Impact of multidisciplinary radiologic-pathologic correlation conference for benign image-guided breast biopsies on discordance rates and patient outcomes in a community teaching hospital.

As the assessment for radiologic-pathologic concordance, particularly for benign image-guided breast biopsies, is crucial in the management of patients with imaging abnormalities, many health institutions now conduct multidisciplinary conferences to assess the imaging and pathology findings in patients who had image-guided needle biopsy. We aimed to identify the radiologic-pathologic discordance rates and changes in patient outcomes resulting from the implementation of radiologic-pathologic correlation conferences in a community teaching hospital. Twenty-two (5.6%) out of 393 cases presented were deemed discordant given that the imaging characteristics of the lesions were far too suspicious radiologically to correlate with the benign pathology. Six cases were recommended for further imaging (four had stable lesion on follow- up, one was lost to follow-up and one case eventually had surgical excision which showed atypia); 14 cases for repeat core needle/excisional biopsy (seven had surgical excision with benign histology, five did not have surgery but showed stable lesion on imaging, two were lost to follow-up); one case for close imaging follow-up (lesion ultimately disappeared); the remaining case for second opinion (no follow-up data). The rad-path correlation conference led to a higher level of patient care with significant change in practice across our hospital network.

Does Initial Imaging Modality Affect Breast Biopsy Upgrade Rates? A Single Institution Review.

INTRODUCTION: Image-guided core needle biopsy (CNB) is the standard for diagnostic breast biopsy. However, the upgrade rate to a higher order lesion defined as identification of malignancy on final pathology from surgical excision remains problematic. MATERIALS AND METHODS: A retrospective chart review of all core needle biopsies from 2008 to 2012 was performed. We identified lesions demonstrating atypia without associated malignancy on core needle biopsy and recorded multiple factors to evaluate predictors of upgrade. RESULTS: Of 151 independent core needle biopsies recorded, 26.5% were upgraded to a higher order lesion. Concurrent mammogram and ultrasound (US) were associated with higher sampling error than any individual imaging modality (P = .021). MRI had a trend toward lower rate of upgrade rate but did not reach statistical significance. DISCUSSION: Although MRI had a lower rate of upgrade rate due to sampling error, this did not reach significance possibly because of our small sample size.

Tamoxifen use in patients with ductal carcinoma in situ and T1a/b N0 invasive carcinoma.

BACKGROUND: The purpose of this study was to determine how often patients with ductal carcinoma in situ and T1a/b N0 cancer are offered and accept tamoxifen for secondary chemoprevention. STUDY DESIGN: A retrospective review of 284 patients with T1a/b N0 invasive cancer treated between February 1995 and December 2001 and 129 patients with DCIS treated after September 1998 was carried out. Patient and tumor characteristics associated with being offered and accepting tamoxifen were compared. RESULTS: Tamoxifen was offered to 67% of the invasive cancer patients and accepted by 76% (51% of the entire group). Hormone receptor status was the only significant predictor of being offered tamoxifen (p = 0.004). Older age (p = 0.04), Caucasian race (p = 0.01), and parity (p = 0.04) in premenopausal women were significant predictors of tamoxifen acceptance on univariate analysis. After the publication of the National Surgical Adjuvant Breast and Bowel Project P-1 trial, significantly more patients were offered tamoxifen (p = 0.02), but acceptance rates did not change. Tamoxifen was offered to 91% of the ductal carcinoma in situ patients and accepted by 73% (67% overall). Lumpectomy was associated with significantly higher rates of being offered (p = 0.02) and accepting tamoxifen (p = 0.002) on univariate analysis. CONCLUSIONS: Factors associated with tamoxifen risks and benefits correlate poorly with the use of the drug.

Final results of a phase II trial of preoperative TAC (docetaxel/doxorubicin/cyclophosphamide) in stage III breast cancer.

BACKGROUND: The use of preoperative chemotherapy for breast cancer has been demonstrated to result in similar disease-free survival (DFS) and overall survival (OS) as postoperative adjuvant chemotherapy. Additionally, the rate of pathologic complete response (pCR) in the breast after preoperative chemotherapy has been shown to correlate with survival. The objective of this study was to determine the pCR rate in patients with stage III breast cancer treated with 4 cycles of TAC (docetaxel 75 mg/m2, doxorubicin 50 mg/m2, cyclophosphamide 500 mg/m2) on day 1 before surgery. PATIENTS AND METHODS: From November 1998 through August 2001, we treated 40 patients (mean age, 47 years) with stage III breast cancer with TAC administered every 3 weeks for 4 cycles. RESULTS: We now report follow-up at 24 months. Responses were seen in 83% of patients, with 25% experiencing a clinical complete response, of which 4 patients (10%) had pCRs. At a follow-up of 2 years, data on DFS and OS are available on 37 patients: 12 patients (38%) had disease progression, and 7 patients (21%) had died. Despite the use of prophylactic ciprofloxacin, some degree of myelosuppression was seen in all patients, with 24 patients (63%) experiencing grade 3/4 neutropenia. CONCLUSION: Based on the pCR rate seen in this trial, docetaxel given concomitantly with AC (doxorubicin/cyclophosphamide) for 4 cycles does not appear to be superior to 4 cycles of AC as preoperative treatment for stage III breast cancer. Based on other trials, longer durations of therapy and/or sequencing of AC and docetaxel may result in a higher pCR rate.

A predictive model for the development of hormone-responsive breast cancer.

BACKGROUND: Effective therapies to reduce the risk of hormone-sensitive breast cancers (ER or PR positive) exist. Available models predict the risk of breast cancer without addressing hormone receptor status. The purpose of this study was to identify risk factors predictive of the development of hormone-sensitive cancers. METHODS: A total of 1285 invasive breast cancers in 1263 women were identified from a prospectively maintained database. Risk factors were compared for ER+ and ER- cancers by using Fisher's exact test. RESULTS: Models were developed for premenopausal and postmenopausal women. In premenopausal women, white race, age at menarche < 12 years, and nulliparity or age at first birth > 20 years were used. The risk of ER+ cancer increased from 67.7% with 0 variables to 83.8% with all three (P = .013). In postmenopausal women, white race and a history of estrogen therapy were used. With none of the variables present, the incidence of ER+ cancer was 70.0%; it was 77.6% with one variable and 85.4% with both variables (P = .002). In postmenopausal women, variables predicted significant differences in hormone sensitivity only for those aged < or = 60 years. In the subset of women with information on alcohol use, adding this variable to the model improved the prediction of hormonal status. CONCLUSIONS: Our findings, if prospectively validated, may help identify those who would obtain the greatest benefit from hormonal chemoprevention strategies for breast cancer risk reduction.

A comparison of ductoscopy-guided and conventional surgical excision in women with spontaneous nipple discharge.

INTRODUCTION: Radiologic imaging is routinely used to evaluate women with spontaneous nipple discharge (SND), but definitive diagnosis is usually only achieved by surgical terminal duct excision (TDE). Ductoscopy has been reported to result in improved localization of intraductal lesions and may avoid surgery in women with endoscopically normal ducts. MATERIALS AND METHODS: We conducted a retrospective review of the records of 117 consecutive women who underwent ductoscopy to guide ductal excision (scope-DE) or received conventional TDE without ductoscopy. Two women had atypical ductal lavage cytology and the remainder presented with SND from 1 or more duct. Preoperative evaluation included radiologic imaging as clinically indicated. RESULTS: Fifty-nine women underwent scope-DE, and 58 underwent conventional TDE. There were no significant differences in age, race, discharge characteristics, or radiologic findings. The proportion of women with intraductal neoplasia was slightly greater in the group undergoing scope-DE (88% vs. 81%, P = 0.2). In the conventional TDE group, 8.5% were found to have atypical hyperplasia or duct carcinoma in situ compared with 18.6% in the scope-DE group. In the ductoscopy group, 22 of 59 (37.3%) had lesions >5 cm from the nipple, compared with 1 of 17 women for whom distance of the lesion from the nipple was known in the conventional group (P = 0.02). Of the ductoscopy-detected cancers, 5 of 6 had no symptoms other than SND, whereas 1 of the 4 malignancies in the conventional group presented as SND alone. DISCUSSIONS: Ductoscopy identifies intraductal lesions in a high proportion of women with SND, and it may contribute to more accurate resection of these. A prospective study is required to obtain an unbiased assessment of these possible advantages.

Ductal lavage findings in women with known breast cancer undergoing mastectomy.

BACKGROUND: Ductal lavage has the potential to detect cancer by sampling breast epithelium in asymptomatic high-risk women. To assess the utility of ductal lavage as a cancer diagnostic test, we investigated the association between ductal lavage cytologic findings and histologic findings in women with known breast cancer undergoing mastectomy. METHODS: Ductal lavage was performed in the operating room before mastectomy on 44 breasts from 32 women with known cancer and on eight breasts from seven women undergoing prophylactic mastectomy, two with occult malignancy. If the ductal lavage sample from one or more ducts contained enough epithelial cells for a cytologic diagnosis, lavaged ducts were injected with a mixture of colored dye, gelatin, and a radiographic contrast compound after mastectomy, and breast tissue was radiographed and sectioned. Histologic findings in ducts with and without dye were recorded. Associations between cytologic results and histologic results were examined by univariate and multivariable analyses. RESULTS: At least one duct was lavaged in 36 breasts (mean = 1.4 ducts per breast); all histologic and cytologic procedures were completed in 28 breasts and in 39 ducts. Markedly atypical or malignant cytology was found in five cancer-containing breasts. In 39 ducts with complete cytologic and histologic data and when marked atypia or malignant cells defined a positive cytologic test, sensitivity was 43% (95% confidence interval [CI] = 23% to 72%), specificity was 96% (95% CI = 86% to 100%), and accuracy was 77% (95% CI = 63% to 89%). When mild or marked atypia or malignant cells defined a positive cytologic test, sensitivity was 79% (95% CI = 57% to 96%), specificity was 64% (95% CI = 46% to 83%), and accuracy was 69% (95% CI = 55% to 83%). When all 31 cytologically evaluable breasts were analyzed, sensitivity was 17% (95% CI = 7% to 35%), specificity was 100% (95% CI = 5% to 100%), and accuracy was 19% (95% CI = 9% to 38%). CONCLUSION: In breasts with cancer, ductal lavage appears to have low sensitivity and high specificity for cancer detection, possibly because cancer-containing ducts fail to yield fluid or have benign or mildly atypical cytology.

Factors influencing outcomes for breast conservation therapy of mammographically detected malignancies.

OBJECTIVE: To evaluate the importance of surgeon caseload, lesion type, and biopsy type on outcomes in breast conservation therapy (BCT). BACKGROUND: Breast conservation therapy has low rates of morbidity and mortality and is being performed with increasing frequency. Its primary advantage is cosmetic, and the amount of breast tissue resected is the main determinant of cosmetic outcomes. STUDY DESIGN: Two hundred seventeen consecutive patients undergoing breast conservation therapy at Northwestern Memorial Hospital for mammographically detected breast cancer were evaluated. The volume of tissue excised was compared with the volume of the tumor as a ratio. Univariate and multivariate analyses of the relationships between the specimen-to-tumor-volume ratio (STVR) and histologic diagnosis, biopsy type, surgeon caseload, and lesion type were examined. RESULTS: The mean (log scale) STVR was significantly lower when the mammographic lesion was identified as a mass or architectural distortion versus calcifications (p < 0.001 in multivariate analysis). Mean log (STVR) was also decreased for higher-caseload surgeons (p = 0.02). Core biopsy before lumpectomy was associated with significantly increased mean log (STVR) (83 versus 50, p = 0.05) without significantly increasing the rate of negative margins. CONCLUSIONS: Mammographic lesion type and biopsy method were associated with the amount of tissue excised relative to tumor size as measured by STVR. In addition, surgeons with higher caseloads were better able to perform needle localization lumpectomy to negative margins while limiting the volume of normal breast tissue excised.

Changes in breast cancer therapy because of pathology second opinions.

BACKGROUND: Examination of pathology slides is a routine part of a breast cancer second opinion. The purpose of this study was to determine how often the pathologic second opinion (1) altered the diagnosis and (2) resulted in a change in the surgical procedure. METHODS: Patients presenting between 1997 and 2001 for a second opinion after a biopsy diagnosis of breast cancer (invasive or noninvasive) were included in this study. RESULTS: There were 340 patients presenting for second opinions regarding 346 breast cancers. Sixty-eight pathologic second opinions (20%) did not result in any change in pathology or prognostic factors, whereas in the remaining 80%, some change occurred. Major changes that altered surgical therapy occurred in 7.8% of cases, and pathology review provided additional prognostic information in 40%. Changes were more common in in situ carcinoma than invasive carcinoma (P =.004), but biopsy type (core vs. excisional biopsy) was not a significant predictor of change in pathologic information. CONCLUSIONS: This study confirms the benefit of a pathology second opinion to improve preoperative estimates of prognosis and to determine the appropriate surgical procedure. Missing information on grade and histological subtype was responsible for a large number of cases, suggesting a need for widespread application of standardization and quality improvement in pathology reporting.

Factors that influence surgical choices in women with breast carcinoma.

BACKGROUND: In the absence of medical contraindications, survival after undergoing breast-conserving therapy (BCT), mastectomy (M), and mastectomy with immediate reconstruction (MIR) is equal. The authors studied demographic factors to identify the variables that differed significantly among women making different surgical choices. METHODS: Women with ductal carcinoma in situ or clinical Stage I or II breast carcinoma with no contraindications for BCT or MIR who were treated between 1995 and 1998 were identified from a prospectively collected data base. Demographic and tumor factors were compared using the Fisher exact test. RESULTS: There were 578 women with 586 tumors who did not have contraindications for BCT or MIR. Among this group, 85.2% of women chose BCT, 9.2% of women chose M, and 5.6% of women chose MIR. Women undergoing M alone were older and were more likely to have Stage II carcinoma compared with women undergoing BCT. Patients undergoing M or MIR were more likely to have had a prior breast biopsy compared with patients who chose BCT. Marital status and employment approached significance (P = 0.06); however, a family history of breast carcinoma was not a predictor of treatment choice. CONCLUSIONS: The current findings suggest a need for patient education strategies that emphasize the lack of influence of age and prior breast biopsy on the use of BCT. Differences in demographic variables may reflect true variations in patient preference among groups, emphasizing the need to address the spectrum of treatment options with patients.

Ductal lavage and ductoscopy: the opportunities and the limitations.

Two related techniques of breast epithelial sampling have emerged in the past several years: ductal lavage, in which fluid-yielding nipple ducts are cannulated at their orifices and lavaged with saline while the breast is intermittently massaged; and ductoscopy, in which discharging or fluid-yielding duct orifices are dilated, intubated with a microendoscope, and the lumen directly visualized. Both of these techniques have significant potential in terms of allowing the repeated sampling of ductal epithelium over time and, as such, have generated considerable enthusiasm. However, data regarding the impact of these techniques on the detection of significant breast disease is very scant. It is important at the outset of the assessment of this new technology that breast cancer clinicians and clinical researchers think carefully about the standards of evidence that need to be met regarding the benefits of these procedures before they are widely adopted. In this review of the rationale and early results of these procedures, we attempt to define some of these evidentiary requirements.

Modified radical mastectomy with knife technique.

Infusion of the breast with a tumescent solution of dilute epinephrine hydrochloride in lactated Ringer solution in patients undergoing modified radical mastectomy allows the procedure to be performed rapidly with scalpel dissection and minimal blood loss. The classic technique of modified radical mastectomy with addition of the tumescent solution is described herein.