Intervention for Hepatic and Pulmonary Metastases in Breast Cancer Patients: Prospective, Multi-institutional Registry Study-IMET, Protocol MF 14-02.

BACKGROUND: One fourth of early-stage breast cancer cases become metastatic during the follow-up period. Limited metastasis is a metastatic disease condition in which the number of metastatic sites and the extent of the disease both are limited, and the disease is amenable to metastatic intervention. This prospective study aimed to evaluate intervention for limited metastases in the lung, liver, or both. METHODS: The study enrolled luminal A/B and/or human epidermal growth factor receptor 2 (HER2)-neu+ patients with operable lung and/or liver metastases in the follow-up assessment after completion of primary breast cancer treatment and patients with a diagnosis of metastasis after 2014. Demographic, clinical, tumor-specific, and metastasis detection-free interval (MDFI) data were collected. Bone metastasis in addition to lung and liver metastases also was included in the analysis. The patients were divided into two groups according to the method of treatment for metastases: systemic therapy alone (ST) group or intervention (IT) group. RESULTS: Until June 2020, 200 patients were enrolled in the study. The demographic data were similar between the two groups. The median follow-up time was 77 months (range 55-107 months) in the IT group (n = 119; 59.5%) and 57 months (range 39-84) in the ST-only group (n = 81; 40.5%). The median MDFI was 40 months (range 23-70 months) in the IT group, and 35 months (range 13-61 months) in the ST-only group (p = 0.47). The groups had similar surgeries for the primary tumor and axilla. Most of the patients had liver metastases (49.5%, n = 99), and 42% (n = 84) of the patients had lung metastases. Both lung and liver metastases were found in 8.5% (n = 17) of the patients. The primary tumor was estrogen receptor/progesterone receptor-positive in 75% (n = 150) of the patients, and 32% (n = 64) of the patients had HER2-neu+ tumors. Metastatic-site resection was performed for 32% (n = 64) of the patients, and 27.5% (n = 55) of the patients underwent metastatic ablative interventions. In the Kaplan-Meier survival analysis, the hazard of death (HoD) was 56% lower in the IT group than in the ST-only group (hazard ratio [HR], 0.44; 95% confidence interval [CI] 0.26-0.72; p = 0.001). The HoD was lower in the IT group than in the ST-only group for the patients younger than 55 years (HR, 0.32; 95% CI 0.17-0.62; p = 0.0007). In the multivariable Cox regression model, HoD was significantly lower for the patients who underwent intervention for metastases and had an MDFI longer than 24 months, but their liver metastases doubled the risk of death compared with lung metastases. CONCLUSION: Metastasis-directed interventions have reduced the risk of death for patients with limited lung/liver metastases who are amenable to interventions after completion of primary cancer treatment. For a select group of patients, such as those with luminal A/B or HER2-neu+ breast cancer who are younger than 55 years with limited metastases to the lung and liver or an MDFI longer than 24 months, surgical or ablative therapy for metastases should be considered and discussed on tumor boards.

Favorable outcome with sentinel lymph node biopsy alone after neoadjuvant chemotherapy in clinically node positive breast cancer at diagnosis: Turkish Multicentric NEOSENTI-TURK MF-18-02-study.

PURPOSE: Factors affecting local outcome were evaluated in patients with clinically node-positive (cN+) breast cancer at diagnosis, who underwent sentinel lymph node biopsy (SLNB) alone after neoadjuvant chemotherapy (NAC). METHODS: Between 2004 and 2018, 303 cytopathology-proven cN (+) patients in a multicentric registry, who received NAC and underwent SLNB alone were analysed. All patients had regional nodal irradiation. RESULTS: Median age was 46 (23-70). Of those, 211 patients had ypN0 disease (69.6%), whereas 92 patients had ypN (+) disease including 19 (20.6%) isolated tumor cells (ITC), 33 micrometastases (35.9%) and 40 macrometastases (43.5%). At a median follow-up of 36 months (24-172), one patient (0.3%) with macrometastatic SLN was found to have locoregional recurrence as chest wall and supraclavicular LN metastases at the 60th month. Five-year disease-free survival (DFS) and disease specific survival (DSS) rates were 87% and 95%, respectively. Patients with cT3/4 (HR = 2.41, 95% CI; 1.14-5.07), non-luminal molecular pathology (HR = 2.60, 95% CI, 1.16-5.82), and non-pCR in the breast (HR = 2.11, 95% CI, 0.89-5.01) were found to have an increased HR compared to others in 5-year DFS. However, no difference could be found between ypN0 and ypN ITC and micrometastasis (HR = 1.23, 95% CI, 0.44-3.47), whereas there was a slight increase in HR of patients with ypN macrometastasis versus ypN0 (HR = 1.91, 95% CI, 0.63-5.79). CONCLUSION: ALND could be avoided in meticulously selected cN (+) patients who underwent SLNB after NAC having breast and/or nodal pCR, cT1-2, or low volume residual nodal disease with luminal pathology, as long as axillary radiotherapy is provided.

Comparison of subpectoral versus dual-plane implant based immediate breast reconstruction after nipple-areola sparing mastectomy.

BACKGROUND: Selection of implant pocket and size is a dilemma for surgeons especially if radiation therapy is envisaged after implant based immediate breast reconstruction (IBR). The aim of this study is to compare complication rates between subpectoral and the dual plane polyglactin mesh supported IBR after nipple-areola sparing mastectomy. PATIENTS AND METHOD: Reconstructive analysis of 208 breasts of 190 patients with breast cancer undergoing implant based IBR at a single university hospital were evaluated. The patients were reconstructed with either dual-plane polyglactin mesh supported (n=91) or subpectoral (n=117) implant based IBR after nipple-areola sparing mastectomy. Demographic data, and postoperative complications were compared. RESULTS: The mean age was 43.3 years. Early complications encountered in 12% (n=25) and late complications occurred in 18% (n=37) of breasts. Both early (13,7% vs 9.9%, P=0.406) and late complications (24.8% vs 8.8%, P=0.003) were more common in subpectoral group, but only late complication occurrence rate was statistically significant. Capsular contracture (P=0.000), inframammary fold problems (P=0.010), bottoming-out (P=0.370), mechanical shift (P=0.036) and animation deformity (P=0.007) were all more common in subpectoral group. Only rippling deformity (P=0.011) was more common in dual plane group. CONCLUSIONS: Dual plane IBR has acceptable complication rates compared to subpectoral IBR. It is associated with less capsular contracture, fewer animation and bottoming-out deformity and better inframammary fold appearance.

Effectiveness of Pilates-based exercises on upper extremity disorders related with breast cancer treatment.

Breast cancer treatment causes upper extremity (UE) impairments. This study aims to assess the efficacy of Pilates-based exercises (PE) in comparison with combined exercise (CE) and home exercise (HE) groups, in the rehabilitation of UE disorders related with breast cancer treatment. Fifty-five patients were randomly allocated to PE, CE (consisting of strengthening, stretching and range of motion [ROM] exercises) and HE groups (consisting of CE group exercises). Pain (using visual analogue scale), ROM (using digital goniometer), muscle strength (using dynamometer and pinch gauge), functional status (using Constant-Murley scale and Disabilities of the Arm, Shoulder and Hand scale) were evaluated before and after intervention. For data analyses (using spss 21 version), one-way ANOVA, paired samples t-test and Kruskal-Wallis test were performed (p ≤ .05 was considered statistically significant). The data obtained in this study revealed significant improvements in almost all the parameters measured in the PE and CE groups, and some improvements were superior to HE group. PE seemed to have resulted similar improvements in pain, muscle strength and functional status when compared to CE group. Therefore, PE seems to be an effective method of rehabilitation of patients with UE disorders related with breast cancer treatment, and might be considered for use as an alternative to CE in this population.

Ovarian cancer presenting as an axillary mass: Case series and literature review.

AIM: Ovarian cancer is a common cause of death in women worldwide. The purpose of this article was to report a case series and draw physicians' attention to the benefits of histpathologic techniques in determining uncommon metastatic diseases. METHODS: In this study, we report a case series of axillary involvement of ovarian cancer in 6 patients. The data were collected between 2006 and 2015 by analyzing patient's characteristics, and biochemical and immunohistochemical features. No pathologic lesions were detected in breasts. Specific immunohistochemical methods such as GCDFP-15, CA12-5, WT-1, and PAX-8 supported evidence of metastasis from ovarian cancer to axillary lymph nodes. RESULTS: Biochemical tests showed increased levels of CA12-5 in all patients. In 5 patients, GCDFP-15 was negative and WT-1 was positive with specific immunohistochemical staining. PAX-8 was positive in 3 of 5 patients. CONCLUSIONS: Physicians need to be aware that histopathologic and immunohistochemical results can make a significant contribution in determining the true primary tissue of metastatic adenocarcinoma, even in the absence of typical clinical findings.

Preoperative chemotherapy for T2 breast cancer is associated with improved surgical outcome.

BACKGROUND: The aim of this study is to compare the clinical outcome in T2 breast cancer patients who underwent preoperative chemotherapy (PC) and who did not. The study also tried to define a subgroup of patients, who are more beneficial after PC in terms of lower re-excision rates, better cosmetic results and local recurrence free survival. MATERIALS AND METHODS: 251 consecutive patients treated for nonmetastatic T2 invasive breast cancer were analyzed retrospectively. Of those; 141 underwent primary surgery (PS) followed by chemotherapy, whereas 110 were treated with combination of PC and surgery. RESULTS: The patients who were treated with PC had a significantly higher incidence of negative margins and lower rate of re-excision (5% vs. 16%, p = 0.02). Of all patients attempted breast conserving surgery (BCS), patients in the PC group were more likely to undergo BCS as their definitive operation compared to patients with PS group (BCS rates; PC group: 99% vs. PS group: 92%, p = 0.05). Multifocal disease (OR: 7, 95% Cl, 2.7-18.4, p = 0.0001) and PC (OR = 0.2; 95% CI, 0.06-0.72, p = 0.01) were factors associated with margin positivity in patients treated with BCS. There was no statistically significant difference in 5 year local-recurrence free survival rates between 2 groups. CONCLUSIONS: Our study shows that PC significantly decreases the re-excision in patients undergoing BCS with primary T2 breast tumors. This data suggests that any patient with a tumor greater than 2 cm might be considered for PC to increase BCS success with final negative margins.

Positive or close margins in breast conserving surgery: is re-excision always necessary?

BACKGROUND: More than half of re-excision specimens after breast conserving surgery (BCS) are found to be free of residual tumor at definitive histology. The aim of this study was to identify clinicopathological factors along with intrinsic subtypes of the tumor (luminal A, luminal B, HER2-overexpressing, triple-negative) associated with residual tumor in re-excision or mastectomy specimen. METHODS: Two hundred forty-eight patients with initial BCS, who underwent one or more re-excisions or mastectomy because of close or positive margins were reviewed. RESULTS: Residual cancer was found in 50% of re-excision(s) or mastectomy specimens. Patients with multifocality (vs unifocality; OR = 5.2; 95% CI, 2.6-10.4) or positive nodes (vs negative nodes; OR = 2.5; 95% CI, 1.4-4.4), or positive margins (vs close margins; OR = 1.7; 95% CI = 1.0-2.9) were more likely to have residual tumor in re-excision or mastectomy specimen compared to others. CONCLUSION: Our results suggest that further surgery is often indicated in patients with node positive or multifocal cancers or positive margins after BCS since residual disease cannot be ruled out. Re-excision or mastectomy could be omitted in patients with close margins with favorable factors such unifocal tumor or node negative disease.

Gastric metastasis of malignant fibrous histiocytoma presenting as gastrointestinal bleeding.

Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. With only 4 cases described in the available English literature up to now, gastric metastasis of MFH is extremely rare. Among them only one case has been reported to lead to gastrointestinal bleeding. We report the case of a 55-year-old woman who underwent total gastrectomy, 14 months after resection of an MFH from the right side of retroperitoneum. The neoplasm was detected at the time of diagnostic workup for upper gastrointestinal bleeding. The resected specimen contained multiple polypoid nodular lesions which were located in the greater curvature. The clinical and pathological characteristics of gastric metastasis of MFH are presented herein with review of literature.

Prognostic and predictive factors after surgical treatment for locally recurrent rectal cancer: a single institute experience.

OBJECTIVE: Resection of locally recurrent rectal cancer (LRRC) after curative resection represents a difficult problem and a surgical challenge. The aim of this study was to evaluate the results of resecting the local recurrence of rectal cancer and to analyze factors that might predict curative resection and those that affect survival. PATIENTS AND METHODS: A retrospective review was performed in 50 patients who underwent surgical exploration with intent to cure LRRC between April 1998 and April 2005. All of the patients had previously undergone resection of primary rectal adenocarcinoma. Of these patients' charts, operation and pathology reports were reviewed. Primary tumor and treatment details, hospital of initial treatment and TNM stage were registered. The following data were collected concerning the detection of the local recurrence; date of recurrence, symptoms at the time of presentation and diagnostic work-up. Perioperative complication and date of discharge were also gathered. The recurrent tumors were classified as not fixed (F0), fixed at one site (F1) and fixed to two or more sites (F2) according to the preoperative and peroperative findings. Microscopic involvement of surgical margins and localization of recurrence were noted based on pathology reports. RESULTS: The median time interval between resection of primary tumor and surgery for locally recurrent disease was 24 (4-113) months. In a statistical analysis, initial surgery, complaints of patients, increasing number of sites of the recurrent tumor fixation in the pelvis, location of the recurrent tumor were associated with curative surgery. Curative, negative resection margins were obtained in 24 (48%) of patients; in these patients a median survival of 28 months was achieved, compared to 12 months (p=0.01) in patients with either microscopic or gross residual disease. Primary operation and CEA level at recurrence were also found to be important factors associated with improved survival. There was no operative mortality and, the complication rate was 24%. CONCLUSIONS: This study demonstrated that many patients with LRRC can be resected with negative margins. The type of primary surgery, symptoms, location, and fixity of recurrent tumor are associated with the increased possibility of carrying out curative resection. Previous surgery and curative surgery are significant predictors of both disease-specific survival and overall survival.

Primary ovarian cancer presenting with axillary lymph node metastases: a report of two cases.

BACKGROUND: Axillary lymph node metastasis of primary ovarian cancer is rare. CASE I: A 74-year-old woman presented with a 2 x 2 cm hard, mobile mass in the right axilla. She had a history of stage IIIA epithelial ovarian cancer which was diagnosed and treated four years previously. A right lateral wall involvement of the rectum was detected in abdominal tomography. A right axillary lymph node dissection and low anterior resection of the rectum were performed. Histopathologic examination showed ovarian epithelial serous papillary adenocarcinoma metastases to axillary lymph node and the rectum. CASE 2: A 38-year-old woman presented with a 3 x 2 cm hard, mobile mass in the right axilla. She was treated surgically and by systemic chemotherapy with a diagnosis of stage IIIA epithelial ovarian cancer two years previously. A trucut biopsy was taken from the enlarged axillary lymph node, and histopathological examination revealed metastases of primary ovarian cancer. Complete axillary lymph node dissection was performed and metastases of ovarian papillary adenocarcinoma were found in 11 of the 30 lymph nodes. CONCLUSION: Supradiaphragmatic lymph node involvement of primary ovarian cancer is very rare. We report here two cases presenting with axillary metastases of ovarian cancer.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer.

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (0.2 cm). Five patients had isolated tumor cells detected by IHC (

The role of sentinel lymph node biopsy with blue dye alone in breast cancer patients with excisional biopsy.

PURPOSE: Sentinel lymph node biopsy (SLNB) appears to offer an excellent alternative method to routine axillary lymph node dissection for staging patients with breast cancer. The aim of this study is to evaluate the effect of excisional biopsy on identification and false negative rate of sentinel lymph node biopsy with blue dye alone in breast cancer patients with clinically negative axilla. MATERIAL AND METHODS: From March 1998 to March 2003, 266 consecutive sentinel lymph node biopsies (SLNB) were performed using isosulfan blue dye alone. Patients were divided into two groups. One hundred and four patients (39.1%) had previously undergone an excisional biopsy (Group I); in 162 patients (60.9%), pre-operative diagnosis was obtained by either fine-needle aspiration biopsy (FNAB) or core biopsy (Group II). Following sentinel lymph node biopsy, all patients had axillary lymph node dissection (ALND). Data concerning patients, sentinel lymph nodes and the status of the axilla were collected and compared using Fisher's exact test. A p value of less than 0.05 was considered statistically significant. RESULTS: The sentinel lymph node was successfully identified by blue dye in 94.3% (251/266) of patients. Mean lymph nodes removed from the axilla was 19 (range 11-36) and the mean number of sentinel nodes was 2 (range 1-5). The identification and false negative rate were unrelated to size, type or location of the tumour, or a previous surgical biopsy. CONCLUSIONS: SLNB with blue dye for evaluation of the axilla is a rapid and accurate technique that provides increased efficacy in the detection of lymphatic metastasis when careful pathologic evaluation with serial sections is performed. The risk-benefit analysis of lymphatic mapping with blue dye provides improvement in staging, with reduced morbidity and hospital stay, and the elimination of general anaesthesia. The technique may also be used safely and accurately in breast cancer patients with excisional biopsy.

Breast conserving surgery after primary chemotherapy in locally advanced breast cancer.

PURPOSE: Primary chemotherapy is being given in the treatment of locally advanced breast cancers (LABC), but a major concern is local recurrence after therapy. The aim of this study was to assess the role of breast conserving surgery (BCS) in patients with locally advanced breast cancer. MATERIAL AND METHODS: Twenty-eight patients, presenting LABC (T any, N 012, M0) were treated with primary chemotherapy comprising of cyclophosphamide, doxorubicin and fluorouracil and then BCS followed by radiotherapy were examined between the years 1992-2002 retrospectively. Before neoadjuvant chemotherapy, seven patients (25%) were Stage IIB, 19 patients (68%) Stage IIIA and two patients (7%) Stage IIIB. Survival times and curves were established according to the Kaplan-Meier method and compared by means of the log-rank test. The chi-square test and log rank test were performed for univariate statistical analysis of each prognostic factor. P values in multivariate analysis were carried out by the Cox's proportional hazards regression model. All p values were two-sided in tests and p values <0.05 were considered significant. RESULTS: Clinical down staging was obtained in 25 (89%) of patients. Three (11%) patients had complete clinical response, 22 (78%) patients with partial response and 3 (11%) had stable disease. The primary tumour could not be palpated after chemotherapy in 6 (21%) of 28 patients presenting with palpable mass, therefore needle localization was performed for BCS. Median follow-up was 51.9 months (ranging 10 to 118 months). Local recurrence was detected in 4 (14%) patients. Distant metastasis developed in 5 (18%) patients. Three of the patients died of distant metastases and two of them are alive at 49 months. Five-year survival rate was 66%. Statistically, there were no significant factors in terms of local recurrence. Histological grade and menopause status were significantly associated with overall survival (p = 0.018) and nuclear grade was the one significant factor on distant disease-free survival in univariate analysis (p = 0.006). In multivariate analysis, there were no significant factors in terms of overall and distant disease-free survival CONCLUSIONS: Negative margin is more important than the clinical and histological parameters, such as pretreatment stage, clinical response rate, ER and PR in terms of local recurrence. BCS can be performed safely by achieving free surgical margin in patients who have small sized tumour and with either N2 axillary involvement or skin invasion.

Laparoscopic treatment of mesenteric cysts.

Mesenteric cysts are rare intraabdominal tumors. We review the diagnosis, laparoscopic management, patient's outcome and follow-up of evaluation for three cases of mesenteric cyst that presented to Istanbul University, Istanbul Medical School, Department of Surgery, from 1999 to 2002. All of the patients presented with nonspecific abdominal symptoms such as constipation, abdominal discomfort, and anorexia. Preoperative evaluation for differentiating mesenteric cyst from malignancy is made by abdominal ultrasound and computed tomography. The procedure was completed laparoscopically using three trocars in three patients. In one patient retroperitoneal resection was performed. There were no intraoperative or postoperative complications. The follow-up periods ranged from 6 to 36 months, and there were no recurrences. Currently, the surgical treatment of mesenteric cyst should be performed by laparoscopy, which offers significant advantages in terms of reduced morbidity and hospital stay. For appropriate cases in which cyst arises from mesenterium of colon, the retroperitoneal approach should be applied.

Bilateral nipple necrosis in a breastfeeding woman with Behçet's disease.

Behçet's disease is a chronic, multisystem disorder. A 23-year-old female patient diagnosed with Behçet's disease 3 years earlier was admitted with deep ulcers on both areolae caused by detachment of the nipples following breastfeeding since spontaneous delivery of her baby. Physical examination revealed a necrotic ulcer crater 2 cm in diameter on each breast, with the lactiferous ducts draining into these. Incisional biopsy sample from the areola ulcer border on the left breast showed leukocytoclastic vasculitis. Breastfeeding was stopped, and local wound care and systemic corticosteroid therapy were started. After 4 weeks, epithelialization tissue filled the ulcers, leveling the crater base with the areola. Bilateral nipple necrosis in a breastfeeding woman is a rare entity. It is thought that in the present case minor trauma caused by breastfeeding accompanied by neutrophilic infiltration resulting from amplified inflammatory response and leukocytoclastic vasculitis attributable to Behçet's disease was responsible for the necrosis.