Success of neoadjuvant chemotherapy in conversion of mastectomy to breast conservation surgery.

Neoadjuvant chemotherapy (NC) in patients with breast cancer results in high response rates and has been used with the purpose of reducing tumor size and achieving breast conservation (BC) in individuals who initially require mastectomy. Our objective is to determine the success of NC in achieving BC in women who initially were not candidates for BC. We conducted a cohort study of women with invasive breast cancer who required mastectomy but desired BC surgery. Outcomes measured were tumor response and rates of BC. Thirty-seven women had a mean age of 45 years. Mean tumor size was 51 mm, and 62 per cent were larger than 4 cm. Tumors were predominantly infiltrating ductal carcinoma (83.3%) and high grade (62.2%). Cyclophosphamide, doxorubicin, and 5-fluorouracil with or without taxotere were most commonly used (86%). Complete clinical and pathologic responses were seen in 32.4 per cent and 10.8 per cent of patients, respectively. BC was achieved in 56.7 per cent of cases. Only initial tumor size predicted tumor regression and success of BC (P = 0.014). Neither tumor histology nor biologic markers predicted tumor response. In conclusion, NC is an effective alternative in achieving tumor reduction and BC in selected patients who require mastectomy but desire BC surgery.

Axillary regional recurrence after sentinel lymph node biopsy for breast cancer.

The accuracy of sentinel lymph node biopsy (SLNB) staging in breast cancer has been demonstrated in studies comparing it with axillary dissection. There is a 5 per cent false-negative rate, but this does not always correlate with axillary recurrence. Our purpose was to determine the rate of axillary lymphatic recurrence in breast cancer patients who had a negative SLNB. We conducted a cohort study of breast cancer patients who underwent SLNB between 2001 and 2005. Only patients who had a negative SLNB were included. Patient demographics and tumor factors were reviewed. Outcomes measured were axillary and systemic recurrence and survival. Eighty-nine patients with a mean age of 54.4 +/- 9.9 years were included. Eighty-nine per cent of cases had infiltrating ductal carcinoma histology. Mean tumor size was 19 +/- 14 mm. Breast conservation surgery was done in 65 cases and mastectomy in 24. A mean of 2.3 +/- 2.4 SLN were found. After a median follow-up of 2.15 years, 1 (1%) patient developed a lymphatic recurrence in the axilla. SLNB provides accurate staging of breast cancer. Patients with negative SLNB do not require axillary dissection.

Percutaneous excisional biopsy of palpable breast masses under ultrasound visualization.

A palpable breast mass is a common reason for surgical consultation. Our goal was to determine whether ultrasound-guided vacuum-assisted core biopsy (US-VACB) is safe and effective in completely removing presumed benign palpable breast masses. We conducted a cohort study of 201 consecutive patients with presumed benign palpable masses who underwent removal with US-VACB. The main outcome measured was the successful removal of palpable masses. Palpable masses were successfully removed with US-VACB in 99% of cases; 2% were cancer and 7.5% were atypical ductal hyperplasia or phyllodes tumor. Two clinical recurrences representing a seroma were seen on follow-up. US-VACB is safe and effective in the initial diagnosis and management of presumed benign palpable breast masses. It provides the benefits of percutaneous biopsy and the palpable abnormality no longer remains.

Intraoperative injection of technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer.

BACKGROUND: Our objective was to determine if intraoperative injection of technetium-99m-labeled sulfur colloid is as effective as preoperative injection in the detection of sentinel lymph nodes (SLNs). METHODS: Two hundred consecutive patients with breast cancer underwent SLN biopsy examination. Radiocolloid was injected in the preoperative area (group A) or immediately after induction of anesthesia in the operating room (group B). RESULTS: The SLN detection rate was similar for groups A (96%) and B (100%; P = .2). Radioactive SLNs were detected in 95% of patients in group A and in 97% of patients in group B (P = .1). The mean number of SLNs harvested was 1.6 and 2.1 for groups A and B, respectively. There was no significant difference in positive SLNs between groups (P = .11). CONCLUSIONS: Intraoperative injection of sulfur colloid is highly effective in the detection of SLNs, avoiding patient discomfort and surgical schedule delays.

Outcomes of clinical and surgical assessment of women with pathological nipple discharge.

There is no consensus about the diagnostic approach to pathologic nipple discharge (PND). We hypothesize that lactiferous duct excision (microdochectomy) or image-guided biopsy are safe and effective means of diagnosis of PND. Eighty-two patients with PND underwent history and physical exam followed by breast sonography and mammogram. Image-guided biopsy was done if imaging studies were positive, whereas microdochectomy was done if normal. Discharge was unilateral (96%), bloody (79%), and spontaneous (62%). The sensitivity, specificity, positive and negative predictive values for the detection of neoplasia were 0.07, 1.0, 1.0, and 0.4 for mammography and 0.26, 0.97, 0.91, and 0.48 for sonography, respectively. Tissue diagnosis revealed papillary lesion (57%), mammary duct ectasia (33%), breast cancer (5%), and inflammatory/infectious (5%) causes. Hemorrhagic discharge associated with pregnancy or infections was managed successfully without surgery. After a median follow-up of 18 months, no PND recurrence was seen, but one patient developed cancer in a different location after diagnosis of atypical ductal hyperplasia. In conclusion, imaging studies provide confirmatory information and a biopsy target when positive. Negative imaging does not reliably exclude neoplasia or malignancy. Microdochectomy provides a sensible and effective approach in the workup of patients with PND.

Outcomes of surgical and sonographic assessment of breast masses in women younger than 30.

Assessment of breast masses in young women is challenging due to normal glandular variance. Our purpose is to define the outcomes of specialized physical exam, selective breast sonography (BUS), and biopsy in women younger than 30. Five hundred forty-two patients younger than 30 referred with a palpable breast mass were studied. Patients' mean age was 24.8. Surgeon's physical exam confirmed a dominant mass in 44 per cent of cases. Thirty-seven per cent had normal clinical exams. Median tumor size was 2.2 cm. On multivariate analysis, a mass on surgeon's clinical exam (P < 0.0001), and BUS (P = 0.0001) predicted the presence of a true mass. Fifty-three per cent of self-detected abnormalities were true masses compared to 18 per cent when detected by the primary care provider (PCP) (P < 0.001). Most common diagnoses were fibroadenoma (72%), breast cysts (4%), or fibrocystic changes (3%). Malignancy occurred in 1 per cent. In summary, breast mass is a common reason for surgical consultation. Normal glandular nodularity is often mistaken for a mass. However, a judicious approach of physical exam by a surgeon using selective BUS and image guided core biopsy provides an efficient and safe approach for diagnosis. Breast malignancy is a rare but serious cause of breast mass in young women.

Diagnosis of palpable breast masses: ultrasound-guided large core biopsy in a multidisciplinary setting.

Cytologic diagnosis of palpable breast masses is an accepted method for diagnosis. However, the high nondiagnostic rate causes repeat biopsy, unnecessary delays, and increased costs. Our purpose is to evaluate the use of ultrasound (US)-guided large-core needle biopsy as part of the minimally invasive multidisciplinary diagnosis of palpable breast masses. We studied 502 consecutive patients with 510 palpable solid breast masses seen and evaluated by a multidisciplinary team. Patients had US-guided core biopsy. Clinical-imaging-pathologic correlation (CIPC) was done in all cases. Core biopsy was deemed conclusive if CIPC was congruent and was used to guide definitive management. The median age of our patients was 39 years. Median tumor size was 2.2 cm. Of these cases, 463 (91%) had a conclusive diagnosis on CIPC. Core needle findings on 47 masses were nondefinitive to guide therapy (fibroepithelial lesion, atypical ductal hyperplasia, intraductal papilloma, CIPC). Three cancers were detected in this group on excisional biopsy. In conclusion, US-guided large-core needle biopsy is a sensitive method for diagnosis of palpable breast masses. Multidisciplinary correlation of clinical findings, imaging, and pathology is essential for success. This approach improves use of operating room resources and maximizes patient participation in the decision-making process.

Sentinel lymph node mapping of breast cancer: a case-control study of methylene blue tracer compared to isosulfan blue.

Isosulfan blue has been traditionally used as a tracer to map the lymphatic system during identification of the sentinel lymph node. However, allergic reactions may be life threatening. We compared the efficacy of methylene blue dye as a tracer for sentinel lymph node biopsy to isosulfan blue dye. In an analysis of 164 cases, there was no clinical or statistically significant difference in the success rate of sentinel node biopsy (P = 0.22), the number of blue sentinel nodes harvested (P = 0.46), the concordance with radioactive sentinel nodes (P = 0.92), or the incidence of metastases (P = 0.87) when methylene blue tracer was compared to isosulfan blue. No adverse reaction to either blue dye was observed. In conclusion, intraparenchymal injection of methylene blue dye is a reliable tracer for the lymphatic system and nodal identification during sentinel node mapping for breast cancer. It is safe, inexpensive, and readily available.

Outcomes of sonography-based management of breast cysts.

BACKGROUND: Ultrasound is commonly used during diagnosis of breast lesions. Our purpose was to study the role of sonography for risk stratification of malignancy in the diagnosis and management of palpable breast cysts. METHODS: This was a cohort study of 176 patients with palpable breast cysts. Sonographic findings were correlated with clinical and pathologic outcomes. RESULTS: Mean cyst size was 2.0 +/- 1.8 cm. Cysts were simple, complex and probably benign, and complex and suspicious for neoplasm in 82.25%, 10.25% and 7.5% of patients, respectively. Thick cyst wall (P = 0.0001), mural tumor (P <0.00001), eccentric mass (P = 0.034), and internal septae (P = 0.031) were predictive of neoplasm. Of cysts >3 cm, 33% were cancerous (P = 0.000027). After 378 days of follow-up, 26 % of cysts had recurred. Recurrence was more frequent in patients with bilateral or multiple cysts (P = 0.004). CONCLUSIONS: Sonography is useful in risk stratification of malignancy in breast cysts. There is a high risk of recurrence after cyst aspiration.

Use of preoperative breast ultrasonography for mapping of breast cancer extent improves resection margins during breast conservation surgery.

BACKGROUND: Positive margins after breast conservation surgery occur frequently and negatively influence local control rates. HYPOTHESIS: Preoperative breast ultrasonography reduces the incidence of positive margins during breast conservation surgery. DESIGN: Case-control analysis. PATIENTS AND INTERVENTION: One hundred twenty-two consecutive patients with invasive breast cancer were studied. Palpation or needle-wire-guided breast conservation surgery was used in the first 61 patients (group 1). Preoperative breast ultrasonography was added to the protocol in the last 61 patients (group 2). MAIN OUTCOME MEASURES: Incidence of positive margins, distance to closest margin. RESULTS: There was a 3.7-fold reduction in positive margins (P =.04, 95% confidence interval, 1.06-16.73) and improved resection margins (P =.04, 95% confidence interval, 0.14-3.88) when breast ultrasonography was used. Reexcision of margins was done in 11% (7 of 61 patients) in group 1 and 3% (2 of 61 patients) in group 2 (P =.17). CONCLUSION: Preoperative breast ultrasonography improves the margins of resection and decreases the incidence of positive margins during breast conservation surgery.

Lymphatic tumor burden negatively impacts the ability to detect the sentinel lymph node in breast cancer.

Sentinel lymph node (SLN) biopsy is the preferred method of nodal breast cancer staging. Techniques of SLN biopsy rely on transport of interstitial molecules through mammary lymphatics. Lymphatic flow may be disrupted by tumor emboli. Increased lymphatic tumor burden may be responsible for failure to identify the sentinel lymph node in patients with breast cancer. A prospective database of 110 patients who had SLN biopsy between January 2001 and December 2002 was analyzed. The number of metastatic axillary lymph nodes was used as a measure of lymphatic tumor burden. SLN was found in 94 per cent of cases. It was not found in seven patients; five of them had extensive axillary metastases (71%) compared to 23 per cent when SLN was found (P = 0.001). The average number of metastatic lymph nodes was larger when SLN was not found compared to when SLN was found (12.8 vs. 3.9, respectively, P = 0.002). Increasing numbers of metastatic nodes correlated with decreasing success in SLN biopsy (P = 0.075). The incidence of axillary metastases is higher in patients in whom the sentinel node is not found. High lymphatic tumor burden may have a causative role in SLN biopsy technical failure. Axillary dissection should be performed if SLN is not found, regardless of the tumor size or histology.

Tc-99m Sestamibi Scintimammography for the Evaluation of Breast Masses in Patients with Radiographically Dense Breasts.

The objective of this study was to evaluate the usefulness of technetium-99m sestamibi (MIBI) scintimammography for the diagnosis of breast cancer in patients with palpable breast masses that cannot be adequately evaluated by mammography due to the presence of radiographically dense breasts. At 5 minutes after intravenous injection of MIBI, scintimammograms were obtained in 80 patients who had grade 3 or 4 glandular density on mammograms and a palpable breast mass. Excisional biopsy or FNA biopsy was obtained in 68 lesions in 67 patients. Scintimammography (22 true positive, 4 false positive, 41 true negative, 1 false negative) resulted in a sensitivity of 95.6%, specificity 91.1%, positive predictive value 84.6%, and negative predictive value 97.6%. Mammography (19 true positive, 21 false positive, 24 true negative, 4 false negative) resulted in a sensitivity of 73.9%, specificity 53.3%, positive predictive value 44.7%, and negative predictive value 80%. MIBI scintimammography has a higher sensitivity and specificity than mammography in patients with radiographically dense breasts. It is useful as an adjunct to mammography in those patients with radiographically dense breasts for the characterization of palpable masses. Although sensitivity of mammography in this cohort was high, its specificity was significantly lower than scintimammography. If validated in prospective studies it could provide a safe way of avoiding a breast biopsy in patients with benign findings on clinical exam, mammography, and needle aspiration cytology.