Bracketed Localization in Breast-Conserving Surgery: Indications and Success Rates From a Single, High Volume, Academic Breast Cancer Center.

BACKGROUND: Bracketed localization is a technique used to help localize lesions for breast-conserving surgery (BCS). To date, there are no guidelines for when bracketed localization should be used in clinical practice. Based on our experience, we aim to provide criteria that should prompt surgeons to consider bracketing. METHODS: A single-institution retrospective chart review was performed on patients who underwent bracketed localization for BCS between 2015 and 2021. Lesion characteristics were recorded including lesion span, number of lesions, histology type on core needle biopsy and surgical specimen, margin status, and need for additional surgery. RESULTS: One hundred and thirteen cases were analyzed. Imaging showed an average lesion span of 5.0-cm. Multifocal lesions represented 45% of cases. Ductal carcinoma in situ (DCIS) was a histological component in 64% of core needle biopsies and 76% of surgical specimens. Negative margins were achieved in 82% of patients on the first excision. Additional surgery was performed in 17% of patients. Invasive lobular carcinoma had the highest additional surgery rate at 23%. Negative margins with BCS were achieved in 96% of cases, including those with successful re-excision. DISCUSSION: This descriptive study shows that bracketed localization was most often employed for patients with large lesion spans, multifocality, and a DCIS or invasive lobular component. While these characteristics are typically associated with higher rates of positive margins, our cohort's rate of additional surgery was comparable to the national average for all BCS operations. These results argue that surgeon utilization of bracketed localization may be beneficial in these clinical scenarios.

Malignant phyllodes tumor with extensive lipomatous differentiation.

Phyllodes tumors are uncommon neoplasms of the breast. Lipomatous differentiation of malignant phyllodes tumor is a rare stromal alteration of this fibroepithelial tumor, demonstrated as a fat-containing mass on imaging. We present the case of a 46-year-old woman who was diagnosed with a malignant phyllodes tumor of the breast that demonstrated extensive lipomatous differentiation.

Trends in the Use of Percutaneous Versus Open Surgical Breast Biopsy: An Update.

PURPOSE: Despite the emergence of core-needle (percutaneous) biopsy as the standard of breast care, open surgical breast biopsies continue to be performed with variable frequency. The aim of this study was to compare trends in the use of percutaneous and open surgical breast biopsies and the relative roles of radiologists and surgeons in performing them. METHODS: The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were reviewed, and trends were studied in the total volume of breast biopsies performed in the Medicare fee-for-service population and in volumes of imaging-guided percutaneous biopsies (IGPBs) and open surgical biopsies. Using Medicare's physician specialty codes, the numbers of procedures performed by different specialties were determined. Trends in the type of imaging used for IGPBs were analyzed using the relevant Current Procedural Terminology codes, introduced in 2014. RESULTS: Between 2004 and 2016, utilization of IGPBs increased from 124,423 to 187,914 (+51%), whereas the use of open surgical breast biopsies declined from to 6,605 to 2,373 (-64%). IGPBs performed by radiologists increased from 89,493 to 160,485 (+79%), and IGPBs by surgeons declined from 30,264 to 24,703 (-18%). Among IGPBs from 2014 to 2016, ultrasound-guided and MRI-guided percutaneous biopsies increased, whereas stereotactic biopsies declined. CONCLUSIONS: There is a steady upward trend in the utilization of imaging-guided breast biopsies, and a majority are performed by radiologists. Ultrasound is the primary guidance technique used in percutaneous breast biopsies.

DR5 activation of caspase-8 induces DC maturation and immune enhancement in vivo.

Non-homeostatic tissue apoptosis in vivo has been shown to induce inflammatory responses and facilitate the cross-presentation of proteins within apoptotic bodies. We hypothesize that in the presence of foreign antigens, the apoptotic-inflammatory process improves immune priming; further, molecules that trigger apoptosis may be adapted for use as immune adjuvants. One very attractive molecule in this context is the tumor necrosis factor receptor (TNFR) family molecule DR5/TRAIL-receptor 2. We show a significant improvement in CD8(+) T-cell mediated vaccine immunity with the use of death receptor-5 (DR5) as an immune adjuvant, a property that is correlated with the activation of caspases-8 (casp8) and dependent on its ability to induce apoptosis in vivo.

Co-immunization with plasmid IL-12 generates a strong T-cell memory response in mice.

Plasmid encoded exogenous IL-12 delivered as a DNA vaccine adjuvant has been shown to improve vaccine-induced immunity. In particular, pIL-12 greatly improves antigen (Ag)-specific cytotoxic tlymphocyte (CTL) activity in immunized mice. The longevity of this response has not previously been studied in detail. We have studied the effect of co-immunization with pIL-12 on HIV gp160 and Influenza A Hemeagglutinnin-specific memory immune responses. Mice co-immunized with pIL-12 and plasmid encoded antigens maintained a greater memory response than those immunized with the plasmid antigen alone which could be measured at least 6 months after vaccination. Further, this translated to an improved outcome after challenge of long term rested mice that were previously immunized. The strength of the immune response as well as the number of Ag-specific T-cells is proportional to the number of Ag-specific cells primed by the vaccination regimen.

Engineering cross-presentation in vivo.

Apoptotic bodies deliver antigens (Ags) to the cross-presentation pathways of dendritic cells (DCs), where their presentation has been associated with both the maintenance of tolerance as well as the induction of protective immunity. The manner in which apoptotic bodies are generated, their abundance in relation to local DCs, and the milieu in which they are generated appear to be the major factors determining whether apoptotic bodies will induce CD8(+) T cell activation or anergy. These observations have been extended to the field of vaccination, where the engineered apoptosis of Ag-bearing/loaded cells in vivo has been used to prime strong CD8(+) T cell immunity. This review will examine Ag capture and cross-presentation by DCs, with particular emphasis on the manipulation of apoptotic bodies in vivo for the purpose of vaccination.