factor receptor mutation, therapy with gefitinib 250 mg/day was started 2 days after a Caesarean section (preceded by treatment for fetal lung maturation). A healthy girl was delivered in the 30th week of pregnancy. Staging with computed tomography (CT) after delivery revealed an unstable fracture of Th2 with compression of the spinal cord. Neurosurgery was performed, consisting of a ventral corporectomy of Th1-2 followed by an anterior and posterior osteosynthesis for stabilization. The patient was discharged without neurological deficits within 1 week. Subsequent treatment with gefitinib improved the performance status of the patient, and CT scans of the chest and an MRI of the brain showed the size of the tumor to be shrinking. Meanwhile, the infant developed appropriately for her age.After 14 months of the first diagnosis, the patient experienced neurological symptoms (aphasia, confusion) due to neoplastic meningeosis and cerebral venous sinus thrombosis together with local tumor progression in the lung. One course of chemotherapy, combining carboplatin/pemetrexed/bevacizumab, was given without clinical response. Despite best supportive care, the patient died 17 months after diagnosis in October 2013.

Sentinel node mapping performed before preoperative chemotherapy may avoid axillary dissection in breast cancer patients with negative or micrometastatic sentinel nodes.

BACKGROUND: Sentinel node (SN) biopsy after preoperative chemotherapy (PC) in breast cancer patients is associated with a lower identification rate (IR) and an increased false-negative rate (FNR) compared with SN biopsy in untreated patients. Our aims were to examine the feasibility of SN mapping before PC and the possibility to assess the lymph node status after chemotherapy through a follow-up lymphatic mapping. METHODS: SN biopsy was performed in 45 clinically node-negative breast cancer patients before PC. A follow-up lymphatic mapping was done after completion of chemotherapy and irrespective of the lymph node status was followed by axillary lymph node dissection (ALND). RESULTS: SN mapping before chemotherapy identified a mean of 2.3 SNs in all patients (IR 100%). Nineteen patients revealed a negative SN; 26 patients had a positive SN (micrometastasis found in 6/26 patients). After PC follow-up lymphatic mapping was successful in 29 of 45 patients (IR 64%). IR for follow-up mapping was 80% for patients with a negative or micrometastatic SN before chemotherapy compared with 45% for patients with macrometastatic SNs (P = .027, Fisher exact test). None of the patients with a negative or micrometastatic SN before chemotherapy revealed positive lymph nodes after PC (P = .031, McNemar test) and the FNR for follow-up lymphatic mapping in these patients was 0%. Contrary to that, 15 of 20 patients with a macrometastasis before PC had positive nodes after chemotherapy, and the FNR of follow-up mapping in these patients was 50%. CONCLUSIONS: Patients with a negative SN before PC may forego complete ALND after PC, whereas this may not be valid for patients with macrometastatic SNs. Follow-up lymphatic mapping in patients with positive nodal status before chemotherapy is associated with a low IR and a high FNR.

The use of sentinel node biopsy in breast cancer patients undergoing skin sparing mastectomy and immediate autologous reconstruction.

BACKGROUND: Intraoperative frozen section examination of the sentinel node in breast cancer patients is associated with a high number of incorrect negative results with the sentinel node becoming positive in the permanent examination and necessitating a secondary axillary lymph node dissection. A reoperation of the axilla following skin-sparing mastectomy and immediate autologous tissue reconstruction may compromise the vascular pedicle of the flap and should be avoided. METHODS: Eighty breast cancer patients underwent skin-sparing mastectomy with immediate autologous reconstruction and sentinel node biopsy followed by axillary lymph node dissection irrespective of the result of the frozen section of the sentinel node. The goal of the study was to identify a subgroup of patients with incorrect negative sentinel node(s) in the frozen section who may forego a secondary axillary lymph node dissection due to a low risk of positive nonsentinel nodes. RESULTS: Frozen section examination of the sentinel node was negative in 58 patients and positive in 22 patients. Permanent histologic examination revealed tumor in 13 of 58 (22.4 percent) sentinel node(s) found negative in the frozen section. None of these 13 patients showed positive nodes in the axillary specimen, whereas nine of 22 patients with their metastases in the sentinel node found through intraoperative frozen section examination had additional positive nonsentinel node(s) (p = 0.001). CONCLUSIONS: Patients with incorrect negative sentinel node(s) found in the frozen section examination had a significantly decreased risk for additional positive nonsentinel node(s) compared with patients with sentinel node metastases found in the frozen section. However, to avoid a secondary axillary lymph node dissection, the authors suggest performing sentinel node biopsy before mastectomy under local anesthesia to have the permanent result of the sentinel node available before a planned reconstruction.