Tumor-to-breast volume ratio as measured on MRI: a possible predictor of breast-conserving surgery versus mastectomy.

BACKGROUND: The surgical approach to breast cancer changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision. OBJECTIVES: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy). METHODS: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy. RESULTS: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001). CONCLUSION: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.

Yield of selective magnetic resonance imaging in preoperative workup of newly diagnosed breast cancer patients planned for breast conserving surgery.

The role of routine preoperative magnetic resonance imaging (MRI) in newly diagnosed breast cancer patients planned for breast conserving surgery is presently being debated. In our medical center we practice selective use of preoperative MRI; we sought to examine the yield of MRI in this highly selected group of patients. A retrospective study of all newly diagnosed breast cancer patients presenting between January 2007 and July 2010 to the Tel Aviv Sourasky Medical Center (Tel Aviv, Israel) was completed. Patients planned for breast conserving surgery who underwent preoperative MRI were included in this study. Patients and tumor characteristics, indication for MRI, findings on MRI, consequent workup, and impact on surgical treatment were recorded. Association between preoperative characteristics and yield of MRI was examined. During the study period, 105 patients that were candidates for breast conserving surgery underwent preoperative evaluation with MRI. Use of breast MRI increased over time. Rates of mastectomy were stable throughout the study years. Dense mammogram was the most frequent (51, 68%) indication for MRI. Additional suspicious findings were found in 41 (39%) patients, prompting further workup including 36 biopsies in 25 patients, of which 22 (61%) were with cancer. These additional findings prompted a change in the surgical plan in a third of the patients. In most patients (92; 88%) clear margins were achieved. Limiting the use of MRI in the preoperative workup of breast cancer patients to a selected group of patients can increase the yield of MRI.

A prospective, controlled study of the botanical compound mixture LCS101 for chemotherapy-induced hematological complications in breast cancer.

BACKGROUND: This prospective, controlled study evaluated the safety, tolerability, and efficacy of the mixture of botanical compounds known as LCS101 in preventing chemotherapy-induced hematological toxicity in breast cancer patients. METHODS: Female patients diagnosed with localized breast cancer were randomly allocated to receive treatment with either LCS101 or placebo capsules, in addition to conventional chemotherapy. The study intervention was initiated 2 weeks prior to the initiation of chemotherapy and continued until chemotherapy was completed, with participants receiving 2 g of LCS101 capsules thrice daily. Subjects were assessed for the development of hematological and nonhematological toxicities, as well as the tolerability and safety of the study intervention. RESULTS: Sixty-five breast cancer patients were recruited, with 34 allocated to LCS101 and 31 allocated to placebo treatment. Patients in the treatment group developed significantly less severe (grades 2-4) anemia (p < .01) and leukopenia (p < .03) when comparing grades 0-1 with grades 2-4, with significantly less neutropenia (p < .04) when comparing grades 0-2 with grades 3-4. This effect was more significant among patients undergoing a dose-dense regimen. No statistically significant effect was found with respect to nonhematological toxicities, and side effect rates were not significantly different between the groups, with no severe or life-threatening events observed in either group. CONCLUSION: The addition of LCS101 to anthracycline- and taxane-based chemotherapy is safe and well tolerated, and may significantly prevent some chemotherapy-induced hematological toxicities in early breast cancer patients. These results should encourage further larger and more extensive clinical trials.

Focal asymmetric breast density: mammographic, sonographic and pathological correlation in 97 lesions--a call to restrain biopsies.

BACKGROUND: The imaging parameters that mandate further diagnostic workup in focal asymmetric breast densities are not clearly defined. OBJECTIVES: To identify indications for further workup in FABD by comparing mammographic and ultrasonographic findings with the pathology results of women with FABD. METHODS: Ninety-four women (97 FABD) were referred for core needle biopsy after incidental discovery of FABD on routine mammograms (n=83) or on diagnostic mammograms performed for palpable masses (n=11). Clinical data included the patient's age, use of hormone replacement therapy, family history of breast cancer, and the presence of a palpable mass. Mammograms and sonograms were evaluated for lesion size and location, associated calcifications, architectural distortion, and change from previous examinations when available. Two patient groups emerged according to the pathological findings and the data were compared. RESULTS: The average age, size and location of the lesions in the malignant (n=5) and benign (n=92) groups were similar. There was a significant difference (P<0.05) for the presence of a clinically palpable mass (60% vs. 9%, respectively), a cluster of calcifications (60% vs. 12%), associated architectural distortion (exclusively in the malignant group) and a solid mass on sonography (50% vs. 9%). The malignant group had a higher rate of family history of breast cancer and HRT use. CONCLUSIONS: FABD usually present a benign etiology and can safely be managed by follow-up. The presence of an architectural distortion, a cluster of malignant-appearing or indeterminate calcifications, a sonographic mass with features of possible malignancy, or a clinically palpable mass mandates tissue diagnosis.

Preoperative clinical, mammographic and sonographic assessment of neoadjuvant chemotherapy response in breast cancer.

BACKGROUND: The current methods for pre- and post-chemotherapy examination of the extent of disease in the breast and lymph nodes do not provide sufficiently accurate information and, not infrequently, the surgeon has to re-operate. OBJECTIVES: To correlate the findings between three methods of examination (physical examination, ultrasonography, mammography), all performed by the same oncologic and radiologic team, in patients with locally advanced breast cancer or a tumor/breast tissue ratio that precludes breast-conserving surgery. METHODS: Forty patients (median age 48 years, range 24-73) with locally advanced breast cancer or with a tumor/breast ratio that precluded breast-conserving surgery were evaluated by the same medical team and received neoadjuvant chemotherapy. Surgery was performed in all, and the pathologic specimen was correlated with the results of the other examinations. RESULTS: In the pre-chemotherapy evaluation, the imaging findings of the breast correlated with the physical findings in 78% of the patients and with the axilla examination in 66.7%. In the post-chemotherapy analysis, imaging agreed with the physical findings of the breast in 62.2% and in 76.3% of the axilla. Sonography best detected occult breast disease and axillary lymph nodes but correlated with pathology in only 58% of the patients in diagnosing breast tumor and in 65.8% in diagnosing axillary lymph nodes. Mammography correlated with breast and lymph node pathology in half the patients. CONCLUSIONS: None of the classical methods of post-neoadjuvant chemotherapy evaluations could adequately delineate the actual extent of the disease in the breast and axillary lymph nodes. More exacting techniques of imaging combined with the classical methods are required.

Neoadjuvant treatment with paclitaxel and epirubicin in invasive breast cancer: a phase II study.

BACKGROUND AND OBJECTIVES: The modern management of locally advanced breast cancer includes a multimodal approach consisting of neoadjuvant chemotherapy (usually given as initial treatment), surgery, radiotherapy and adjuvant hormone therapy. This therapeutic approach converts many patients with initially unresectable disease to reasonable surgical candidates, with acceptable rates of loco-regional disease control. Induction of a pathological complete response (pCR) with modern chemotherapy agents or combined with immunotherapy, when applicable, should be one of the primary goals of neoadjuvant therapy in order to achieve better disease-free and overall survival in this subset of patients. Neoadjuvant chemotherapy is now standard for patients with locally advanced breast cancer, and this method of treatment has been extended to patients with earlier disease without affecting the treatment outcome. The objectives of this study were: (1) to conduct a phase II study to assess the efficacy and availability of epirubicin and paclitaxel in the neoadjuvant setting in women with locally advanced or high tumour-to-breast ratio breast cancer (no patient in either of these subgroups was a candidate for breast-conserving surgery prior to chemotherapy); (2) to evaluate the incidence of clinically relevant toxicity and, in particular, cardiac toxicity after treatment with an epirubicin + paclitaxel regimen in this group of patients. METHODS: In this open-label, phase II, single-centre trial carried out in a university-affiliated tertiary-care municipal hospital, the rate of objective response, evaluated by clinical and pathological examinations, was the primary endpoint of the study. Other endpoints were the rates of breast-conserving surgery, local recurrence, disease-free survival and overall survival. Sixty patients were enrolled from September 1998 to September 2003 with a median follow-up of 56 months (range 16-96). All 60 women met the criteria for inclusion and agreed to participate in the study. They were diagnosed as having locally advanced or high tumour-to-breast ratio breast cancer that did not initially permit breast-conserving surgery. Epirubicin 75 mg/m(2) and paclitaxel 175 or 200 mg/m(2) were administered for five courses. Rates of adverse events were also analysed. RESULTS: Eight patients experienced a pCR, five had a pathological partial response with an almost complete pathological response, and 39 were able to undergo breast-conserving surgery. Adverse effects were mostly of grade 1 or 2 severity. The most common adverse reactions were fatigue and neutropenic fever. One patient developed local recurrence during the median 56-month follow-up. Among examined biological markers, only estrogen receptor negativity was a strong predictor of a pCR. The rates of disease-free and overall survival following the neoadjuvant combination were similar for those who had tumours positive for the estrogen receptor and those who were negative for this. CONCLUSION: Treatment with a combination of epirubicin and paclitaxel enabled lumpectomy in a substantial proportion of women who were previously deemed to not be suitable candidates for breast-conserving surgery. Clinical responses were not influenced by the initial tumour volume, and the only statistically significant predictor of pCR was the estrogen receptor status of the tumour.

[Paget's disease of the breast].

Paget's disease of the breast is a rare malignancy of the nipple-areola complex, comprising 0.5-4% of all breast cancers which is often associated with an underlying in-situ or invasive carcinoma in the breast parenchyma. It is manifested by progressive eczematoid changes of the areola with persistent soreness or itching. Due to the seemingly benign appearance, diagnosis is often delayed by more than six months. There are two main theories regarding the histogenesis of the disease: the epidermotropic and the in-situ transformation. The first suggests that Paget cells are ductal cells that have migrated from an underlying carcinoma of the breast parenchyma to the epidermis of the nipple. The second postulates that nipple keratinocytes undergo transformation into malignant cells independent from any pathology within the breast parenchyma. Prognosis is determined by the nature of the concurrent tumor in the breast. In 50% of cases a palpable mass is evident and it usually represents an infiltrating carcinoma with involved axillary lymph nodes. In the absence of a mass the prognosis is invariably better as it usually reflects a noninvasive tumor (DCIS). The standard treatment has been mastectomy. However in an era when breast conserving surgery is implemented even for advanced infiltrating breast tumors, there might be a role for such a treatment for selected patients with Paget's disease.

Diagnosis and treatment of breast fibroadenomas by ultrasound-guided vacuum-assisted biopsy.

HYPOTHESIS: Ultrasound-guided vacuum-assisted biopsy (UGVAB) can serve as an efficient tool for the diagnosis and excision of breast fibroadenomas. DESIGN: Patients with a clinically and radiographically suspected breast fibroadenoma were prospectively referred for UGVAB to confirm the diagnosis and to attempt to excise the lesion. PATIENTS: Fifty-two female patients, aged 19 to 68 years, were included in the 2-year study. All had at least 1 suspected fibroadenoma. The procedure was performed for a total of 56 lesions. INTERVENTIONS: Imaging modalities prior to biopsy to confirm the clinical suspicion included Doppler ultrasound and mammography or Doppler ultrasound alone. Tumor size and volume were recorded. Ultrasound-guided vacuum-assisted biopsy was performed in all cases, with guidance using the 11-gauge Mammotome handheld vacuum-assisted biopsy system (Ethicon Endo-Surgery Inc, Cincinnati, Ohio). MAIN OUTCOME MEASURES: Major end points included diagnosis compatibility rate, excision rate, complications, and short-term follow-up. RESULTS: A tissue diagnosis was obtained in all cases and was compatible with the clinical diagnosis of fibroadenoma. Complete excision was achieved in all lesions less than or equal to 1.5 cm (mean volume, 0.25 mL). All lesions greater than 2 cm (mean volume, 1 mL) were incompletely excised. Of the 20 lesions measuring 1.5 to 2.0 cm, 11 (55%) were completely excised. The volume of all completely excised lesions was less than 0.9 mL. Four lesions with a volume less than 0.9 mL were incompletely excised due to bleeding. Ten of the 13 cases with incomplete excision were confident enough with the diagnosis to choose imaging follow-up instead of surgery. Two patients (16%) were referred by the radiologist for surgical excision. Only 1 patient with incomplete removal (8%) felt uncomfortable with the remnant lump and requested surgical excision. CONCLUSIONS: Although the breast fibroadenoma is a common benign breast tumor, the treatment and follow-up of these lesions is still debatable. We suggest that UGVAB, which has a well-documented role in the diagnosis of breast lesions, may provide an option for the definitive treatment of breast fibroadenomas.