The aim of this study was to determine the potential of screening breast ultrasound to improve breast cancer detection in women with mammographically normal, but dense breasts. Six Connecticut radiology practices with 12 total sites participated in a retrospective chart review. The total number of screening mammograms, screening ultrasounds broken down by BIRADS (Breast Imaging Reporting and Data System) codes, and the number of positive and negative biopsies were collected from November 2009 through November 2010. Demographic data on the patients with positive biopsies as well as cancer staging were also collected. Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value were calculated. A total of 72,030 screening mammograms and 8,647 screening ultrasounds were performed at the research sites during the study period. Relevant research indicates that 41% of the female population has dense breasts. In this study, 12% (8,647/72,030) underwent follow‐up breast ultrasound screening. A total of 86% (7,451/8,647) of the ultrasounds were BIRADS 1 or 2, 9% (767/8,647) were BIRADS 3, 5% (429/8,647) were BIRADS 4 or 5. Of those 429 recommended to undergo biopsy 418 were performed and 28 cancers were found. There was one false negative. Screening breast ultrasound in women with mammographically normal, but dense breasts has a Positive Predictive Value (PPV) of 6.7% (28/418), Negative Predictive Value (NPV) of 99.9% (7,450/7,451), sensitivity of 96.6% (28/29), and a specificity of 94.9% (7,450/7,851). Screening ultrasound had an additional yield of 3.25 per 1,000 cancers in women with dense breasts and normal mammograms and no additional risk factors. As with all screening tests, time, cost, and false positive risk must be considered.
Breast cancer research examining either molecular profiles or biomarker subtypes has focused on the estrogen receptor negative/progesterone receptor negative/human epidermal growth factor receptor 2 negative (ER-/PR-/HER2-) and ER-/PR-/HER2+ subtypes. Less is known about the epidemiology or clinical outcome of the other subtypes. This study examines the eight combinations of ER/PR/HER2 in patients with invasive breast cancer. The 5-year relative survival and the distribution among demographic, socioeconomic, and tumor characteristics of each of the subtypes are examined. Using the California Cancer Registry, 61,309 women with primary invasive breast cancer were classified according to ER/PR/HER2 status. Five-year relative survival was computed for the eight subtypes. Bivariate analyses were used to assess the distribution of cases across all subtypes. Multivariate logistic regression was used to compute the adjusted odds of having one of the five subtypes with the best and worst survival. Survival varied from 96% (ER+/PR+/HER2-) to 76% (ER-/PR-/HER2+ and ER-/PR-/HER2-). The four subtypes with the poorest survival were all ER negative. Women who were younger than age 50, non-Hispanic black or Hispanic, of the lowest SES groups, and had stage IV tumors that were undifferentiated were overrepresented in ER-/PR-/HER2+ and triple negative (ER-/PR-/HER2-) subtypes. Asian Pacific Islanders had increased odds (OR = 1.41; 95% confidence interval [CI] = 1.26-1.57) of having the ER-/PR-/HER2+ subtype. Stage III tumors (OR = 1.25; 95% CI = 1.08-1.44) and stage IV tumors (OR = 1.58; 95% CI = 1.27-1.98) had higher odds than stage I tumors of being ER-/PR-/HER2+. Stage IV tumors (OR = 0.54; 95% CI = 0.44-0.67) strongly decreased the odds of the ER-/PR-/HER2- subtype. Poorly differentiated and undifferentiated tumors were over 20 times as likely as well-differentiated tumors of being ER-/PR-/HER2- or ER-/PR-/HER2+. There are considerable differences in survival, demographics, and tumor characteristics among the eight subtypes. We recommend reporting breast cancer as an ER/PR/HER2 subtype and precisely documenting demographic and tumor characteristics.
Our study was to compare the clarity with which calcifications are seen on conventional mammography (CM) with the same calcifications on digital breast tomosynthesis (DBT). We define clarity as the sharpness, contrast, and diagnostic quality by which the calcifications were depicted. In a HIPPA compliant Institutional Review Board approved study, 3,000 women volunteered to have both a screening mammogram and a DBT study. A total of 119 sequential cases with relevant calcifications (not clearly benign) were reviewed. Two board certified, dedicated, breast imaging radiologists reviewed the CM and DBT images in an unblinded paired comparison. Only the mediolateral oblique (MLO) projection was available for the DBT studies. The MLO and craniocaudal projections were reviewed using the 2D images. Window and leveling, and electronic zoom were permitted. Unlimited time was allowed to provide a subjective assessment as too how well the calcifications were seen, from a diagnostic perspective, when the two studies were evaluated side‐by‐side. In 41.6% of the cases, the readers felt that calcifications were seen with superior clarity on DBT. In 50.4% of the cases, the visibility of calcifications was the same for DBT and CM, and in 8% of the cases, calcifications were seen with greater clarity on CM than DBT. In 92% of the cases, the clarity with which calcifications were seen on DBT was equal to or better than for CM and in almost half, the clarity on DBT was judged to be better than for CM. Our analysis shows that calcifications can be demonstrated with equal or greater clarity on DBT as on CM, thus allowing for comparable, and, perhaps, improved interpretive analysis of detected calcifications.
Nipple‐sparing mastectomy ( NSM ) is considered an oncologically safe option for select patients. As many patients are candidates for nipple‐sparing or skin‐sparing mastectomy ( SSM ), reliable patient‐reported outcome data are crucial for decision‐making. The objective of this study was to determine whether patient satisfaction and/or health‐related quality of life ( HRQOL ) were improved by preservation of the nipple with NSM compared to SSM and nipple reconstruction. Subjects were identified from a prospectively maintained database of patients who completed the BREAST ‐Q following mastectomy and breast reconstruction between March and October 2011 at Memorial Sloan Kettering Cancer Center. Fifty‐two patients underwent NSM followed by immediate expander‐implant reconstruction. A comparison group consisted of 202 patients who underwent SSM followed by immediate expander‐implant reconstruction and later nipple reconstruction. HRQOL and satisfaction domains as measured by BREAST ‐Q scores were compared in multivariate linear regression analyzes that controlled for potential confounding factors. NSM patients reported significantly higher scores in the psychosocial (p = 0.01) and sexual well‐being (p = 0.02) domains compared to SSM patients. There was no significant difference in the BREAST ‐Q physical well‐being, satisfaction with breast, or satisfaction with outcome domains between the NSM and SSM groups. NSM is associated with higher psychosocial and sexual well‐being compared to SSM and nipple reconstruction. Preoperative discussion of such HRQOL outcomes with patients may facilitate informed decision‐making and realistic postoperative expectations.
: Breast enhancement with artificial implants is one of the most frequently performed cosmetic surgeries but is associated with various complications, such as capsular contracture, that lead to implant removal or replacement at a relatively high rate. For replacement, we used transplantation of progenitor-supplemented adipose tissue (cell-assisted lipotransfer; CAL) in 15 patients. The stromal vascular fraction containing adipose tissue progenitor cells obtained from liposuction aspirates was used to enrich for progenitor cells in the graft. Overall, clinical results were very satisfactory, and no major abnormalities were seen on magnetic resonance imaging or mammogram after 12 months. Postoperative atrophy of injected fat was minimal and did not change substantially after 2 months. Surviving fat volume at 12 months was 155 ± 50 mL (Right; mean ± SD) and 143 ± 80 mL (Left) following lipoinjection from an initial mean of 264 mL. These preliminary results suggest that CAL is a suitable methodology for the replacement of breast implants.
We report the outcomes of the European prospective study on prepectoral breast reconstruction using preshaped acellular dermal matrix for complete breast implant coverage. Seventy‐nine patients were enrolled between April 2014 and August 2015 all over Europe using a single protocol for patient selection and surgical procedure, according to the Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons joint guidelines for the use of acellular dermal matrix in breast surgery. The preshaped matrix completely wraps the breast implant, which is placed above the pectoralis major, without detaching the muscle. A total of 100 prepectoral breast reconstructions with complete implant coverage were performed. This series, with mean follow‐up of 17.9 months, had two cases of implant loss (2.0%) including one necrosis of the nipple and one wound breakdown (1.0% respectively). No implant rotations were observed. Good cosmetic outcomes were obtained with natural movement of the breasts and softness to the touch; none of the patients reported experiencing pain or reduction in the movements of the pectoralis major muscle postoperatively. The use of preshaped acellular dermal matrix for a complete breast implant coverage in selected patients is safe and gives satisfactory results, both from the aesthetic view point and the low postoperative complication rates. Further studies reporting long‐term outcomes are planned.
Significant advances have been made to the reconstructive tools available to plastic surgeons allowing for the re‐exploration of subcutaneous breast reconstruction. The purpose of the current study is to examine the safety, efficacy, and aesthetic results of subcutaneous breast reconstruction by a single‐surgeon. A retrospective chart review was performed on all patients undergoing subcutaneous implant‐based breast reconstruction between April 2012 and September 2014. All implants were fully wrapped in Alloderm and placed in the subcutaneous (pre‐pectoral) plane. Primary outcome was a successful subcutaneous breast reconstruction. All complications were recorded. Aesthetics of the preoperative and postoperative photographs were examined. A total of 135 breasts (79 patients) were reconstructed. Direct‐to‐implant reconstruction was performed in 8 patients (10%). Successful breast reconstruction was achieved for 130 breasts in 76 patients (96%). Sixty‐nine patients (87%) had a course free of any unexpected event or complication. There were no patients with implant extrusion or skin necrosis requiring operative intervention. When comparing pre‐mastectomy breasts with post‐mastectomy reconstructions, there was an improvement in the overall aesthetic outcome. Subcutaneous post‐mastectomy breast reconstruction is safe and effective with comparable complication rates to standard techniques. Yet, this minimally invasive approach does not sacrifice the aesthetic results. Long‐term studies will be required to prove the durability of aesthetic results overtime.
It is desirable to have a strategy for evaluation of breast cancer service screening programs years before the long‐term breast cancer mortality data are available. Since successful mammography screening has a significant impact on two components of the TNM (tumor size, node status, presence or absence of distant metastases) classification system, tumor size and node status, we investigated the effect of the randomized breast screening trials on incidence of advanced stage disease and on the subsequent breast cancer death rate. In the trials that achieved a 20% or greater reduction in advanced stage disease, there was an average breast cancer mortality reduction of 28% among women invited to screening (attenders and nonattenders combined). In the trials that achieved a reduction in advanced stage disease of less than 10%, there was no reduction in breast cancer mortality among women invited to screening. This study provides evidence that the average mortality reduction in all the trials underestimates the true mortality reduction, and that substantially greater breast cancer mortality reductions can be expected in screening programs that are effective in reducing advanced stage breast cancer. In addition, monitoring the incidence of advanced stage breast cancer in an ongoing screening program can provide a sensitive and early indicator of the subsequent mortality from the disease.
Phyllodes tumors are a rare distinctive fibroepithelial tumors of the breast and their management continues to be questioned. The aim of our study was to examine the treatment and outcome of 165 patients with phyllodes tumors and to review the options for surgical management. This is a retrospective study of 165 patients who presented to the Institut Curie between January 1994 and November 2008 for benign, borderline or malignant phyllodes tumors. The median follow‐up was 12.65 months [range 0–149.8]. The median age at diagnosis was 44 years [range 17–79]. One hundred and sixty patients (97%) had breast‐conserving treatment, of whom 3 patients (1.8%) had oncoplastic breast surgery. Younger women had a significantly higher chance of having a benign phyllodes tumor (p = 0.0001) or a tumor of small size (p < 0.0001). Histologic examination showed 114 benign (69%), 37 borderline (22%) and 14 malignant tumors (9%). The median tumor size was 30 mm [range 5–150]. The tumor margins were considered incomplete (<10 mm) in 46 out of 165 cases (28%) with 52% revision surgery. Only the tumor grade was a significant risk factor for incomplete tumor margins (p = 0.005). Fifteen patients developed local recurrence (10%) and two, metastases. In univariate analysis, the histologic grade (p = 0.008), and tumor size (p = 0.02) were significative risk factors for local recurrence with an accentuated risk for “borderline” tumors and tumors of large size.).Similar results were obtained using multivariate analysis (p = 0.07). The mainstay of treatment for phyllodes tumors remains excision with a safe surgical margin, taking advantage breast conserving surgery where amenable. For borderline or malignant phyllodes tumors or in cases of local tumor recurrence, mastectomy, and immediate breast reconstruction may become the preferred option. Genetic analysis will potentially supplement classical histologic examination in order to improve our management of these tumors. The role of adjuvant treatments is unproven and must be considered on a case‐by‐case basis.
Extreme oncoplasty is a breast conserving operation, using oncoplastic techniques, in a patient who, in most physicians' opinions, requires a mastectomy. These are generally large, greater than 5 cm multifocal or multicentric tumors. Many will have positive lymph nodes. Most will require radiation therapy, even if treated with mastectomy. Sixty‐six consecutive patients with multifocal, multicentric, or locally advanced tumors that spanned more than 50 mm were studied (extreme cases). All patients underwent excision and oncoplastic reconstruction using a standard or split wise pattern reduction and immediate contralateral surgery for symmetry. All received postexcisional standard whole breast radiation therapy with a boost to the tumor bed. The extreme cases were compared with 245 consecutive patients with unifocal or multifocal tumors that spanned 50 mm or less (standard cases). All extreme patients were advised to have a mastectomy; all sought a breast conserving second opinion. Diagnostic evaluation included digital mammography, ultrasound, MRI , and PET ‐ CT (if invasive). Standard cases did extremely well. No ink on tumor was achieved 96% of the time among 245 patients. The median tumor size was 21 mm (mean 23 mm). Margins equal or greater than 1 mm were achieved in 88.6% of patients. Seventeen (6.9%) standard patients underwent re‐excision to achieve wider margins and only one patient (0.4%) was converted to mastectomy. With 24 months of median follow‐up, three patients (1.2%) experienced local recurrence. For extreme cases, no ink on tumor was achieved 83.3% of the time, which is comparable to published positive margin rates after standard lumpectomy. The median tumor size was 62 mm (mean 77 mm). Margins equal or greater than 1 mm were achieved in 54.5% of patients. Six (9.1%) extreme patients underwent re‐excision to achieve wider margins and four patients (6.1%) were converted to mastectomy. With a follow‐up of 24 months, one patient (1.5%) experienced a local recurrence. Extreme oncoplasty is a promising new concept. It allows successful breast conservation in selected patients with greater than 5 cm multifocal/multicentric tumors. It may be useful in patients with locally advanced tumors following neo‐adjuvant chemotherapy. From a quality of life point of view, it is a better option than the combination of mastectomy, reconstruction, and radiation therapy. Long‐term data on recurrence and survival are not available, using this approach. Based on historical data, it is expected the local recurrence will be somewhat higher but that there will be little or no impact on survival.
: Lymphedema (LE) is a well-known postoperative complication after axillary node dissection (ALND). Although, sentinel lymph node dissection (SLND) involves more focused surgery and less disruption of the axilla, early reports show up to 13% of patients experience some symptoms of LE. The purpose of this study was to determine predictors of arm LE in our patients under going SLND with or without an ALND. One hundred and thirty-seven breast cancer patients were treated at a comprehensive cancer center. Prospective measurement of arm volume was carried every 6 months from date of diagnosis. This data base was retrospectively reviewed for tumor stage, treatment, and subjective complaints of LE. Objective LE was defined as a change greater than 200 mL compared with the control arm. Univariate and multivariate analyses were performed. Arm volume changes were measured over 24 months (median follow-up 20 months) in 137 women: 82 stage I, 48 stage II, and 5 stage III; median age 56 years. Breast-conserving surgery was performed in 133 patients. All patients underwent SLND for axillary staging and for 52 patients this was the only axillary staging procedure. All node-positive patients (31) and 54 node-negative patients under went an immediate completion ALND, the latter as part of a study protocol. At 24 months, 16 (11.6%) patients were found to have objective LE (>200 mL increase). Patient age, tumor size, number of nodes harvested, or adjuvant chemotherapy was not found to be predictive of LE by univariate analysis. The risk of developing postoperative LE was primarily and significantly related to the patients' BMI (p = 0.003). Multivariate analysis revealed patients with a BMI >30 (obese) had an odds ratio of 2.93 (95% CI 1.03-8.31) compared with those with a BMI of <25 of having LE. Symptomatic LE (SLE), as defined by patient complaints was recorded in six of the above 16 patients, no SLE was recorded in patients without objective signs of edema. Univariate subgroup analysis compared the symptomatic to the nonsymptomatic patients and revealed the median number of nodes removed was higher in the symptomatic patients (17 verses 9, p = 0.045); however, these patients had a lower BMI (p = 0.0012). The mean change in arm volume was not significantly different between the groups. SLE occurs in one third of patients with objective arm swelling and most likely is multi-factorial in etiology. Although patients undergoing SLN were recorded as having objective LE, none reported SLE. The development of LE within 2 years of surgery is associated with the patient's BMI and this should be considered in preoperative counseling.
The purpose of this article was to retrospectively evaluate the benefits of screening breast ultrasound in women with dense breast tissue following enactment of Connecticut Bill 458 in O ctober 2009. This bill mandated that women be informed of their breast density and the possible benefit of ultrasound as an additional screening modality. Institutional approval was obtained from the institutional review board for this retrospective study. A total of 5519 women with dense breasts were screened with ultrasound in the year after the law went into effect from O ctober 2009 to S eptember 2010 (post law group). We focused on the women who had negative mammograms and biopsy recommendations based on ultrasound findings ( BIRADS 4 and 5). The data were compared with those from a group of 1319 women who were screened with breast ultrasound before the law went into effect between O ctober 2008 and S eptember 2009 (pre law group). Prior to the law, ultrasound studies were performed only at the referring clinician's request. Of the 5,519 women in the post law group, 10 malignant lesions were found, with a cancer detection rate of 0.18% , biopsy rate of 3.3%, and a positive predictive value of 5.5% . The tumor size on ultrasound ranged from 4 to 15 mm; mean 9.7 mm. Sentinel lymph node biopsy was negative in 7 of 10 patients. Of the 1,319 women in the pre law group, 20 biopsies were recommended, all of which were benign. No malignancies were detected in the pre law group. Establishment of a formal screening breast ultrasound program as an adjunct to mammography in women with dense breasts increased our cancer detection rate following enactment of Connecticut Bill 458.
USA states have begun legislating mammographic breast density reporting to women, requiring that women undergoing screening mammography who have dense breast tissue (Breast Imaging Reporting and Data System [ BI ‐ RADS ] density c or d) receive written notification of their breast density; however, the impact that misclassification of breast density will have on this reporting remains unclear. The aim of this study was to assess reproducibility of the four‐category BI ‐ RADS density measure and examine its relationship with a continuous measure of percent density. We enrolled 19 radiologists, experienced in breast imaging, from a single integrated health care system. Radiologists interpreted 341 screening mammograms at two points in time 6 months apart. We assessed intra‐ and interobserver agreement in radiologists'; interpretations of BI ‐ RADS density and explored whether agreement depended upon radiologist characteristics. We examined the relationship between BI ‐ RADS density and percent density in a subset of 282 examinations. Intraradiologist agreement was moderate to substantial, with kappa varying across radiologists from 0.50 to 0.81 (mean = 0.69, 95% CI [0.63, 0.73]). Intraradiologist agreement was higher for radiologists with ≥10 years experience interpreting mammograms (difference in mean kappa = 0.10, 95% CI [0.01, 0.24]). Interradiologist agreement varied widely across radiologist pairs from slight to substantial, with kappa ranging from 0.02 to 0.72 (mean = 0.46, 95% CI [0.36, 0.55]). Of 145 examinations interpreted as “nondense” ( BI ‐ RADS density a or b) by the majority of radiologists, 82.8% were interpreted as “dense” ( BI ‐ RADS density c or d) by at least one radiologist. Of 187 examinations interpreted as “dense” by the majority of radiologists, 47.1% were interpreted as “nondense” by at least one radiologist. While the examinations of almost half of the women in our study were interpreted clinically as having BI ‐ RADS density c or d, only about 10% of examinations had percent density >50%. Our results suggest that breast density reporting based on a single BI ‐ RADS density interpretation may be misleading due to high interradiologist variability and a lack of correspondence between BI ‐ RADS density and percent density.
To determine if the addition of breast ultrasound in women with dense breasts finds cancers that otherwise would have been obscured. Retrospective chart review from five sites from October 2009 through December 2013. Data included: number of screening mammograms; number of screening ultrasounds; Breast Imaging Reporting Data System code results; biopsy results including type of lesion, size, nuclear grade, receptor and node status, and patient demographic data. Year 1, 2,706 ultrasound with 151 biopsies yielded 11 cancers, positive predictive value (PPV) 7.3%. Detection rate of 4.0/1,000. Year 2, 3,351 ultrasounds with 180 biopsies yielded 11 cancers and high risk lesions ( HRL ), PPV 6.1%. Detection rate 3.3/1,000. Year 3, 4,128 ultrasounds with 148 biopsies yielded 13 cancers and HRL , PPV 8.8%. Detection rate 3.1/1,000. Year 4, 3,331 ultrasounds with 53 biopsies yielded 11 cancers and HRL , PPV of 20.1%. Detection rate of 3.3/1,000. Lesion size ranged 0.3–8.0 cm. Patient age 45–77 years. Three tumors nuclear grade 3 and 1 nuclear grade 2 had positive sentinel nodes. 8 patents had risk factors other than dense breasts. Cancers in patients with prior negative screening ultrasound measured 0.4–1.2 cm and were node negative. Breast ultrasound in women with dense breasts detects mammographically occult malignancy. Over 4 years, the PPV doubled indicating increased accuracy of lesions biopsied while rate of detection remained stable. Lesions were of all cancer types, grade and hormonal status. Only high grade cancers were sentinel node positive and women returning for yearly ultrasound had small lesions with no positive sentinel nodes.
To determine if the addition of screening breast ultrasound in women with mammographically normal but dense breasts improves breast cancer detection. The study utilized a retrospective chart review. Data collected included: (a) total number of screening mammograms; (b) total number of dense breast screening ultrasounds; (c) screening ultrasound Breast Imaging Reporting Data System ( BI ‐ RADS ) code results; (d) biopsy results; and (e) demographic data on women with malignant biopsies. Data were obtained from sites throughout Connecticut from November 1, 2010 to October 31, 2011. Data from 5 Connecticut radiology practices covering 10 sites were collected. Sites conducted a total of 57,417 screening mammograms and 10,282 dense breast screening ultrasounds. Of the screening ultrasounds, 87% (8,972/10,282) were BI ‐ RADS 1 or 2, 9% (875/10,282) were BI ‐ RADS 3, 4% (435/10,282) were BI ‐ RADS 4 or 5, and 39 were found to have a cancer or high‐risk lesion on biopsy. This correlates to 3.8 cancers or high‐risk lesions per 1,000 women screened. If high‐risk lesions are excluded, there are 24 cases of biopsy proven malignancy corresponding to 2.3 cancers per 1,000 women screened. In this study, screening breast ultrasound in women with mammographically normal but dense breasts demonstrated a positive predictive value of 9% (39/435) and specificity of 96% (8,972/9,368). Based on the data collected from sites throughout Connecticut, screening breast ultrasound in women with dense breast parenchyma detects mammographically occult malignancy and high‐risk lesions. The results are especially significant given recent studies suggesting that breast density is an independent risk factor for breast cancer and that mammography is less effective in detecting cancer in dense breasts. The improved specificity and sensitivity between the 1st and 2nd years’ suggests there is a learning curve that may continue to improve the results.
Radioactive seed localization ( RSL ) has emerged as an alternative to wire localization ( WL ) in patients with nonpalpable breast cancer. Few studies have prospectively evaluated patient satisfaction and outcomes with RSL . We report the results of a randomized trial comparing RSL to WL in our community hospital. We prospectively enrolled 135 patients with nonpalpable breast cancer between 2011 and 2014. Patients were randomized to RSL or WL . Patients rated the pain and the convenience of the localization on a 5‐point Likert scale. Characteristics and outcomes were compared between groups. Of 135 patients enrolled, 10 were excluded (benign pathology, palpable cancer, mastectomy, and previous ipsilateral cancer) resulting in 125 patients. Seventy patients (56%) were randomized to RSL and 55 (44%) to WL . Fewer patients in the RSL group reported moderate to severe pain during the localization procedure compared to the WL group (12% versus 26%, respectively, p = 0.058). The overall convenience of the procedure was rated as very good to excellent in 85% of RSL patients compared to 44% of WL patients (p < 0.0001). There was no difference between the volume of the main specimen (p = 0.67), volume of the first surgery (p = 0.67), or rate of positive margins (p = 0.53) between groups. RSL resulted in less severe pain and higher convenience compared to WL , with comparable excision volume and positive margin rates. High patient satisfaction with RSL provides another incentive for surgeons to strongly consider RSL as an alternative to WL .
Papillary lesions of the breast range from benign to atypical to malignant. Although papillomas without frank cancer are benign, their management remains controversial. When a core needle biopsy of a lesion yields a diagnosis of intraductal papilloma with atypia, excision is generally recommended to rule out a concurrent malignant neoplasm. For intraductal papillomas without atypia, however, recommendations for excision versus observation are variable. The aims of this study are to evaluate the rate of concurrent malignancies for intraductal papilloma diagnosed on core needle biopsy and to assess the long‐term risk of developing cancer after the diagnosis of a papillary lesion. This single institution retrospective study analyzed 259 patients that were diagnosed with intraductal papilloma ( IDP ) by core needle biopsy from 1995 to 2010. Patients were grouped by initial diagnosis into three groups (papilloma without atypia, papilloma with atypia, and papilloma with atypical duct hyperplasia or atypical lobular hyperplasia ( ADH / ALH ) and followed up for long‐term outcomes. After a core needle biopsy showing IDP with atypia or IDP + ADH / ALH , surgical excision yielded a diagnosis of concomitant invasive or ductal in situ cancer in greater that 30% of cases. For intraductal papilloma without atypia, the likelihood of cancer was much lower. Moreover, even with excision, the finding of intraductal papilloma with atypia carries a significant risk of developing cancer long‐term, and such patients should be followed carefully and perhaps should be considered for chemoprevention.
To review the imaging and pathologic features of a series of lesions detected at digital breast tomosynthesis ( DBT ), which are occult to conventional digital mammography ( DM ). We retrospectively reviewed 268 consecutive breast imaging reporting and data system 4 and 5 lesions imaged with both DM and DBT at our facility from July 2012 through April 2013. For each lesion, we recorded the mammographic finding, breast density, mode of biopsy, and pathology results. A total of 19 lesions were identified at DBT that were occult to DM . Sixty three percent (12/19) of these lesions were identified in dense breasts. Architectural distortion was seen in 74% (14/19) of cases and spiculated masses accounted for the remaining 26% (5/19). The positive predictive value of biopsy was 53% (10/19). Seven cases were infiltrating ductal carcinomas and three were infiltrating lobular carcinomas. High‐risk lesions accounted for 47% (9/19) of the lesions, the majority of which were radial scars 67% (6/9). Eighty four percent (16/19) of the lesions underwent ultrasound guided core biopsy while the remainder underwent magnetic resonance imaging guided core biopsy. DBT may demonstrate suspicious lesions that are occult to DM , particularly in women with dense breasts. Such lesions have a high likelihood of malignancy and warrant biopsy.
Predicting response to neo-adjuvant chemotherapy (NAC) and survival in locally advanced breast cancer (LABC) is important. This study investigated the prognostic value of tumor heterogeneity evaluated with textural analysis through F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and diffusion-weighted imaging (DWI). We enrolled 83 patients with LABC who had completed NAC and curative surgery. Tumor texture indices from pretreatment FDG PET and DWI were extracted from histogram analysis and 7 different parent matrices: co-occurrence matrix, the voxel-alignment matrix, neighborhood intensity difference matrix, intensity size-zone matrix (ISZM), normalized gray-level co-occurrence matrix (NGLCM), neighboring gray-level dependence matrix (NGLDM), and texture spectrum matrix. The predictive values of textural features were tested regarding both pathologic NAC response and progression-free survival. Among 83 patients, 46 were pathologic responders, while 37 were nonresponders. The PET texture indices from 7 parent matrices, DWI texture indices from histogram, and 1 parent matrix (NGLCM) showed significant differences according to NAC response. On multivariable analysis, number nonuniformity of PET extracted from the NGLDM was an independent predictor of pathologic response (P = .009). During a median follow-up period of 17.3 months, 14 patients experienced recurrence. High-intensity zone emphasis (HIZE) and high-intensity short-zone emphasis (HISZE) from PET extracted from ISZM were significant textural predictors (P = .011 and P = .033). On Cox regression analysis, only HIZE was a significant predictor of recurrence (P = .027), while HISZE showed borderline significance (P = .107). Tumor texture indices are useful for NAC response prediction in LABC. Moreover, PET texture indices can help to predict disease recurrence.
First‐line surgical options for early stage breast cancer and ductal carcinoma in situ include breast conserving surgery or mastectomy. We analyzed factors that influence the receipt of mastectomy and resultant trends over time. Registry analysis was carried out for 21,869 women who underwent up‐front surgical treatment for stage 0, I or II breast cancer between 1998 and 2007 using data from the Kentucky Cancer Registry. We examined the trend of treatment over time and assessed the probability of receiving mastectomy using multivariate logistic regression. Overall, 54.5% of women received breast conservation and 45.5% received mastectomy over a 10‐year period (annual BCS rate range: 46.9–61.2%). The overall mastectomy rate substantially decreased from 53.1% in 1998 to 38.8% in 2005 (p < 0.0001), but then increased to 45% in 2007 (p < 0.001). Between 2005 and 2007, the increase in mastectomies in the age groups of <50 years, 50–69 years, and ≥70 years was 7.5% (p = 0.0351), 4.9% (p = 0.0132) and, 8.0% (p = 0.0283), respectively. On multivariate analysis, the rate of receiving mastectomy was drastically higher for women with stage I or II (versus in situ) disease and moderate or poorly differentiated (versus well differentiated) histology. The rate was modestly higher for uninsured and government‐insured (versus privately insured) patients, patients older than 70 years (versus younger), rural (versus urban) location, receptor negative (versus receptor positive) disease, and unusual histologies (versus ductal and lobular histology). There was no statistically significant difference in surgical choice with regard to race. Determinants of mastectomy for in situ and early stage breast cancer include stage, histology, age, insurance status, county of residence, receptor status. The rate of mastectomy declined until 2005 and is now increasing across all age groups, especially for women < 50 years and ≥70 years.