Malignant Phyllodes Tumor with Heterologous Osteosarcomatous and Rhabdomyosarcomatous Elements: A Case Report and Literature Review.

Phyllodes tumor (PT) is an uncommon fibroepithelial lesion of the breast. PT can be classified as benign, borderline, and malignant based on semi-quantitative assessment of stromal hypercellularity and overgrowth, cytologic atypia, mitotic activity, tumor border, and presence of malignant heterologous elements. PT is considered malignant by default, if malignant heterologous elements are encountered. The heterologous elements include liposarcoma, angiosarcoma, osteosarcoma, chondrosarcoma, and rhabdomyosarcoma. Malignant PT (MPT) with rhabdomyosarcomatous component is extremely rare, and only a few cases are reported. Here, we present a case of MPT with mixed osteosarcomatous and rhabdomyosarcomatous elements in a 51-year-old female, with review of the literatures and discussion of the differential diagnosis.

The Effect of Surgeon Referral and a Radiation Oncologist Productivity-Based Metric on Radiation Therapy Receipt Among Elderly Women With Early Stage Breast Cancer: Analysis From a Tertiary Cancer Network.

Purpose: : Guidelines for early-stage breast cancer allow for radiation therapy (RT) omission after breast conserving surgery among older women, though high utilization of RT persists. This study explored surgeon referral and the effect of a productivity-based bonus metric for radiation oncologists in an academic institution with centralized quality assurance review. Methods and materials: : We evaluated patients ≥70 years of age treated with breast conserving surgery for estrogen receptor (ER)+ pT1N0 breast cancer at a single tertiary cancer network between 2015 and 2018. The primary outcomes were radiation oncology referral and RT receipt. Covariables included patient and physician characteristics and treatment decisions before versus after productivity metric implementation. Univariable generalized linear effects models explored associations between these outcomes and covariables. Results: : Of 703 patients included, 483 (69%) were referred to radiation oncology and 273 (39%) received RT (among those referred, 57% received RT). No difference in RT receipt pre- versus post-productivity metric implementation was observed (P = .57). RT receipt was associated with younger patient age (70-74 years; odds ratio [OR], 2.66; 95% confidence interval [CI], 1.54-4.57) and higher grade (grade 3; OR, 7.75; 95% CI, 3.33-18.07). Initial referral was associated with younger age (70-74; OR, 5.64; 95% CI, 3.37-0.45) and higher performance status (Karnofsky performance status ≥90; OR, 5.34; 95% CI, 2.63-10.83). Conclusions: : Nonreferral to radiation oncology accounted for half of RT omission but was based on age and Karnofsky performance status, in accordance with guidelines. Lack of radiation oncologist practice change in response to misaligned financial incentives is reassuring, potentially reflecting incentive design and/or centralized quality assurance review. Multi-institutional studies are needed to confirm these findings.

Outcomes of Breast Cancer Patients with High Volume of Residual Disease Following Neoadjuvant Chemotherapy.

PURPOSE: The use of neoadjuvant chemotherapy (NAC) in patients with operable breast cancer allows for assessment of treatment response and subsequent tailoring of adjuvant therapy. Data are limited with respect to outcomes among patients with a heavy residual tumor burden after NAC. We report outcomes in patients who had exceptionally poor responses to NAC: those with >9 involved nodes after NAC or with 5 cm or more of residual disease in the breast. METHODS AND MATERIALS: Between June 2014 and April 2020, 1511 patients with breast cancer received NAC followed by surgery at our institution. Poor responders, defined as those with positive nodes or residual tumor in the breast, were identified for analysis. Patients were further classified into 3 groups for comparison purposes: (1) 1 to 3 positive nodes; (2) 4 to 9 positive nodes; or (3) >9 positive nodes and/or >5 cm of residual tumor, which was defined as high-volume residual (HVR). Recurrence and survival outcomes were compared based on residual disease burden after NAC. RESULTS: Among 934 poor responders, 539 patients had 1 to 3 positive nodes (ypN1), 215 had 4 to 9 positive nodes (ypN2), and 180 had HVR disease. Specifically, 118 had >9 positive nodes (HVR), and 62 patients had >5 cm of residual tumor in the breast. With a median follow-up of 31 months (interquartile range, 18-46), the 5-year overall survival rate was 88% among ypN1, 76% among ypN2, and 72% among patients with HVR disease (P < .001). The 5-year distant recurrence-free survival and locoregional recurrence incidences were 82% and 7.6% among ypN1 versus 67% and 8.4% among ypN2 versus 53% and 12% among HVR, respectively. CONCLUSIONS: Our work suggests that patients with HVR disease are at high risk for locoregional and distant recurrence as well as death, despite best available standard-of-care treatment. Intensification of locoregional therapies and/or alternative adjuvant systemic treatment may improve outcomes in these poor responders.

Attitudes and access to resources and strategies to improve quality of radiotherapy among US radiation oncologists: A mixed methods study.

INTRODUCTION: We aimed to assess contouring-related practices among US radiation oncologists and explore how access to and use of resources and quality improvement strategies vary based on individual- and organization-level factors. METHODS: We conducted a mixed methods study with a sequential explanatory design. Surveys were emailed to a random 10% sample of practicing US radiation oncologists. Participating physicians were invited to a semi-structured interview. Kruskal-Wallis and Wilcoxon rank-sum tests and a multivariable regression model were used to evaluate associations. Interview data were coded using thematic content analysis. RESULTS: Survey overall response rate was 24%, and subsequent completion rate was 97%. Contouring-related questions arise in ≥50% of clinical cases among 73% of respondents. Resources accessed first include published atlases (75%) followed by consulting another radiation oncologist (60%). Generalists access consensus guidelines more often than disease-site specialists (P = 0.04), while eContour.org is more often used by generalists (OR 4.3, 95% CI 1.2-14.8) and younger physicians (OR 1.33 for each 5-year increase, 95% CI 1.08-1.67). Common physician-reported barriers to optimizing contour quality are time constraints (58%) and lack of access to disease-site specialists (21%). Forty percent (40%, n = 14) of physicians without access to disease-site specialists indicated it could facilitate the adoption of new treatments. Almost all (97%) respondents have formal peer review, but only 43% have contour-specific review, which is more common in academic centres (P = 0.02). CONCLUSION: Potential opportunities to improve radiation contour quality include improved access to disease-site specialists and contour-specific peer review. Physician time must be considered when designing new strategies.

The role of SOX11 immunostaining in confirming the diagnosis of mantle cell lymphoma on fine-needle aspiration samples.

BACKGROUND: Mantle cell lymphoma (MCL) demonstrates cytologic features that overlap with those of other types of B-cell non-Hodgkin lymphomas (B-cell NHLs) containing small to medium-sized cells. The accurate diagnosis of MCL is important because MCL has relatively more aggressive biologic behavior and thus requires specific treatment regimens. Fine-needle aspiration (FNA) is used for diagnosing or staging lymphoma, often with the help of immunophenotyping by flow cytometry. However, the cellularity of an FNA sample may not be high enough for flow cytometry, leading to diagnostic difficulty. SOX11 immunostaining is helpful in the diagnosis of MCL in histologic sections. However, to the authors' knowledge, its diagnostic value for FNA samples has not been studied to date. METHODS: Immunostains for SOX11 were performed on 69 FNA cases with final diagnoses of MCL (13 cases, including 10 classic type and 3 blastoid variant), marginal zone lymphoma (8 cases), follicular lymphoma (10 cases), small lymphocytic lymphoma (12 cases), Burkitt lymphoma (9 cases), plasma cell myeloma (7 cases), and benign lymph nodes (10 cases). Preparation types included cytospin slides (65 cases), direct smears (2 cases), and cell block sections (2 cases). The percentage of positive cells (defined as nuclear staining) and staining intensity were recorded. RESULTS: All 13 cases of MCL were positive for SOX11 staining, with 12 cases demonstrating diffuse positivity. All other types of B-cell NHL cases, plasma cell myelomas, and benign lymph nodes were found to have negative results. Weak staining was found in 1 MCL case of blastoid variant. CONCLUSIONS: SOX11 immunostaining on FNA samples is highly sensitive and specific for MCL and can be used as a reliable adjunct to confirm MCL, especially in a recurrent setting.