Breast conserving surgery after primary chemotherapy in locally advanced breast cancer.

PURPOSE: Primary chemotherapy is being given in the treatment of locally advanced breast cancers (LABC), but a major concern is local recurrence after therapy. The aim of this study was to assess the role of breast conserving surgery (BCS) in patients with locally advanced breast cancer. MATERIAL AND METHODS: Twenty-eight patients, presenting LABC (T any, N 012, M0) were treated with primary chemotherapy comprising of cyclophosphamide, doxorubicin and fluorouracil and then BCS followed by radiotherapy were examined between the years 1992-2002 retrospectively. Before neoadjuvant chemotherapy, seven patients (25%) were Stage IIB, 19 patients (68%) Stage IIIA and two patients (7%) Stage IIIB. Survival times and curves were established according to the Kaplan-Meier method and compared by means of the log-rank test. The chi-square test and log rank test were performed for univariate statistical analysis of each prognostic factor. P values in multivariate analysis were carried out by the Cox's proportional hazards regression model. All p values were two-sided in tests and p values <0.05 were considered significant. RESULTS: Clinical down staging was obtained in 25 (89%) of patients. Three (11%) patients had complete clinical response, 22 (78%) patients with partial response and 3 (11%) had stable disease. The primary tumour could not be palpated after chemotherapy in 6 (21%) of 28 patients presenting with palpable mass, therefore needle localization was performed for BCS. Median follow-up was 51.9 months (ranging 10 to 118 months). Local recurrence was detected in 4 (14%) patients. Distant metastasis developed in 5 (18%) patients. Three of the patients died of distant metastases and two of them are alive at 49 months. Five-year survival rate was 66%. Statistically, there were no significant factors in terms of local recurrence. Histological grade and menopause status were significantly associated with overall survival (p = 0.018) and nuclear grade was the one significant factor on distant disease-free survival in univariate analysis (p = 0.006). In multivariate analysis, there were no significant factors in terms of overall and distant disease-free survival CONCLUSIONS: Negative margin is more important than the clinical and histological parameters, such as pretreatment stage, clinical response rate, ER and PR in terms of local recurrence. BCS can be performed safely by achieving free surgical margin in patients who have small sized tumour and with either N2 axillary involvement or skin invasion.

Comparison of subdermal and peritumoral injection techniques of lymphoscintigraphy to determine the sentinel lymph node in breast cancer.

PURPOSE: The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer. METHODS: Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically. RESULTS: In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections. CONCLUSION: The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Biological considerations in locally advanced breast cancer treated with anthracycline-based neoadjuvant chemotherapy: thymidine labelling index is an independent indicator of clinical outcome.

The present retrospective study aims to determine the clinical value of thymidine labelling index (TLI) together with other established clinical and biological factors in 116 locally advanced breast cancer (LABC) patients treated with anthracycline-based neoadjuvant chemotherapy, surgery, adjuvant chemotherapy and radiotherapy. TLI was determined in 71 LABC patients with a median of 2.62% (0-23.64%) and a mean of 4.71% +/- 5.54. As a result of neoadjuvant chemotherapy, 85 patients (73%) responded to chemotherapy (CT), whereas 31 patients were unresponsive (27%). No relationship has been found between the pretreatment biological variables including TLI, estrogen receptor (ER), progesteron receptor (PgR) status and clinical parameters such as the chemotherapy response rates and axillary lymph node involvement following chemotherapy. Median follow-up was 35 months (18-97 months) and the 3-year overall survival (OS) and disease free survival (DFS) rates were 71.6% and 52.2%, respectively. In univariate analysis, patients with inflammatory breast cancer, high TLI-index (> or = 2.62%), lymph node (LN) positivity or > 3 positive lymph nodes following neoadjuvant chemotherapy and without any response to neoadjuvant chemotherapy were found to have worse DFS and OS-rates and high local and systemic recurrence rates. In multivariate analysis, TLI was estimated as the most powerful independent factor affecting the OS in LABC patients among the other established clinical and biological parameters (p = 0.02). These results suggest that TLI is an important independent indicator of clinical outcome in patients with LABC and these patients with high TLI levels require more effective treatment modalities.

Can preoperative lymphoscintigraphy be used as a guide in treatment planning of breast cancer?

PURPOSE: The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging. MATERIALS AND METHODS: Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla. RESULTS: Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage. CONCLUSIONS: Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

99Tcm-tetrofosmin scintigraphy in the evaluation of palpable breast masses.

201Tl and 99Tcm-MIBI have been used to evaluate palpable breast masses. The aim of this study was to evaluate the potential of 99Tcm-tetrofosmin as a new tumour localizing agent in patients with palpable breast masses. Nineteen palpable breast masses were evaluated in 18 patients. Each patient received 740 MBq 99Tcm-tetrofosmin intravenously. Ten minutes after the injection, planar breast images in the anterior, right lateral and left lateral views were obtained with the patient in the supine position. Mammography and ultrasonography were performed in all patients. Biopsy or mastectomy with axillary dissection was performed in all patients. Thirteen of 14 primary breast tumours were detected (9 invasive ductal carcinomas, 3 invasive lobular carcinomas, 1 papillary carcinoma). One patient with mucinous carcinoma did not demonstrate 99Tcm-tetrofosmin accumulation. Four of five patients with histopathologically proven benign lesions did not demonstrate 99Tcm-tetrofosmin accumulation (2 fibrocystic diseases, 2 fibroadenomas). 99Tcm-tetrofosmin accumulation was seen in a patient with chronic mastitis. The sensitivity and specificity of 99Tcm-tetrofosmin for malignant breast lesions was 92 and 80% respectively. Four of seven (57%) axillary lymph node metastases showed 99Tcm-tetrofosmin uptake. In conclusion, 99Tcm-tetrofosmin shows real promise for use in evaluating patients with palpable breast masses.

Comparison of fine needle aspiration cytology and excisional biopsy in palpable breast cancers.

It is essential to know the nature of breast lesions before surgery. One of the well-known procedures is the cytologic diagnosis by means of Fine Needle Aspiration (FNA). We planned a prospective comparative study to assess how reliable FNA is for breast masses in our institution. 338 ladies with palpable breast lesions underwent FNA cytology and the results were malignant nature in 89 patients, atypia in 33, atypia suspicion in 24, benign in 171, and insufficient material in 21. Histopathologic examinations of the specimens confirmed that 89 of 89 malignant cytology cases were malignant (100%), 25 of 33 atypia cases were malignant (75%), 9 of 24 atypia suspicion cases were malignant (37%), 12 of 171 benign cases were malignant (7%). Most of the malignant cytology cases consisted of invasive ductal carcinomas (78%). Invasive lobular carcinoma represented suspicious cytology in 42%. FNA is 100% specific and 91% sensitive. Lesions containing rich stroma and fewer cells (lobular, colloidal carcinoma) exhibited mainly suspicious findings. We conclude that FNA is a simple, cheap and safe procedure yielding enough information to diagnose breast masses. It allows possible and accurate treatment options to be explained to the patient before surgery. Suspicious cytology should be confirmed by excisional biopsy because of its high malignant potential. If clinical and mammographic findings supports benign cytology, lesions can be followed up.

Surgical treatment of hepatic hydatid disease.

The results of surgery in 38 patients with hepatic hydatid disease are described. Cystectomy was done in four patients with small peripheral cysts. For them the mean postoperative stay was 8.2 days. Partial cystectomy, introflexion and omentoplasty were performed in 28 patients with uncomplicated large cysts. The mean postoperative stay for these patients was 8.6 days. One patient in this group died of massive hemorrhage and disseminated intravascular coagulation. Exploration of the common bile duct and choledochoduodenostomy were required in three patients who had large cysts complicated by rupture into the biliary tree. This complication resulted in a mean postoperative stay of 11.5 days. Three patients who had cysts complicated by pyogenic infection were treated with tube drainage. They were discharged with their tubes in place after a mean hospital stay of 26.5 days. Hydrogen peroxide 10% was used as a scolicidal agent and was successful in preventing dissemination. All patients underwent ultrasonography 3 months after surgery, and 28 (74%) were followed up by annual examination. There was no recurrence after a mean follow-up of 2.7 years. The results suggest that surgical treatment of hepatic hydatid disease should be governed by the size, location and complications of the cyst. The combination of partial cystectomy, introflexion and omentoplasty was safe and effective therapy for patients with large hepatic cysts uncomplicated by pyogenic infection.