Young breast cancer in a specialised breast unit in Singapore: clinical, radiological and pathological factors.

INTRODUCTION: Whilst only 5.5% to 7% of breast cancer occurs in women less than 40 years of age in the West, the incidence has been reported in up to 18% in Asian population. This study seeks to evaluate our unit's experience in breast cancer in young women. MATERIALS AND METHODS: A retrospective review of our database identified women with newly diagnosed breast cancer from January 2006 to February 2011. Patient demographics, clinical presentation, imaging and pathological findings and treatment received were determined. RESULTS: Out of a total of 1160 women with breast cancer, 135 (11.6%) were under 40 years of age and made up our study population. The most common presentation was a self-detected breast lump. Most patients did not have a positive family history. Mammography demonstrated abnormal findings in 78% of patients. Ultrasound was very sensitive in the evaluation of a breast lump and demonstrated abnormal findings in 95%. Out of 129 women, 40 (31%) underwent breast-conserving surgery of which 5 (12.5%) proceeded to mastectomy due to involved margins. Also, 89 out of 129 women (69%) underwent mastectomy of which 19 (21.3%) had immediate reconstruction. Of a total of 121 primary resections, 94% were invasive ductal carcinoma while 15.5% were pure ductal in-situ carcinomas. The majority (61.2%) showed high grade disease. CONCLUSION: Most young breast cancer patients present with a self-detected breast lump and do not have a positive family history. A strong clinical index of suspicion and appropriate breast imaging workup are useful for the early and accurate diagnosis of breast cancer in young women.

Attitudes toward fertility preservation in female cancer patients.

OBJECTIVE: To survey patient attitudes toward fertility preservation techniques in the case of infertility from cancer treatment. STUDY DESIGN: A cross-sectional survey on adolescent cancer patients (ACPs) aged 15-21 years and their parents, as well as on breast cancer patients (BCPs). RESULTS: A total of 69% of ACPs were aware of the problem of infertility. However, only 31% recalled being spoken to about treatment effects on fertility. Parents were significantly more likely to have been spoken to (58% vs. 31%, p < 0.022) and tended to be more interested in fertility preservation. The groups were in agreement that cancer therapy should not be delayed. Of the BCPs, 67% expressed substantial concern regarding infertility. They were more likely to have been spoken to and tended to be younger and nulliparous, although statistical significance was not reached. Again, most were unwilling to delay therapy. CONCLUSION: There is an interest infertility preservation amongst our patients, but the medical information received may influence, to a certain extent, the attitudes of the patients. Greater emphasis should therefore be placed on counseling the patient during the treatment planning process.

Selective use of adrenal venous sampling in the lateralization of aldosterone-producing adenomas.

INTRODUCTION: It has been suggested that routine adrenal venous sampling (AVS) is necessary to lateralize an aldosterone-producing adenoma in patients with primary hyperaldosteronism. However, the success rate of AVS is variable, with potential risks. We review our experience at University of California San Francisco (UCSF), where AVS is used only selectively, to determine outcomes with this approach. METHODS: All patients undergoing adrenalectomy for aldosteronoma at UCSF from January 1995 to October 2004 were included. Outcome after adrenalectomy was determined based on plasma levels of aldosterone and potassium, rates of persistent hypertension, and reduced use of antihypertensive medications. RESULTS: Altogether, 65 patients were included in the study, 52 (80%) of whom had their adrenal tumors lateralized based on computed tomography scans, magnetic resonance imaging, or both. The remaining 13 (20%) patients had doubtful localization of their lesions on imaging. We did not routinely perform AVS in patients with definitive imaging findings. Thus, only 4 (8%) patients with definitive imaging findings underwent AVS, and one was unsuccessful. Of the 13 patients with doubtful lateralization on imaging, 8 underwent AVS. With this practice, biochemical cure rates after adrenalectomy were up to 100%, and hypertension resolved or was improved in 85% of patients. CONCLUSIONS: AVS may be performed selectively only when preoperative imaging cannot definitively lateralize the aldosteronoma. This practice in our center has resulted in high cure rates. During the era of improved imaging resolution and experience, mandatory routine AVS is not necessary to achieve high cure rates for aldosteronomas.

Primary tumor characteristics predict sentinel lymph node macrometastasis in breast cancer.

Selective sentinel lymphadenectomy (SSL) is rapidly becoming the standard of care in the surgical management of patients with early breast cancer. Sentinel lymph node macrometastasis has been well documented in the literature to have a higher risk of nonsentinel node tumor involvement when compared to micrometastasis. The aim of our study was to determine the primary tumor characteristics associated with sentinel node macrometastasis that will allow us to preoperatively determine this subgroup of patients at risk. This study was a retrospective review of 644 patients who underwent successful SSL as part of their surgical treatment of breast cancer at the University of California San Francisco Carol Franc Buck Breast Care Center from November 1997 to August 2003. All patients underwent preoperative lymphoscintigraphy followed by wide excision or mastectomy and sentinel lymphadenectomy with or without axillary lymph node dissection. One hundred twenty-two patients had positive sentinel nodes on histology. Micrometastasis was present in 43 of these patients and macrometastasis in the remaining 79. Statistical analysis showed that a tumor size greater than 15 mm, poor tubule formation by the tumor cells, and lymphovascular invasion were significantly associated with sentinel node macrometastasis. A high mitotic count showed a trend but was not significant in our study. Patients with a tumor size greater than 15 mm, poor tubule formation, and lymphovascular invasion are at risk of having sentinel node macrometastasis. These patients can be identified preoperatively based on imaging and biopsy criteria, allowing the option of selective intraoperative pathologic evaluation of the sentinel node and immediate completion axillary dissection as necessary.

The effect of sentinel node tumor burden on non-sentinel node status and recurrence rates in breast cancer.

BACKGROUND: Routine axillary lymph node dissection (ALND) after selective sentinel lymphadenectomy (SSL) in the treatment of breast cancer remains controversial. We sought to determine the need for routine ALND by exploring the relationship between sentinel lymph node (SLN) and non-SLN (NSLN) status. We also report our experience with disease relapse in the era of SSL and attempt to correlate this with SLN tumor burden. METHODS: This was a retrospective study of 390 patients with invasive breast cancer treated at a single institution who underwent successful SSL from November 1997 to November 2002. RESULTS: Of the 390 patients, 115 received both SSL and ALND. The percentage of additional positive NSLNs in the SLN-positive group (34.2%) was significantly higher than in the SLN-negative group (5.1%; P = .0004). The SLN macrometastasis group had a significantly higher rate of positive NSLNs (39.7%) compared with the SLN-negative group (5.1%; P = .0001). Sixteen patients developed recurrences during follow-up, including 6.1% of SLN-positive and 3.3% of SLN-negative patients. Among the SLN macrometastasis group, 8.7% had recurrence, compared with 2.2% of SLN micrometastases over a median follow-up period of 31.1 months. One regional failure developed out of 38 SLN-positive patients who did not undergo ALND. CONCLUSIONS: ALND is recommended for patients with SLN macrometastasis because of a significantly higher incidence of positive NSLNs. Higher recurrence rates are also seen in these patients. However, the role of routine ALND in patients with a low SLN tumor burden remains to be further determined by prospective randomized trials.

Ratio of positive to total number of sentinel nodes predicts nonsentinel node status in breast cancer patients.

Selective sentinel lymphadenectomy (SSL) has replaced axillary lymph node dissection (ALND) for many patients with early breast cancer and negative sentinel lymph nodes (SLNs). Yet many patients with a positive SLN are undergoing unnecessary ALND, as no further disease is found in the axilla. The aim of our study was to determine factors associated with additional positive lymph nodes in the axilla in patients who have a positive SLN. This was a retrospective study of patients undergoing SSL with ALND as part of their treatment for breast cancer at a single institution from November 1997 to August 2003. Only patients with one or more positive SLNs were selected for this study. There were 86 patients who fit our study criteria. Of these, 38% had further positive lymph nodes upon ALND. More than one positive SLN and a ratio of positive SLNs to total SLNs of greater than 0.5 were found to be predictors for additional axillary nodal involvement in both univariate and multivariate analyses. The number of positive SLNs and the ratio of positive SLNs to total SLNs is an indication of total tumor burden in the sentinel nodes and may be a reflection of the propensity of the tumor for further lymphatic invasion in the axillary basin.

Positive predictive value of BI-RADS categorization in an Asian population.

The Breast Imaging Reporting And Data System (BI-RADS) categorization of mammograms is useful in estimating the risk of malignancy, thereby guiding management decisions. However, in Asian women, in whom breast density is increased, the sensitivity of mammography is correspondingly lower. We sought to determine the positive predictive value of BI-RADS categorization for malignancy in our Asian population and, hence, its value in helping us to choose between the various modalities for breast biopsy. We retrospectively reviewed all patients with occult breast lesions detected on mammography or ultrasound who underwent needle-localization open breast biopsy (NLOB) in our institution over a 6-year period. There were 470 biopsies in 427 patients; 16% of lesions were malignant. The positive predictive value of BI-RADS 4 and 5 lesions for cancer was 0.27 and 0.84, respectively. While most BI-RADS 5 mass lesions were invasive cancers, the majority of calcifications in this category were in situ carcinomas. We conclude that BI-RADS remains useful in aiding decision-making for biopsy in our Asian population. Based on positive predictive values, we recommend percutaneous breast biopsy for initial evaluation of lesions categorized as BI-RADS 4 or less. For BI-RADS 5 lesions with microcalcifications, open surgical biopsy as a diagnostic and therapeutic procedure may be more appropriate. In the case of a BI-RADS 5 lesion associated with a mass, initial percutaneous biopsy may be useful for diagnosis, followed by a planned single-stage surgical procedure as necessary.