ACR Appropriateness Criteria® Imaging of the Axilla.

This publication reviews the current evidence supporting the imaging approach of the axilla in various scenarios with broad differential diagnosis ranging from inflammatory to malignant etiologies. Controversies on the management of axillary adenopathy results in disagreement on the appropriate axillary imaging tests. Ultrasound is often the appropriate initial imaging test in several clinical scenarios. Clinical information (such as age, physical examinations, risk factors) and concurrent complete breast evaluation with mammogram, tomosynthesis, or MRI impact the type of initial imaging test for the axilla. Several impactful clinical trials demonstrated that selected patient's population can received sentinel lymph node biopsy instead of axillary lymph node dissection with similar overall survival, and axillary lymph node dissection is a safe alternative as the nodal staging procedure for clinically node negative patients or even for some node positive patients with limited nodal tumor burden. This approach is not universally accepted, which adversely affect the type of imaging tests considered appropriate for axilla. This document is focused on the initial imaging of the axilla in various scenarios, with the understanding that concurrent or subsequent additional tests may also be performed for the breast. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

High-Resolution Full-3D Specimen Imaging for Lumpectomy Margin Assessment in Breast Cancer.

BACKGROUND: Two-dimensional (2D) specimen radiography (SR) and tomosynthesis (DBT) for breast cancer yield data that lack high-depth resolution. A volumetric specimen imager (VSI) was developed to provide full-3D and thin-slice cross-sectional visualization at a 360° view angle. The purpose of this prospective trial was to compare VSI, 2D SR, and DBT interpretation of lumpectomy margin status with the final pathologic margin status of breast lumpectomy specimens. METHODS: The study enrolled 200 cases from two institutions. After standard imaging and interpretation was performed, the main lumpectomy specimen was imaged with the VSI device. Image interpretation was performed by three radiologists after surgery based on VSI, 2D SR, and DBT. A receiver operating characteristic (ROC) curve was created for each method. The area under the curve (AUC) was computed to characterize the performance of the imaging method interpreted by each user. RESULTS: From 200 lesions, 1200 margins were interpreted. The AUC values of VSI for the three radiologists were respectively 0.91, 0.90, and 0.94, showing relative improvement over the AUCs of 2D SR by 54%, 13%, and 40% and DBT by 32% and 11%, respectively. The VSI has sensitivity ranging from 91 to 94%, specificity ranging from 81 to 85%, a positive predictive value ranging from 25 to 30%, and a negative predicative value of 99%. CONCLUSIONS: The ROC curves of the VSI were higher than those of the other specimen imaging methods. Full-3D specimen imaging can improve the correlation between the main lumpectomy specimen margin status and surgical pathology. The findings from this study suggest that using the VSI device for intraoperative margin assessment could further reduce the re-excision rates for women with malignant disease.

The Prognostic Value of the AJCC 8th Edition Staging System for Patients Undergoing Neoadjuvant Chemotherapy for Breast Cancer.

BACKGROUND: The American Joint Committee on Cancer (AJCC) 8th edition staging system for breast cancer has been validated in the upfront surgery setting, but has not been examined for its prognostic impact on patients undergoing neoadjuvant chemotherapy. METHODS: The National Cancer Data Base was used to identify patients with invasive unilateral breast cancer from 2010 to 2015 who underwent neoadjuvant chemotherapy. AJCC clinical stage classification was compared between the 7th and 8th editions. Receiver operating characteristic analysis of Kaplan-Meier overall survival (OS) was used to determine the predictive fit of the 7th and 8th edition staging in estimating OS. RESULTS: AJCC 7th and 8th clinical staging assignments were applied to 57,466 patients who underwent neoadjuvant chemotherapy for stage I-III breast cancer from 2010 to 2015. Overall, 37.5% of patients were downstaged and 27.8% were upstaged from the 7th to the 8th edition classification. Kaplan-Meier curves comparing 7th and 8th edition staging differed in OS rates, with a mean follow-up time of 41.5 months. AJCC 8th edition prognostic staging was a better predictor of OS than 7th edition anatomic staging for both clinical stage [area under the curve (AUC) 0.67 vs. 0.62, p < 0.01] and pathological stage (AUC 0.70 vs. 0.66, p < 0.01). CONCLUSIONS: Sixty-five percent of patients have a shift in clinical stage in the AJCC 8th edition. AJCC 8th edition staging has better predictive value for OS than 7th edition staging. While validation of these findings with an independent dataset is needed, 8th edition staging will help improve prognostic modeling in patients undergoing neoadjuvant chemotherapy.

Outcomes in patients with small node-negative invasive breast cancer.

PURPOSE: There is controversy whether systemic therapy is warranted in patients with small node-negative tumors, especially among those with HER2+ and triple negative breast cancers (TNBC). In this study we sought to compare survival and recurrence rates (RR) in patients with T1mi,a,bN0M0 breast cancer by tumor type. METHODS: Review of a prospectively maintained data base between January 1, 2000 through December 31, 2013 identified 71 patients with HER2+ tumors, 545 with hormone receptor (HR)+ /HER2- tumors, and 45 with TNBC. The three groups were compared with respect to RR, disease-free survival (DFS), and overall survival (OS). Patients with HER2+ disease and TNBC who received chemotherapy were compared to those who did not. RESULTS: At mean follow-up of 4.9 years, the 5-year OS was 95% and 5-year DFS was 98%. RR for HER2+ , HR+ /HER2- , and TNBC was 7.0%, 3.7%, and 4.4% respectively (P = 0.2). There was no significant difference in OS (P = 0.9) and DFS (P = 0.4) amongst the three groups. On multivariable analysis, use of adjuvant chemotherapy was not associated with improvement in DFS or OS. When patients with HER2+ breast cancer and TNBC who received chemotherapy were compared to those who did not, there was no difference in death rates (P = 0.3). CONCLUSIONS: Patients with T1mi,a,bN0M0 invasive breast cancer have an excellent prognosis. The three molecular subtypes differed significantly in age, tumor size, and tumor grade, but had similar RR, DFS, and OS. Chemotherapy was not associated with improved survival. Tumor subtype may not influence recurrence and survival in such small early stage tumors.

Lymph node wire localization post-chemotherapy: Towards improving the false negative sentinel lymph node biopsy rate in breast cancer patients.

PURPOSE: To evaluate whether the disease status of the pre-neoadjuvant chemotherapy (NAC) core biopsied lymph node (preNACBxLN) in patients with node positive breast cancer corresponds to nodal status of all surgically retrieved lymph nodes (LNs) post-NAC and whether wire localization of this LN is feasible. MATERIALS AND METHODS: HIPPA compliant IRB approved retrospective study including breast cancer patients (a.) with preNACBxLN confirmed metastases, (b.) who received NAC, and (c.) underwent wire localization of the preNACBxLN. Electronic medical records were reviewed. Fisher's exact test was used to compare differences in residual disease post-NAC among breast cancer subtypes. RESULTS: 28 women with node positive breast cancer underwent ultrasound guided wire localization of the preNACBxLN, without complication. There was no evidence of residual nodal disease for 16 patients, with mean 4.4 (median 4) LNs resected. 12 patients had residual nodal metastases, with mean 9.2 (median 7) LNs resected and mean 2.3 (median 2) LNs with tumor involvement. 11 patients had metastases detected within the localized LN. One patient had micrometastasis in a sentinel LN, despite no residual disease in the preNACBxLN. Patients with luminal A/B breast cancer more often had residual nodal metastases (86%) at pathology, as compared to patients with HER2+ (20%) and Triple Negative breast cancer (50%), though not quite achieving statistical significance (p=0.055). CONCLUSION: Ultrasound guided wire localization of the preNACBxLN is feasible and may improve detection of residual tumor in patients post-NAC.

Bracketed radioactive seed localization vs bracketed wire-localization in breast surgery.

Multiple localizers placed in a bracketed fashion facilitates excision of radiographically extensive breast lesions. In this study, bracketed radioactive seed localization (bRSL) was compared to bracketed wire localization (bWL). We hypothesized that bRSL would achieve adequate margins and decrease re-operation rates with similar or less specimen volumes (SV) than bWL. Retrospective review identified patients who underwent bracketed breast procedures at an academic medical center. Data collected included patient demographics, tumor features, treatment variables, and surgical outcomes. Wilcoxon rank-sum test and chi-square test were used to compare continuous and categorical data, respectively. A multivariable logistic regression model was used to evaluate the association between re-excision and localization technique after adjusting for clinically relevant variables. Patients who underwent bWL were 3.9 times more likely to undergo re-excision compared to patients in bRSL group (OR=3.9, 95% CI: 2.0-7.4). Initial and total SV did not significantly differ between the two groups (P=.4). Patients were significantly more likely to undergo a mastectomy in the bWL group than in the bRSL group (24% vs 7%; P<.01). For patients undergoing excision of radiologically extensive breast lesions, bRSL serves as an alternative to bWL. In this retrospective study, bRSL was associated with a decreased re-excision rate with similar SV and a lower rate of mastectomy when compared to bWL.

Bilateral Mastectomy as Overtreatment for Breast Cancer in Women Age Forty Years and Younger with Unilateral Operable Invasive Breast Cancer.

BACKGROUND: Young women with breast cancer (BC) have an increased risk of contralateral breast cancer (CBC) compared with older women. This may contribute to the rising rates of bilateral mastectomy (BM), but it is unclear if BM leads to improved outcomes. METHODS: A prospectively maintained database was reviewed. Patient and tumor characteristics, survival, and rate of CBC were compared in women age ≤40 years treated for unilateral Stage 1-3 BC from January 2000 through December 2013. RESULTS: Patients ranged in age from 20 to 40 (mean 36) years. Of the 446 women, 188 had breast conservation surgery (BCS), 78 had unilateral mastectomy (UM), and 183 had BM. UM, BCS, and BM groups did not differ in mean age, tumor type, hormone receptor status, or Her2 status. Patients in the BCS and BM group had smaller, fewer node-positive (p = 0.02) and lower grade tumors (p < 0.01) compared with the UM group. With a median follow-up of 79 months, Disease-free survival was similar for patients treated with BM, BCS (p = 0.22), or UM (p = 0.75). OS was significantly worse in the patients treated with UM (0.02) but was not different between the BCS and BM groups. CBC incidence was 2% (5/263) in patients who underwent BCS or UM, and 0.4% (1/244) in patients without a germline genetic mutation. CONCLUSIONS: BCS and UM resulted in similar disease-free survival (DFS) as BM in patients age 40 years and younger with BC. BCS and BM had similar OS, whereas UM patients had worse OS. Invasive CBC incidence was less than 0.5% at 10 years in patients without identified germline genetic mutations.

Oncological and Surgical Outcomes After Nipple-Sparing Mastectomy: Do Incisions Matter?

BACKGROUND: While nipple-sparing mastectomy (NSM) for the treatment of breast cancer is becoming more accepted, technical aspects are still evolving. Data regarding risk factors contributing to complications after NSM are limited. This study evaluated technical aspects on outcomes of NSM. METHODS: Review of our database identified 201 patients who had NSM during the period from January 2012 to June 2015. We compared the effect of operative techniques on surgical outcomes. RESULTS: A total of 351 NSM were performed in 201 patients. Mean patient age was 47 years. Inframammary (47 %) or periareolar (35 %) incisions were most frequent. Tumescence was used in 203 (58 %) NSM. Skin flaps were created using sharp dissection in 213 (61 %) and electrocautery in 138 (39 %) breasts. Nipple areola complex (NAC) necrosis was seen in 56 (16 %) breasts, of which 7 were severe (2 %). A higher rate of NAC complications was seen with periareolar incisions (p = 0.02). Sharp dissection did not result in significant rates of flap necrosis compared with electrocautery. Ten patients (3 %) had a positive anterior/deep margin, of which 7 (64 %) had an inframammary approach. Twenty-two (11 %) patients had an infection that required intravenous antibiotics. Fourteen (7 %) patients had implant loss. Dissection technique was not associated with implant loss (p = 1.0) or infection (p = 0.84). Forty-two (12 %) patients had radiation and seven (16 %) required implant removal. CONCLUSIONS: NSM has an acceptable complication rate. NAC necrosis requiring excision or implant loss is rare. Postmastectomy radiation is a significant risk factor for implant loss. Inframammary incisions have fewer ischemic complications but may result in tumor-involved margins.

The staging value of sentinel lymph node biopsy for breast cancer: translating pathologic findings to clinical practice.

Axillary nodal status is an important prognostic factor in guiding locoregional and systemic treatment for breast cancer. Sentinel lymph node biopsy (SNB) has revolutionized axillary staging by replacing axillary lymph node dissection (ALND) in node-negative women. Even in select patients whose sentinel lymph nodes (SLNs) contain metastases, SNB alone has become an accepted method of managing the axilla. Identification of micrometastases through immunohistochemical analysis of SLNs that are tumorfree on hematoxylin and eosin staining (H&E) does not confer additional clinical benefit. The use of SNB after neoadjuvant chemotherapy (NAC) remains controversial. In addition to axillary nodal status, tumor biology plays an increasingly important role in guiding therapeutic decisions.

Impact of weight change during neoadjuvant chemotherapy on pathologic response in triple-negative breast cancer.

Triple-negative breast cancer (TNBC) is an uncommon but aggressive subtype of breast cancer. Obesity has been associated with an increased risk of breast cancer and worse prognosis. Some studies suggest that obese patients are less likely to achieve pathologic complete response (pCR) to neoadjuvant chemotherapy (NCT) and experience worse overall survival. Ki-67 is a proliferation marker that correlates with tumor aggressiveness. The goal of this study was to examine the impact of weight change during NCT for TNBC on pathologic response and Ki-67 reduction. Retrospective review identified 173 TNBC patients treated between 2004 and 2011. Data were collected on patient demographics, pre- and post-NCT body mass index (BMI), Ki-67, and pCR. Data analysis was performed using the two-tailed Student's t-test, analysis of variance (ANOVA), and Fisher's exact test. Sixty-six patients met final study criteria. Forty-three patients lost weight during chemotherapy and 23 gained weight. Patients in the weight gain group were significantly younger (P = 0.0013). There was no significant difference between the two groups in terms of Ki-67 reduction (P = 0.98) or pCR (P = 0.58). When patients were separated into normal weight (BMI<25 kg/m(2) ), overweight (BMI ≥ 25 and <30 kg/m(2) ), and obese (BMI ≥ 30 kg/m(2) ), there was no significant difference in Ki-67 among those groups either before or after NCT. The degree of obesity did not have a significant impact on Ki-67 reduction. Weight change during NCT does not appear to correlate with Ki-67 change or achieving pCR in TNBC. This may reflect the nature of this subtype of breast cancer that is less responsive to the hormonal effects that adipose tissue exerts on cancer cell proliferation.

Intraduodenal sarcoma recurrence of retroperitoneal origin: an unusual cause for a duodenal obstruction.

Soft tissue sarcomas are uncommon tumors, and intraduodenal soft tissue sarcoma manifestation is even more rare. Only three cases of intraduodenal sarcomas have been reported in the literature thus far. Here, we report a case of an intraduodenal recurrence of a retroperitoneal sarcoma causing bowel obstruction. This unusual recurrence pattern likely relates to the patient's previous resection and radiation treatment, and highlights the benefits, limitations and follow-up strategies after multimodality treatment.

Prevalence of obesity among children and/or grandchildren of adult bariatric surgery patients.

BACKGROUND: Clinical experience suggests that some adults who undergo bariatric surgery have children who are obese. Childhood obesity is associated with increased morbidity and mortality in later life. This study examined the prevalence of obesity among children and grandchildren (< or =12 years of age) of adult bariatric surgery patients. METHODS: Patients in a prospective database of morbidly obese patients who underwent bariatric surgery between January 2004 and May 2007 were recruited by phone and in clinic. Patient demographics, body mass index (BMI) at surgery, and survey data were collected. The survey included questions regarding their child/grandchild's body habitus, weight, and height. Child obesity was defined as BMI percentile > or =95. Statistical significance was set at p < 0.05. RESULTS: One hundred twenty-two patients were enrolled in this study (77% women, mean BMI 49 kg/m(2)). One hundred thirty-four out of 233 children/grandchildren identified had complete data; 41% had a BMI percentile > or =95. Only 29% of these obese children were so identified by the adult respondents. Significantly more biological children/grandchildren were obese than nonbiological (p = 0.013), and significantly more biological children were obese than biological grandchildren (p = 0.027). CONCLUSIONS: This sample of bariatric surgery patients had a high proportion of obese preteen children/grandchildren. Obesity was most prevalent among biological children (vs. biological grandchildren and nonbiological children). Patients often did not recognize the degree of overweight in their children/grandchildren. Because families of bariatric surgery patients often include obese children, interventions aimed at all family members merit consideration.