Is pleomorphic lobular carcinoma really a distinct clinical entity?

BACKGROUND: Attempts to define the clinical behavior of pleomorphic lobular carcinoma (PLC) have been limited to small series, and clinical management strategies have yet to be established. We describe our experience with PLC as compared to classic ILC and invasive ductal carcinoma (IDC). METHODS: From 9/1996 to 5/2003, clinical and histopathologic data for 5,635 patients undergoing primary surgical treatment and sentinel lymph node biopsy for breast cancer were collected. Four hundred eighty one (8.5%) patients were diagnosed with ILC; 3,978 (70.6%) with IDC. Of those with ILC, 356 (74%) patients had material available for pathologic re-review and comprise our study population: 52 were classified as PLC; 298 were classified as classic ILC; and 6 cases were reclassified as IDC. We compared clinical, pathologic, and treatment factors for patients with PLC, ILC, and IDC using the Wilcoxon rank sum and Fisher's exact tests. RESULTS: PLC were larger than ILC and IDC (20 vs. 15 vs. 13, P < 0.001), had more positive nodes (median 1 vs. 0 vs. 0, P < 0.05) and more frequently required mastectomy (63.5% vs. 38.7% vs. 28.8%, P < 0.001). In addition, more patients with PLC had developed metastatic disease compared to patients with ILC (11.5% vs. 3.7%, P < 0.05). CONCLUSIONS: These findings suggest that PLC is a distinct clinical entity that presents at a more advanced stage and may require more aggressive surgical and adjuvant treatment.

Breast cancer recurrence following prosthetic, postmastectomy reconstruction: incidence, detection, and treatment.

BACKGROUND: The purpose of this study was to evaluate the influence of prosthetic reconstruction on the incidence, detection, and management of locoregional recurrence following mastectomy for invasive breast cancer. METHODS: A matched retrospective cohort study was performed. Only patients with invasive breast cancer who had 2 years or more of follow-up and/or patients who had recurrence within 2 years of their primary cancer were included. RESULTS: In total, 618 patients who underwent mastectomy for invasive breast cancer from 1995 until 1999 were evaluated. Three hundred nine patients who had immediate, tissue expander/implant reconstruction were matched to 309 women who underwent mastectomy alone on the basis of age (+/-5 years) and breast cancer stage (I, II, or III). The incidence of locoregional recurrence following mastectomy was 6.8 percent in patients who had reconstruction and 8.1 percent in patients who had mastectomy alone (log rank p = 0.6015). Median time to detection of a locoregional recurrence was 2.3 years (range, 0.1 to 7.2 years) in the reconstructed cohort and 1.9 years (range, 0.1 to 8.8 years) in the nonreconstructed cohort (p = 0.733). Permanent implants were removed following infection in one patient and patient request in two. CONCLUSIONS: These results suggest that there is no difference in the incidence of locoregional recurrence in breast cancer patients who undergo immediate, tissue expander/implant reconstruction compared with those patients who do not have reconstruction. Prosthetic breast reconstruction does not appear to hinder detection of locoregional cancer recurrence. In the majority of patients, management of locoregional recurrence does not necessitate removal of a permanent prosthesis.

Does the benefit of sentinel node frozen section vary between patients with invasive duct, invasive lobular, and favorable histologic subtypes of breast cancer?

BACKGROUND: Although many questions regarding sentinel lymph node (SLN) biopsy in breast cancer have been answered by observational studies and, increasingly, by prospective trials, the role of intraoperative SLN assessment remains a matter of debate. Here we report in detail the results of intraoperative SLN assessment by frozen section (FS), with particular attention to variations in sensitivity and yield by histologic subtype, by tumor size, and by other clinicopathologic parameters. METHODS: Five thousand two hundred ninety-eight consecutive patients with clinical stage T1-3N0 invasive breast carcinoma had SLN biopsy with intraoperative FS at Memorial Sloan Kettering Cancer Center between 1996 and 2004. We report the results of FS by sensitivity (the proportion of all positive SLN detected by FS) and by yield (the proportion of all FS procedures in which the FS was positive). RESULTS: The sensitivity of FS was 61% overall, was higher for invasive duct (ID) than for invasive lobular (IL) cancers (62% vs. 52%; P = 0.006), and was marginally lower for favorable subtypes (46%; P = 0.26). The yield of FS was 21% overall, with no difference between ID and IL cancers (22% vs. 21%; P = 0.49), and with a substantially lower yield for favorable subtypes (3%; P < 0.001). The yield of FS increased with tumor size for ID and IL cancers (P < 0.001), but not for favorable subtypes. For both ID and IL cancers, the sensitivity and yield of FS were significantly higher with younger patient age, increasing tumor size, and lymphovascular invasion. The yield of FS was <10% for all patients with ID or IL tumors < or =1 cm in size who were older than 60 years of age. Among all FS-positive patients, only 45% were identified by the first FS, whereas 91% were cumulatively identified by the first, second, or third FS. CONCLUSIONS: For patients with ID and IL cancers, the overall sensitivity of FS is >50%, but the yield of FS is <10% for individuals > or =60 years of age with T1a/b tumors. Intraoperative FS may not be worthwhile for this low-yield subset, especially for patients with invasive breast cancer of favorable type.

Doctor, what are my chances of having a positive sentinel node? A validated nomogram for risk estimation.

PURPOSE: Lymph node metastasis is a multifactorial event. Several variables have been described as predictors of lymph node metastasis in breast cancer. However, it is difficult to apply these data-usually expressed as odds ratios-to calculate the probability of sentinel lymph node (SLN) metastasis for a specific patient. We developed a user-friendly prediction model (nomogram) based on a large data set to assist in predicting the presence of SLN metastasis. PATIENTS AND METHODS: Clinical and pathologic features of 3,786 sequential SLN biopsy procedures were assessed with multivariable logistic regression to predict the presence of SLN metastasis in breast cancer. The model was subsequently applied to 1,545 sequential SLN biopsies. A nomogram was created from the logistic regression model. A computerized version of the nomogram was developed and is available on the Memorial Sloan-Kettering Cancer Center (New York, NY) Web site. RESULTS: Age, tumor size, tumor type, lymphovascular invasion, tumor location, multifocality, and estrogen and progesterone receptors were associated with SLN metastasis in multivariate analysis. The nomogram was accurate and discriminating, with an area under the receiver operating characteristic curve of 0.754 when applied to the validation group. CONCLUSION: Newly diagnosed breast cancer patients are increasingly interested in information about their disease. This nomogram is a useful tool that helps physicians and patients to accurately predict the likelihood of SLN metastasis.

Single-fraction intraoperative radiotherapy for breast cancer: early cosmetic results.

PURPOSE: To evaluate the cosmetic outcome of patients treated with wide local excision and intraoperative radiotherapy for early-stage breast cancer. METHODS AND MATERIALS: A total of 50 women were treated on a pilot study to evaluate the feasibility of intraoperative radiotherapy at wide local excision. The eligibility criteria included age >60, tumor size 47 cm(3) of treated tissue. Women who had received 18 Gy at the lateral aspects of their cavities had better cosmetic outcomes than did women who had received 20 Gy at the lateral aspects. When comparing the 6- and 12-month results, the scores remained stable for 63%, improved for 17%, and worsened for 20%. CONCLUSION: Intraoperative radiotherapy appears feasible for selected patients. A favorable cosmetic outcome appears to be related to a smaller treatment volume. The cosmetic outcome is acceptable, although additional follow-up is necessary.

A declining rate of completion axillary dissection in sentinel lymph node-positive breast cancer patients is associated with the use of a multivariate nomogram.

OBJECTIVE: To compare sentinel lymph node (SLN)-positive breast cancer patients who had completion axillary dissection (ALND) with those who did not, with particular attention to clinicopathologic features, nomogram scores, rates of axillary local recurrence (LR), and changes in treatment pattern over time. BACKGROUND: While conventional treatment of SLN-positive patients is to perform ALND, there may be a low-risk subgroup of SLN-positive patients in whom ALND is not required. A multivariate nomogram that predicts the likelihood of residual axillary disease may assist in identifying this group. METHODS: Among 1960 consecutive SLN-positive patients (1997-2004), 1673 (85%) had ALND ("SLN+/ALND") and 287 (15%) did not ("SLN+/no ALND"). We compare in detail the clinicopathologic features, nomogram scores, and rates of axillary LR between groups. RESULTS: Compared with the SLN+/ALND group, patients with SLN+/no ALND were older, had more favorable tumors, were more likely to have breast conservation, had a lower median predicted risk of residual axillary node metastases (9% vs. 37%, P < 0.001), and had a marginally higher rate of axillary LR (2% vs. 0.4%, P = 0.004) at 23 to 30 months' follow-up; half of all axillary LR in SLN+/no ALND patients were coincident with other local or distant sites. For patients in whom intraoperative frozen section was either negative or not done, the rate of completion ALND declined from 79% in 1997 to 62% in 2003 to 2004 but varied widely by surgeon, ranging from 37% to 100%. For 10 of 10 evaluable surgeons, the median nomogram scores in the SLN+/no ALND group were

Perpendicular inked versus tangential shaved margins in breast-conserving surgery: does the method matter?

BACKGROUND: In breast-conserving surgery (BCS), the method of margin assessment and the definition of a negative margin vary widely. The purpose of this study was to compare the incidence of positive margins and rates of reexcision between two methods of margin assessment at a single institution. STUDY DESIGN: In July 2004, our protocol for margin evaluation changed from perpendicular inked margins (Group A, n=263) to tangential shaved margins (Group B, n=261). In Group A, margins were classified as positive, close, and negative. Margins designated as "close" were further defined as: < or = 1 mm, < or = 2 mm, and < or =3 mm. In Group B, shaved margins (by definition 2 to 3 mm) were reported as positive or negative. RESULTS: The rate of reported "positive" margins was significantly higher in Group B: 127 of 261 (49%) versus 42 of 263 (16%), p < 0.001. But when patients with "positive, close, or both" kinds of margins were combined in Group A, there was no significant difference between the two techniques. Although the shaved margin was 2- to 3-mm thick, the rate of reexcision in Group B was significantly higher when compared with that in patients with "positive, close, or both" < or =3 mm margins in Group A (75% versus 52%, p < 0.001). The likelihood of finding residual disease remained the same (27% versus 32%, p=NS). CONCLUSIONS: The tangential shaved-margin technique results in a higher proportion of reported positive margins and limits the ability of the surgeon to discriminate among patients with close margins, resulting in a higher rate of reexcision. The fact that many, but not all, patients with positive or close margins in both groups underwent reexcision emphasizes the role of surgical judgment in this setting. Longer followup is required to determine equivalency in rates of local recurrence between these two methods of margin assessment.

Eighteen sensations after breast cancer surgery: a 5-year comparison of sentinel lymph node biopsy and axillary lymph node dissection.

BACKGROUND: The aim of this study is to evaluate prevalence, severity, and level of distress of 18 sensations at baseline (3-15 days) and 5 years after breast cancer surgery, and compare sensations after sentinel lymph node biopsy (SLNB) with those after SLNB plus immediate or delayed axillary lymph node dissection (ALND). METHODS: A total of 187 patients with breast cancer completed the Breast Sensation Assessment Scale at baseline and at 3, 6, 12, 24, and 60 months after surgery to assess prevalence, severity, and level of distress of sensations. Of these, 133 had SLNB, and 54 had SLNB and ALND. Additionally, of the 187 patients, 141 had breast-conservation therapy and 46 had total mastectomy. RESULTS: Sensations were less prevalent, severe, and distressing after SLNB compared with ALND at baseline and at 5 years. This difference was most evident in those who had breast-conservation therapy. Most sensations after SLNB and ALND, even if prevalent, were not severe or distressing. Some sensations remained notably prevalent at 5 years, including tenderness and twinges after SLNB, and tightness and numbness after ALND. Phantom sensations were frequently reported by mastectomy patients. CONCLUSIONS: Prevalence, severity, and level of distress of sensations were lower after SLNB compared with ALND, but some morbidity existed after SLNB. Certain sensations remained highly prevalent in both groups for up to 5 years.

Reoperative sentinel lymph node biopsy: a new frontier in the management of ipsilateral breast tumor recurrence.

BACKGROUND: Breast conservation therapy (BCT) with sentinel lymph node (SLN) biopsy is a well-established standard of care for primary operable breast cancer; 5-10% of BCT patients will develop local recurrence (LR). The question then arises: How best to manage the axilla in the setting of LR after previous BCT and SLN biopsy or axillary dissection (ALND)? METHODS: Between 9/96 and 12/04, 117 reoperative SLN were performed for LR after BCT and either SLN biopsy or ALND more than 6 months previously. Because of wide variation in the number of nodes removed at the initial procedure, validation by backup ALND was not feasible in all cases. RESULTS: Reoperative SLN was successful in 64/117 (55%) patients. SLNs were identified by isotope and dye in 28/64 (44%); isotope only in 29/64 (45%); dye only in 4/64 (6%); 3/64 (5%) unknown. Positive reoperative SLN were found in 10/64 (16%) successful cases. Among 54/64 (84%) patients with negative reoperative SLNs, 23 (43%) had additional non-SLN removed concurrently: these were negative in 21/23 cases (91%). In 2/23 (9%), reoperative SLN were falsely negative: one with a positive intramammary node, and the other with a positive non-SLN palpated at surgery. Success of reoperative SLN was inversely related to number of nodes removed previously, and was more likely to be successful after a previous SLN biopsy than a previous ALND (74% vs. 38%, P = 0.0002). Non-axillary drainage was identified by lymphoscintigraphy significantly more often in reoperative SLN than in primary SLN biopsy (30% vs. 6%, P < 0.0001). There were no local or axillary recurrences at a mean follow up of 2.2 years; 6 patients developed systemic recurrence. CONCLUSIONS: Reoperative SLN biopsy is feasible in the setting of LR after previous BCT/axillary surgery and deserves further study in this increasingly common clinical scenario. The added benefit of lymphoscintigraphy in identifying sites of non-axillary drainage may be greater in the setting of reoperative SLN than for the initial SLN procedure.

Locoregional recurrence after mastectomy: incidence and outcomes.

BACKGROUND: Locoregional recurrences (LRR) after mastectomy may be ominous events, but incidence and outcomes data are limited by heterogeneous study populations and the time period studied. We sought to evaluate the rate of LRR at a single institution in the era of multimodality therapy, identify predictors for isolated LRR, and examine treatment strategies and outcomes of postmastectomy patients with isolated LRR. STUDY DESIGN: In a prospective database, we identified 1,057 patients who underwent mastectomy for invasive cancer at Memorial Sloan-Kettering Cancer Center from 1995 to 1999. Predictive factors for isolated LRR were determined by univariate and multivariate analyses. Treatments and outcomes of patients with isolated LRR were reviewed. All patients with at least 2 years of followup were included. Median followup was 6 years. RESULTS: Overall, LRR developed in 93 of 1,057 (8.8%) patients. Thirty-four (3.2%) had synchronous distant metastases. Distant recurrences developed in thirty-one (2.9%) during the followup period (median followup, 6 years). Twenty-eight patients with LRR (2.6%) remained free of distant disease during the study period. Multivariate analysis showed age less than 35 years, lymphovascular invasion, and multicentricity as major predictors for isolated LRR. In the 28 patients with isolated LRR, 24 had recurrence in the chest wall, 2 in the axilla, and 2 in more than 1 local site. Seventy-eight percent (22 of 28) of patients were rendered disease free with surgery (15 of 22), radiotherapy (13 of 22), chemotherapy (6 of 22), or hormones (9 of 22). CONCLUSIONS: Despite widespread use of adjuvant therapies during the study period, we found an LRR rate after mastectomy of 9%. But for patients presenting with LRR without evidence of distant disease, aggressive multimodality therapy is warranted because many of these patients can be rendered disease free.

Predicting nonsentinel node status after positive sentinel lymph biopsy for breast cancer: clinicians versus nomogram.

BACKGROUND: With increasing frequency, breast cancer patients and clinicians are questioning the need for completion axillary lymph node dissection (ALND) in the setting of a positive sentinel lymph node (SLN). We previously developed a nomogram to estimate the likelihood of residual disease in the axilla after a positive SLN biopsy result. In this study, we compared the predictions of clinical experts with those generated by the nomogram and evaluated the ability of the nomogram to change clinicians' behavior. METHODS: Pathologic features of the primary tumor and SLN metastases of 33 patients who underwent completion ALND were presented to 17 breast cancer specialists. Their predictions for each patient were recorded and compared with results from our nomogram. Subsequently, clinicians were presented with clinical information for eight patients and asked whether they would perform a completion ALND before and after being presented with the nomogram prediction. RESULTS: The predictive model achieved an area under the receiver operating characteristic curve of .72 when applied to the test data set of 33 patients. In comparison, the clinicians as a group were associated with an area under the receiver operating characteristic curve of .54 (P < .01 vs. nomogram). With regard to performing a completion ALND, providing nomogram results did not alter surgical planning. CONCLUSIONS: Our predictive model seemed to substantially outperform clinical experts. Despite this, clinicians were unlikely to change their surgical plan based on nomogram results. It seems that most clinicians can improve their predictive ability by using the nomogram to predict the likelihood of additional non-SLN metastases in a woman with a positive SLN biopsy result.

Can sentinel lymph node biopsy be omitted in patients with favorable breast cancer histology?

BACKGROUND: The widespread use of sentinel lymph node biopsy (SLNB) to replace axillary dissection has broadened the indications for axillary staging in breast cancer. Recent studies have demonstrated a finite risk of lymphedema and sensory morbidity associated with SLNB. We undertook this study to determine whether SLNB could be omitted in clinically node-negative patients with favorable-histology breast cancer. METHODS: We conducted a retrospective review of a prospective database of SLNBs performed at Memorial Sloan-Kettering Cancer Center from 1996 to 2003 to determine the incidence of lymph node metastases by histological subtype. For the favorable subtypes, the patient's age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade were compared by nodal status to determine their predictive value. RESULTS: A total of 196 cases with favorable breast cancer subtypes were identified with a 4.1% (8 of 196) sentinel lymph node (SLN) positivity rate. Each of the histological subtypes included patients with positive SLNs, with the exception of adenoid cystic (n = 4) and secretory (n = 1) breast carcinoma, which were quite rare in our series. When compared by nodal status, the patient's age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade failed to predict those with positive SLNs. CONCLUSIONS: Patients with favorable breast cancer histology have a small risk of axillary SLN metastases. The use of SLNB in these patients should be individualized, taking into consideration the small incidence of axillary metastases and the risks and benefits associated with the SLN procedure.

Is the clinically positive axilla in breast cancer really a contraindication to sentinel lymph node biopsy?

BACKGROUND: Clinically positive axillary nodes are widely considered a contraindication to sentinel lymph node (SLN) biopsy in breast cancer, yet no data support this mandate. In fact, data from the era of axillary lymph node dissection (ALND) suggest that clinical examination of the axilla is falsely positive in as many as 30% of cases. Here we report the results of SLN biopsy in a selected group of breast cancer patients with palpable axillary nodes classified as either moderately or highly suspicious for metastasis. STUDY DESIGN: Among 2,027 consecutive SLN biopsy procedures performed by two experienced surgeons, clinically suspicious axillary nodes were identified in 106, and categorized as group 1 (asymmetric enlargement of the ipsilateral axillary nodes moderately suspicious for metastasis, n = 62) and group 2 (clinically positive axillary nodes highly suspicious for metastasis, n = 44). RESULTS: Clinical examination of the axilla was inaccurate in 41% of patients (43 of 106) overall, and was falsely positive in 53% of patients (33 of 62) with moderately suspicious nodes and 23% of patients (10 of 44) with highly suspicious nodes. False-positive results were less frequent with larger tumor size (p = 0.002) and higher histologic grade (p = 0.002), but were not associated with age, body mass index, or a previous surgical biopsy. CONCLUSIONS: Clinical axillary examination in breast cancer is subject to false-positive results, and is by itself insufficient justification for axillary lymph node dissection. If other means of preoperative assessment such as palpation- or image-guided fine needle aspiration are negative or indeterminate, then SLN biopsy deserves wider consideration as an alternative to routine axillary lymph node dissection in the clinically node-positive setting.

Personal health behaviors in women who have undergone risk-reducing mastectomy.

BACKGROUND: Risk-reducing mastectomy (RRM) remains an effective yet controversial modality for the primary prevention of breast cancer. Is the choice of RRM consistent with a generally proactive healthy lifestyle? METHODS: The National Prophylactic Mastectomy Registry is a volunteer database comprised of 460 women who have undergone bilateral RRM. Each patient received a questionnaire drawn from the Centers for Disease Control Behavioral Risk Factor Surveillance System. Their responses were compared with gender-specific national data from the Centers for Disease Control. RESULTS: Women in the RRM group were statistically more likely to engage in risk-reducing personal health behavior including not smoking, exercising, maintaining their health, and taking advantage of screening programs. CONCLUSIONS: Women in the registry who underwent RRM practiced a more "healthy" lifestyle than gender-matched controls. Therefore, the decision to have prophylactic surgery may have been part of a proactive approach toward their overall physical well-being.

Cytokeratin-positive cells in sentinel lymph nodes in breast cancer are not random events: experience in patients undergoing prophylactic mastectomy.

BACKGROUND: The incidence of immunohistochemistry (IHC)-detected epithelial cell displacement in sentinel lymph node (SLN) biopsy is unknown. In the current study, we address this question by examining the pattern of SLN involvement in patients undergoing prophylactic mastectomy (PM) at Memorial Sloan-Kettering Cancer Center (New York, NY). METHODS: Between January 1999 and January 2003, 5275 patients underwent SLN biopsy. Unilateral or bilateral PM with SLN biopsy was performed in 143 (2.7%) patients, representing 163 PM cases. RESULTS: Occult carcinoma was identified in 13 of 163 (8.0%) PM specimens. Two patients with occult invasive carcinoma had positive SLNs (hematoxylin and eosin). In the remaining 150 PM cases without occult carcinoma (130 patients), 89% underwent IHC analysis of the SLNs. Of these 130 patients, 43 (33%) had one or more prior biopsies in their "cancer-free" breast, a median of 43 days (range, 3-314 days) before PM. A total of 310 SLNs were examined by IHC (mean, 2.3 lymph nodes per PM case). Only 1 of 130 (0.8%) patients without occult carcinoma had an IHC-positive SLN. This patient had Stage IIIC carcinoma of the contralateral breast. IHC-positive SLNs were not identified in any of the 43 patients with a history of prior biopsy. Therefore, only 1 IHC-positive SLN was detected in 310 (0.3%) lymph nodes examined. CONCLUSIONS: IHC-positive cells in SLNs are rare in the absence of cancer and are not the result of previous breast instrumentation. Although the prognostic significance of IHC-positive cells remains controversial, the current study suggests that they are not random events.

The risk of axillary relapse after sentinel lymph node biopsy for breast cancer is comparable with that of axillary lymph node dissection: a follow-up study of 4008 procedures.

OBJECTIVE: We sought to identify the rate of axillary recurrence after sentinel lymph node (SLN) biopsy for breast cancer. SUMMARY BACKGROUND DATA: SLN biopsy is a new standard of care for axillary lymph node staging in breast cancer. Nevertheless, most validated series of SLN biopsy confirm that the SLN is falsely negative in 5-10% of node-positive cases, and few studies report the rate of axillary local recurrence (LR) for that subset of patients staged by SLN biopsy alone. METHODS: Through December of 2002, 4008 consecutive SLN biopsy procedures were performed at Memorial Sloan-Kettering Cancer Center for unilateral invasive breast cancer. Patients were categorized in 4 groups: SLN-negative with axillary lymph node dissection (ALND; n = 326), SLN-negative without ALND (n = 2340), SLN-positive with ALND (n = 1132), and SLN-positive without ALND (n = 210). Clinical and pathologic characteristics and follow-up data for each of the 4 cohorts were evaluated with emphasis on patterns of axillary LR. RESULTS: With a median follow-up of 31 months (range, 1-75), axillary LR occurred in 10/4008 (0.25%) patients overall. In 3 cases (0.07%) the axillary LR was the first site of treatment failure, in 4 (0.1%) it was coincident with breast LR, and in 3 (0.07%) it was coincident with distant metastases. Axillary LR was more frequent among the unconventionally treated SLN-positive/no ALND patients than in the other 3 conventionally treated cohorts (1.4% versus 0.18%, P = 0.013). CONCLUSIONS: Axillary LR after SLN biopsy, with or without ALND, is a rare event, and this low relapse rate supports wider use of SLN biopsy for breast cancer staging. There is a low-risk subset of SLN-positive patients in whom completion ALND may not be required.

Eighteen sensations after breast cancer surgery: a two-year comparison of sentinel lymph node biopsy and axillary lymph node dissection.

PURPOSE/OBJECTIVES: To evaluate the prevalence, severity, and level of distress of 18 sensations at baseline (3-15 days) and 24 months after breast cancer surgery and to compare sensations after sentinel lymph node biopsy (SLNB) with those after SLNB plus immediate or delayed axillary lymph node dissection (ALND). DESIGN: Prospective, descriptive. SETTING: Evelyn H. Lauder Ambulatory Breast Center at Memorial Sloan-Kettering Cancer Center in New York, NY. SAMPLE: 294 women with breast cancer; 214 had undergone breast conserving therapy, and 80 had undergone total mastectomy; 197 had had SLNB, and 97 had had SLNB and ALND. METHODS: Patients completed the Breast Sensation Assessment Scale (BSAS) at baseline and 3, 6, 12, and 24 months after surgery. MAIN RESEARCH VARIABLES: Prevalence, severity, and level of distress of sensations in patients who had undergone breast cancer surgery. FINDINGS: Sensations were less prevalent, severe, and distressing in patients undergoing SLNB than those undergoing ALND. This difference appeared to be limited to those undergoing breast conserving therapy. Most sensations after SLNB and ALND, even if prevalent, were not very severe or distressing. Some sensations persisted as long as two years. These included tenderness after SLNB and numbness after ALND. Patients often reported phantom sensations after total mastectomy. CONCLUSIONS: Overall, prevalence, severity, and level of distress were lower after SLNB compared to ALND, but some morbidity existed after SLNB. Certain sensations remained prevalent in both groups for as long as 24 months. IMPLICATIONS FOR NURSING: Nurses can use information from this study to provide more accurate education and support to patients.

A prospective analysis of the effect of blue-dye volume on sentinel lymph node mapping success and incidence of allergic reaction in patients with breast cancer.

BACKGROUND: This study examined whether the volume of isosulfan blue dye used in sentinel lymph node (SLN) mapping in breast cancer is related to the SLN identification rate or to the incidence of allergic reactions. METHODS: From January 2001 to November 2002, 1728 breast cancer patients underwent 1832 SLN mapping procedures with the combined technique of intraparenchymal blue dye and intradermal radioisotope. Details of each procedure and all allergic reactions were prospectively recorded. Bilateral synchronous SLN procedures were considered as one dye exposure but as two distinct procedures for determining mapping success. Dye-only success was defined as the proportion of cases in which the SLN was identified by blue dye alone. Overall dye success was defined as the proportion of cases in which the SLN was identified by blue dye with or without isotope. RESULTS: When stratified by volume of blue dye, there were no significant differences in dye-only successes, overall dye successes, or mapping failures. Allergic reactions were documented in 31 (1.8%) of 1728 patients. Hypotensive reactions occurred in 3 (.2%) of 1728 patients; 2 (.1%) required pressor support. There was a nonsignificant trend toward fewer allergic reactions with smaller volumes of blue dye. CONCLUSIONS: In combined-technique SLN mapping protocols for breast cancer, using smaller volumes of blue dye may represent a means of optimizing the safety of the procedure without compromising its success.

Role of laparoscopy in the evaluation of the adnexa in patients with stage IV breast cancer.

OBJECTIVE: To describe the utility of laparoscopic evaluation of adnexal masses in women with stage IV breast cancer. METHODS: A retrospective review of gynecologic and breast surgery databases at our institution was performed to identify patients with stage IV breast cancer who underwent surgical evaluation for an adnexal mass or bilateral salpingo-oophorectomy (BSO) between January 1986 and August 2002. Patient demographics and operative and pathologic findings were reviewed. RESULTS: Thirty-one patients were identified. Median age was 47 years (range, 25-79 years). Pathology of the primary breast tumor was infiltrating ductal carcinoma in 58%, invasive lobular carcinoma in 29%, and unspecified in 13%. Median time from diagnosis of stage IV breast cancer to surgical evaluation of the adnexa was 15 months (range, 0-106 months). Surgery consisted of planned laparotomy in four patients and laparoscopic evaluation in 27 patients. Six patients had laparoscopic BSO for hormonal ablation. The remaining 21 patients had laparoscopic evaluation of an adnexal mass. Conversion to laparotomy occurred in three patients based on intraoperative findings of suspected primary ovarian cancer and for technical reasons in one patient. Overall, metastatic breast cancer was diagnosed in 21 (68%) of 31 patients, including two patients with occult metastases undergoing BSO for hormonal ablation. Primary ovarian cancer was found in 3 (10%) of 31 patients, and 7 (22%) of 31 patients had benign findings. Pathologic intraoperative frozen section was obtained in 21 (84%) of 25 patients undergoing laparoscopic evaluation for an adnexal mass. Intraoperative frozen section was concordant with final pathology in 20 (95%) of 21 patients (18 on laparoscopic evaluation, two on laparotomy). CONCLUSIONS: The majority of patients with stage IV breast cancer who present with an adnexal mass will be diagnosed with metastatic breast cancer. A small subset of patients will be diagnosed with primary ovarian cancer; thus, the evaluation of an adnexal mass even in this stage IV setting is warranted. Accurate diagnosis of metastatic breast cancer versus ovarian cancer can be made laparoscopically, thereby avoiding laparotomy in the metastatic breast cancer setting.

A nomogram for predicting the likelihood of additional nodal metastases in breast cancer patients with a positive sentinel node biopsy.

BACKGROUND: The standard of care for breast cancer patients with sentinel lymph node (SLN) metastases includes complete axillary lymph node dissection (ALND). However, many question the need for complete ALND in every patient with detectable SLN metastases, particularly those perceived to have a low risk of non-SLN metastases. Accurate estimates of the likelihood of additional disease in the axilla could assist greatly in decision-making regarding further treatment. METHODS: Pathological features of the primary tumor and SLN metastases of 702 patients who underwent complete ALND were assessed with multivariable logistic regression to predict the presence of additional disease in the non-SLNs of these patients. A nomogram was created using pathological size, tumor type and nuclear grade, lymphovascular invasion, multifocality, and estrogen-receptor status of the primary tumor; method of detection of SLN metastases; number of positive SLNs; and number of negative SLNs. The model was subsequently applied prospectively to 373 patients. RESULTS: The nomogram for the retrospective population was accurate and discriminating, with an area under the receiver operating characteristic (ROC) curve of 0.76. When applied to the prospective group, the model accurately predicted likelihood of non-SLN disease (ROC, 0.77). CONCLUSIONS: We have developed a user-friendly nomogram that uses information commonly available to the surgeon to easily and accurately calculate the likelihood of having additional, non-SLN metastases for an individual patient.