Breast conserving surgery in multicentric breast cancer, preliminary data of our experience.

INTRODUCTION: It is widely supported that multicentric disease of the breast (MCDB) is a contraindication of breast conservative surgery (BCS). MATERIALS AND METHODS: This is a multicentric study (two breast cancer units from Greece, one from France) involving patients with at least two primary tumors in separate quadrants of the breast and no diffuse suspicious microcalcifications on mammography. Sixty-one patients were included in the study, but 49 were followed up to the end. Patients were randomly assigned in total mastectomy (TM) and BCS groups. End point of the study was disease-free survival rates three and five years after initial operation. RESULTS: Three years after BCS, local recurrence (LR) was observed in two patients (7%) and one after five years (total recurrence rate: 11%). A TM was performed in these patients, and in two there was no LR or distant metastasis (DM) five years after. The third patient was disease free two-years later. Three years after TM, eight patients (36.4%) had DM and 14 (63.6%) did not (p = 0.004). Five years after TM, eight patients (36.4%) had DM and 14 patients (63.6%) di not (p = 0.03). CONCLUSION: The results showed that conservative surgery was an alternative surgical option in multicentric breast cancer with good results regarding disease-free survival and recurrence.

Tomosynthesis improves breast cancer detection: our experience.

Breast tomosynthesis (BT) is a novel imaging technology in which an x-ray fan beam sweeps in an arc across the breast, producing tomographic images and it can reduce tissue overlap encountered in conventional two-dimensional (2D) and thus has the potential to improve detection of breast cancer and facilitate accurate differentiation of lesion types. The purpose of this article was to assess the positive predictive value (PPV) of breast cancer with BT versus full-field digital mammography (FFDM) and the assessment of detec- tion of both techniques in the present series.

Sentinel lymph node detection by intranipple injection of patent blue dye in breast cancer: a preliminary report of a feasibility study.

Sentinel lymph node (SLN) biopsy is a well established option for assessing axillary lymph node status in breast cancer. Several techniques have been applied so far (superficial or deeper ones). Based on anatomical features of the lymphatic drainage in the breast, we assessed the feasibility of an intranipple approach for SLN mapping. Our data support the feasibility of SLN detection by our technique, with a high rate of SLN identification, which could be used in clinical practice as an alternative to the peri-areolar approach.

Expression of cathepsin-D in primary breast cancer and corresponding local recurrence or metastasis: an immunohistochemical study.

BACKGROUND/AIM: The role of cathepsin-D is well established in breast cancer progression, being correlated with worse clinical outcomes. However, to our knowledge, no study has been performed investigating its expression in primary breast cancer tumors and their corresponding recurrences or metastasis. MATERIALS AND METHODS: Tissue sections from ten breast cancer cases and their corresponding local recurrences and six breast cancer cases and their corresponding metastases were immunohistochemically assessed for cathepsin-D reactivity. Cases diagnosed as either ductal carcinoma in situ (n=7), or breast carcinoma with no evidence of local recurrence or metastasis during follow-up (n=8) served as controls. RESULTS: Cathepsin-D was significantly up-regulated in all the study groups compared to controls. No difference was found between primary tumors and their corresponding recurrences or metastases. CONCLUSION: Cathepsin-D-expressing breast cancer cells seem to be involved in local recurrence or metastasis formation. Large series are needed to further verify this result with the aim of possible future molecular intervention.

Lymphedema of the arm after surgery for breast cancer: new physiotherapy.

Secondary lymphedema of the upper limb is a complication which can be found in patients who have undergone surgical breast cancer treatment with an axillary dissection. Lymphedema following breast cancer treatment remains a long-term disabling complication which cannot be treated in a decisive and radical manner. The objective of the treatment is to limit complications, to try to preserve the remaining lymphatic system and to develop new anastomosis. It consists of a specific decongestive physiotherapy, which may include a specific lymphatic drainage and skin mobilization, reducing bandages including Mobiderm (Thuasne), and sub-bandage muscular exercises. However variations in the therapy have been recorded by different teams. Our experience in treating lymphedema in Tunisia takes into consideration the epidemiological, climatic, cultural and socio-economic conditions of the country. The difference in our treatment compared to what is being advocated elsewhere essentially consists of the no muscular exercise while wearing a bandage. This is compensated for by daily domestic activities, by prolonging the first two phases of treatment (the intensive phase and the stabilization phase), and by the use of the hydro gel dressing Hydrosob (Hartmann) to prevent blisters induced by the pressure imposed by Mobiderm studs of the bandage on the skin, and also by the superimposition of two types of Mobiderm bandages (small and large blocks).

Quantitative assessment of breast mammographic density with a new objective method.

Women with increased mammographic density (MD) have an increased risk of developing breast cancer. The purpose of our study is to evaluate an experimental method to quantify MD using a program (compatible with Windows XP, Vista and 7) which measures black areas as 0, white areas as 100 and grey scale areas with intermediate values between 0 and 100, depending on the "density" of the area. Digital screening mammograms were directly estimated with this method. Initial idea and steps of the program were based on a Mac utility used by our research team.

Clinical management of HPV-related disease of the lower genital tract.

Cytology remains the mainstay for cervical screening. The need to achieve effective management, limit complications, and preserve reproductive function led to the popularity of local treatment. Although the cure rates for ablative and excisional methods are similar, the excisional method provides a more reliable histopathological diagnosis. Recent evidence revealed increased perinatal morbidity after treatment that appears to be related to the proportion of cervix removed. The human papillomavirus (HPV) DNA test appears to enhance the detection of disease in primary screening, in the triage of minor cytological abnormalities, and in follow-up. Further research on the clinical application of a scoring system is ongoing. The vaccines are now available and appear to be safe, well tolerated, and highly efficacious in HPV naive women. A synergy of vaccination and screening will be required. Treatment for early cervical cancer is increasingly shifting toward more fertility-sparing surgical techniques. Careful selection of patients is essential.

Preliminary results of objective assessment of mammographic percent density.

Breast density assessments performed by using the Breast Imaging Reporting and Data System (BI-RADS) have been completely qualitative and the American College of Radiology (ACR) fibroglandular density descriptors are mainly subjective. However, women with increased mammographic density (MD) have an increased risk of developing breast cancer. The purpose of our study was to evaluate an experimental method to quantify MD using a software utility which measures absolutely black areas as zero and absolutely white areas as 100. In grey scale areas, these values range between 0 and 100, depending on the "density" of the area. Digital screening mammograms were directly estimated with this method. We concluded that there is a significant correlation between ACR quartiles and this grey scale percentage method, although several improvements on the original idea are planned.

Maximizing the benefits of screening mammography for women 40-49 years old.

BACKGROUND: While women aged 50 and older are broadly considered to benefit from screening mammograms, the evidence of any similar advantages for younger women are still considered insufficient to form any substantial conclusions on the matter. The primary goal of this study was to examine whether or not the mortality rate of younger women is benefited by mammography, and if so, how can this beneficial effect be maximized. METHODS: The authors have taken into account all available randomized control trials (RCTs) and have conducted a meta-analysis based on those RCTs to study the effect of mammography on the mortality rate of women younger than age 50. Further interpretation on various aspects of the results has also led to separate meta-analyses, with the RCTs included grouped in accordance to the mean time interval between screening mammograms employed by each study. The findings and conclusions of the comparison were used to calculate the number of mammograms necessary to reduce the absolute death risk, depending on the time interval between screening mammograms. RESULTS: The meta-analysis indicated a reduction in breast-cancer mortality in the intervention group, which reached statistical significance (relative risk (RR) 0.81 [95% CI 0.71-0.93] p < 0.01). Furthermore, when the RCTs included were grouped according to their mean time interval between mammograms, there was a definite increase of statistical significance in favor of those RCTs with shorter interval times (RR 0.76 [95% CI 0.64-0.89] p < 0.01). CONCLUSIONS: The significant mortality rate reduction demonstrated by the meta-analytical results is a key indicator of the beneficial effect of mammography on the age group of women younger than 50. Additionally, the increase in the aforesaid significance when combining RCTs with short time intervals between mammograms, as opposed to those RCTs with longer intervals, suggests that the optimal use of mammographic screening lies with the former. This is better demonstrated when taking in account our approach to answering the practical question of "how many screening mammograms will take to save one life?" in correlation with the mean time interval involved.

Image analysis of breast cancer immunohistochemistry-stained sections using ImageJ: an RGB-based model.

BACKGROUND: Image analysis of tissue sections using RGB image profiling is a modern accepted technique. MATERIALS AND METHODS: A new method of RGB analysis, using the freeware ImageJ, is presented which can be applied to sections with either nuclear or cytoplasmic staining. The step-by-step process is presented and the method is tested using breast cancer specimens immunostained for CK-19 and estrogen receptors. RESULTS: This image analysis easily discriminates CK-19 and estrogen receptor positivity in prepared breast cancer specimens. The method is easy to perform, without the need for previous image transformations. CONCLUSION: Compared to previous methods, this method proved more accurate in estimating the actual colours that an observer recognizes as positive after immunostaining. Further studies are needed to evaluate whether this method is efficient enough to be applied in clinical practice.

Tibolone vaginal versus per os administration in the management of post-menopausal symptoms.

UNLABELLED: Tibolone is a selective tissue estrogenic activity regulator effective in the management of climacteric symptoms, without stimulating endometrial and breast tissue proliferation. It is a well-tolerated treatment regimen with minor adverse effects. The purpose of the current trial was to investigate the efficacy of tibolone administration per os versus per vaginal, concerning the treatment of climacteric symptoms. MATERIAL AND METHOD: A total of 64 post-menopausal healthy women aged 44-55 years (mean 52,5) were enrolled in the study. The patients were divided into three groups: Group A with 24 patients receiving per os Tibolone 2.5 mg x 1 daily for 6 months, Group B with 21 patients receiving vaginally Tibolone 2.5 mg x 1 for 6 months and Group C--with 19 patients receiving only hygienodietetics advices and psychological support for 6 months. All subjects underwent a physical examination, including a transvaginal ultrasonography for the measurement of endometrial thickness and a mammography for the assessment of breast density. RESULTS: In Group A and B, climacteric symptoms were similarly reduced with non significant differences between groups: 79% (19 patients) vs 76% (16 patients) reduction for hot flushes and 83% (20 patients) vs 76% (16 patients) for sweating episodes respectively (p > 0.05). Reduction of hot flushes and sweating episodes was observed in only 2 of 19 patients (10.5%) in group C (p < 0.01). Vaginal route had better results on vaginal dryness-dyspareunia in group B (in 14 patients taken tibolone orally-58% vs 16 patients taken tibolone vaginally-76%). No statistically significant difference was found related to urine symptoms between A and B groups. Tibolone by vaginal route did not cause any severe side effects (apart of a slight discharge) and it was equally (or better) tolerated than oral route. No significant alterations in breast density and BIRADS and no increase in endometrial thickness were observed in all study groups. CONCLUSION: Tibolone is effective in relieving climacteric symptoms indifferent from applications-modus: orally or vaginally. However, further and larger studies are required to confirm results.

[Treatment of leiomyomas with uterine artery embolization. Review of literature].

Embolization of the uterine artery represents a widely accepted invasive method for treatment of fibroids. It is indicated for women in perimenopause with symptomatic leiomyomas who do not require preservation of their fertility functions. The method should be used with caution excluding infectious diseases and malignancies. A experienced interventional radiologist is needed for the completion of the method. Complications are infrequent with rate reaching almost 5%. Few knowledge exists about pregnancy outcomes after uterine artery embolization. For this reason it should be used with caution in young women with symptomatic leiomyomas willing to conceive.

Breast cancer during pregnancy: a mini-review.

BACKGROUND: As modern women delay childbearing, pregnancy-associated breast cancer (PABC) becomes a more frequent problem faced by oncologists, gynecologists, and obstetricians alike. However, no evidence exists concerning the management of this condition. METHODS: We summarized the current literature regarding epidemiology, pathology, diagnosis, treatment and prognosis of PABC. Data were collected by searching PubMed and Medline for the period from 1950 to 2007. RESULTS: There are no randomized controlled trials regarding PABC management. Current evidence suggests that diagnosis may be carried out with limitations regarding staging; surgical treatment may be performed as for the non-pregnant women. Radiotherapy and endocrine therapy are contraindicated during pregnancy, while chemotherapy is allowed after the first trimester. Prognosis is considered poor. Subsequent pregnancy is allowed only 2 years after completing treatment. CONCLUSIONS: Due to lack of prospective randomized controlled clinical studies, both ongoing studies and future evidence are expected to solve problems related to breast cancer management during pregnancy.

Comparative evaluation of multidetector CT and MR imaging in the differentiation of adnexal masses.

The purpose was to compare the accuracy of multidetector CT (MDCT) on a 16-row CT scanner and magnetic resonance (MR) imaging in the characterization of ovarian masses. Preoperative CT examination of the abdomen and MR imaging of the pelvis was performed in 67 women, with clinically or sonographically detected adnexal masses. The CT examinations were performed on a 16-row CT scanner, and the protocol included scanning of the abdomen during the portal phase, using a detector collimation of 16 x 0.75 mm and a pitch of 1.2. We used a 1.5-T magnet unit to perform T1, T2 and fat-suppressed T1-weighted sequences, before and after intravenous administration of gadolinium chelate compounds. The accuracy of multidetector CT and MR imaging in the differentiation between benign and malignant ovarian masses was evaluated, using histopathologic results as the standard of reference. The sensitivity, specificity and accuracy of MDCT in the characterization of ovarian masses were 90.5%, 93.7% and 92.9%, respectively, and that of MR imaging 95.2%, 98.4% and 97.6%, respectively. Although MRI performed slightly better, this did not reach statistical significance. In conclusion, both MDCT on a 16-row CT scanner and MR imaging demonstrated satisfactory results in the characterization of ovarian masses.

Increased levels of tumor markers in the follow-up of 400 patients with breast cancer without recurrence or metastasis: interpretation of false-positive results.

PURPOSE: To analyze, study and interpret the increased levels of tumor markers in breast cancer patients without recurrence or metastasis. PATIENTS AND METHODS: We studied a series of 400 patients with stage 1 breast cancer during a 3-year follow-up after primary treatment. Follow-up included frequent serum estimation of CEA, CA 15.3, CA 125, CA 27-29, TPA and TPS tumor markers. RESULTS: Of 358 patients being continuously disease-free, 18 (5%) cases showed false-positive levels of tumor markers, associated with benign conditions and not to cancer recurrence or metastasis. These conditions included ovarian cysts, thyroid disorders, hepatitis, renal stone and sarcoidosis. CONCLUSION: The value of increased tumor markers should be interpreted cautiously because it doesn't always imply disease recurrence. Tumor markers may increase in many benign conditions.

Transnipple pyramidectomy in pathological nipple discharge: an original minimal surgery technique in a series of 80 cases.

Pathologic nipple discharge presents a diagnostic dilemma as no one diagnostic test has proven clearly superior to any other in the differentiation of benign versus malignant conditions. This is a clinical study of 80 patients with unilateral suspicious nipple discharge whose complete investigation included histological evaluation. A transnipple approach was used to identify, get to and excise the breast tissue suspicious of having caused the pathological discharge, with a pyramide-shaped tissue dissection (pyramidectomy). Specimens satisfactory for histological evaluation were obtained in all cases. Breast cancer was detected in six cases, papillomatosis in four, papillomas in 30, fibrocystic changes in five, ductal ectasia in 31 and non specific findings in four cases. There were no intraoperative complications and functional and healing-esthetic recovery was very good in all cases. It is concluded that transnipple pyramidectomy is a useful technique for a reliable diagnosis of pathologic nipple discharge.

Expression of endothelial PDGF receptors alpha and beta in breast cancer: up-regulation of endothelial PDGF receptor beta.

The PDGF pathway is essential in tumor angiogenesis. Although the expression of the PDGF receptors has been excessively studied on breast cancer cells, few studies exist on PDGFR expression on the tumor endothelial cells. In the present study, it is investigated whether endothelial PDGF receptors' expression is altered in breast cancer. Endothelial PDGFRalpha and beta expression was initially studied under the influence of tumor conditioned medium derived from a breast cancer cell line. Following tissue culture experiments the endothelial expression of both receptors was studied on formalin-fixed paraffin-embedded tissue sections of normal breast and breast cancer specimens. The tissue culture experiment revealed a possible up-regulation of endothelial PDGFRbeta by breast cancer environment. Immunohistochemistry verified the result since 69.7% of the breast cancer sections were positive for PDGFRbeta compared to 43.3% of normal breast sections (p<0.05). No statistical difference was revealed by studying PDGFRalpha expression. In conclusion, our findings support the thesis of possible anti-PDGFRbeta anti-angiogenic therapy, in cases of endothelial PDGFRbeta-expressing breast cancer.

Administration of recombinant human erythropoietin in patients with gynecological cancer before radical surgery.

UNLABELLED: The purpose of this prospective study was to investigate the efficacy of preoperative administration of recombinant human erythropoietin in patients with gynecological cancer. METHODS: The study included 38 women with gynecological cancer who were divided randomly in two groups. Study group A included 20 women with gynecological cancer who received recombinant human erythropoietin (rHuEPO) plus iron supplementation for ten days before surgery and five days postoperatively. Group B (controls) included 18 patients who received only iron supplementation for the same time period. Blood samples were obtained on days -10, -3, 0, +3, +5, +10. RESULTS: The mean hemoglobin level was significantly higher in group A than in group B on the day of the operation and remained significantly higher postoperatively while an inverse relationship was observed for mean ferritin values in the two groups. CONCLUSION: Preoperative administration of rHuEPO in patients with gynecological cancer seems to be effective in the blood management of these patients.

Recombinant human erythropoietin in mildly anemic women before total hysterectomy.

UNLABELLED: The purpose of this study was to investigate the efficacy of preoperative recombinant human erythropoietin (rHuEPO) treatment in a group of mildly anemic women. METHODS: This randomized controlled study included 50 healthy, mildly anemic women who underwent total hysterectomy for leiomyomas. The study group (Group A) included 23 women who received rHuEPO 600 U/kg once weekly for three weeks, plus iron supplementation. The control group (Group B) included 27 women who received only iron supplementation. Blood samples were obtained on days -14, -7, 0, +3, +7 and +14. RESULTS: An increase in preoperative mean hemoglobin concentration was noted in both groups; however, the increase was significantly higher in Group A throughout the study period. Mean reticulocyte count was also significantly higher in this group, whereas mean ferritin level was significantly lower. No postoperative transfusion was needed in Group A, whereas five women were transfused in Group B. CONCLUSION: Rapid and persistent improvement of hematologic parameters makes the use of rHuEPO for preoperative treatment of mildly anemic women with benign uterine pathology a very interesting approach.