Oncoplastic breast surgery to prevent "Bird's beak" deformity in the breast: a comparative retrospective study.

PURPOSES: Breast deformity occurring in the lower pole after breast conserving surgery (BCS) is known as bird's beak (BB) deformity. This retrospective study evaluated the outcomes in breasts reconstructed with a conventional closing procedure (CCP) and a downward-moving procedure (DMP), respectively, after BCS. METHODS: In CCP, the inferomedial and inferolateral portions of breast tissues were reapproximated toward the midline after wide excision to repair the breast defect. In DMP, the retro-areolar breast tissue was detached from the nipple-areolar complex after wide excision, and the upper pole breast tissue was moved downward to refill the breast defect. RESULTS: CCP was performed in 20 patients (Group A), and DMP was performed in 28 patients (Group B). Although retraction of the lower part of the breast was postoperatively observed in 13 (72%) of 18 patients from Group A, it was observed in 7 (28%) of 25 patients in Group B (p < 0.05). The downward pointing of the nipple was observed in 8 (44%) of 18 patients from Group A and in 4 (16%) of 25 patients in Group B (p < 0.05). CONCLUSIONS: DMP is more useful for preventing BB deformity than CCP.

The role of axillary reverse mapping in intraoperative nodal palpation during sentinel lymph node biopsy.

Intraoperative nodal palpation in the axilla is a mandatory part of sentinel lymph node biopsy. However, there is no consensus regarding the definition of suspicious palpable node. The sampling rate and involvement rate of suspicious palpable nodes are inconsistent. We hypothesized that axillary reverse mapping is helpful to select suspicious palpable sentinel lymph nodes more accurately. Patients with clinically negative nodes underwent sentinel lymph node biopsy with intraoperative nodal palpation and axillary reverse mapping. Blue and hot nodes were removed as sentinel lymph nodes. Suspicious palpable nodes that were neither blue nor hot were removed as palpable sentinel lymph nodes. Nodes around blue and hot sentinel lymph node were incidentally removed as para-sentinel lymph nodes. Fluorescent nodes were considered axillary reverse mapping nodes. Patients with positive sentinel lymph node underwent axillary lymph node dissection. Palpable sentinel lymph nodes and para-sentinel lymph nodes were removed in 130 (15%) of 850 patients with clinically negative nodes. Although palpable sentinel lymph nodes and para-sentinel lymph nodes were involved in 19 (15%) of 130 patients, fluorescent palpable sentinel lymph nodes were involved only in 2 patients and fluorescent para-sentinel lymph nodes were not involved. When excluding fluorescent palpable sentinel lymph nodes and para-sentinel lymph nodes, the sampling rate of suspicious palpable nodes significantly decreased (15% vs. 5%, p < 0.01) and the involvement rate of palpable sentinel lymph nodes significantly increased (15% vs. 31%, p < 0.05). Axillary reverse mapping is helpful to avoid an unnecessary removal of palpable nodes without metastases.

Periarterial or perivenous invasion is an independent indicator of lymph node metastasis in invasive breast carcinoma of no special type.

Pathological diagnosis of breast cancer often includes cases of lymph node metastases without lymphatic or lymphovascular invasion by the primary tumor. In this study, to resolve this discrepancy, we designed a sensitive method to detect lymphatic invasion and correlate it with lymph node metastasis. Elastica van Gieson (EVG) staining and D2-40 immunohistochemistry revealed the abundant distribution of lymphatic vessels around blood vessels in the mammary tissue in close proximity to the elastic fibers around the arteries and veins. Based on the histological location of the blood and lymphatic vessels, we hypothesized that, in breast cancer, perivascular invasion is similar to lymphatic invasion and correlates with the presence of lymph node metastasis. Using EVG staining, perivascular invasion was histologically classified into periarterial invasion (periA), perivenous invasion (periV), and periarterial or perivenous invasion (periA/V). We tested our method and compared it to other methods commonly used for identifying lymphatic invasion in 105 patients with invasive breast carcinoma of no special type (IBC-NST) who received minimal preoperative therapy. The correlation between perivascular invasion and lymph node metastasis in these patients was statistically analyzed, including findings related to lymphatic invasion, such as retractile artifacts and perineural invasion. PeriA, periV, and periA/V showed significant correlations with lymph node metastasis. PeriA/V had high sensitivity and negative predictive value. The odds ratio (OR) for periV was significantly high in the univariate analysis, while the ORs for periA/V, retraction artifacts, and perineural invasion were significantly high in both the univariate and multivariate analyses. In particular, periA/V revealed a strong correlation with lymph node metastasis (OR: 61.8). These findings indicate that the IBC-NST periA/V ratio is a sensitive pointer of lymphatic invasion and could be an independent and reliable indicator of lymph node metastasis.

Conservative axillary surgery is emerging in the surgical management of breast cancer.

Axillary lymph node dissection (ALND) has been the standard axillary treatment for breast cancer for a long time. However, ALND is associated with postoperative morbidities, including local sensory dysfunction, reduced shoulder mobility and most notably arm lymphedema. Recently, ALND can be avoided not only in clinically node-negative (cN0) patients with negative sentinel lymph nodes (SLNs), but also in patients with less than 3 positive SLNs receiving breast radiation, axillary radiation, or a combination of the two. Moreover, SLN biopsy has been adopted for use in clinically node-positive (cN +) patients presenting as cN0 after neoadjuvant chemotherapy (NAC); ALND may be avoided in cN + patients who convert to SLN-negative following NAC. Patients who undergo SLN biopsy alone have less postsurgical morbidities than those who undergo ALND. Nevertheless, ALND is still required in a select group of patients. A variety of conservative approaches to ALND have been developed to spare arm lymphatics to minimize arm lymphedema. These conservative procedures seem to decrease the incidence of lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, full conventional ALND removing all microscopic axillary disease may now be unnecessary in both cN0 patients and cN + patients. Regardless, emerging procedures for ALND should still be considered as investigational approaches, as further studies with longer follow-up are necessary to determine the safety of conservative ALND to spare arm lymphatics.

The involvement of axillary reverse mapping nodes in patients with node-positive breast cancer.

INTRODUCTION: Axillary reverse mapping (ARM) procedure is useful in reducing lymphedema. However, concerns regarding oncologic safety have limited the adoption of the ARM procedure. This study aimed to evaluate the involvement of ARM nodes in node-positive breast cancer patients. MATERIALS AND METHODS: Two hundred twenty-three node-positive patients were enrolled in this study: 90 were clinically node-negative, but had one or more positive sentinel lymph nodes (SLNs) (SLN-positive group); 68 were clinicopathologically node-positive (CpN-positive group); and 65 had confirmed nodal involvement and received neoadjuvant chemotherapy (NAC) (NAC group). All patients underwent axillary lymph node dissection with fluorescent ARM. RESULTS: ARM nodes were involved in 33 (36.7%) patients of the SLN-group. Residual ARM nodes after SLN biopsy were involved in 11 patients (12.2%), including 5 patients (19.2%) with crossover type nodes and 6 patients (9.4%) with non-crossover type nodes. However, the difference in involvement rates between the two types was not high enough to be significant. Of these 11 patients, moreover, four patients had three or more than 3 involved SLNs. On the other hand, the involvement rate of ARM nodes in the NAC group was significantly lower than that of the CpN-positive group (35.4% vs. 64.7%: p < 0.01). Despite lower involvement, the risk of metastases in the ARM nodes was still too high to spare ARM nodes in both the NAC group and CpN-positive group. CONCLUSIONS: Suspicious or involved ARM nodes should be removed even when detected in ARM procedure, particularly in NAC-group and CpN-positive-group patients.

Conservative Axillary Surgery May Prevent Arm Lymphedema without Increasing Axillary Recurrence in the Surgical Management of Breast Cancer.

Axillary lymph node dissection (ALND) has been associated with postoperative morbidities, including arm lymphedema, shoulder dysfunction, and paresthesia. Sentinel lymph node (SLN) biopsy emerged as a method to assess axillary nodal status and possibly obviate the need for ALND in patients with clinically node-negative (cN0) breast cancer. The majority of breast cancer patients are eligible for SLN biopsy only, so ALND can be avoided. However, there are subsets of patients in whom ALND cannot be eliminated. ALND is still needed in patients with three or more positive SLNs or those with gross extranodal or matted nodal disease. Moreover, ALND has conventionally been performed to establish local control in clinically node-positive (cN+) patients with a heavy axillary tumor burden. The sole method to avoid ALND is through neoadjuvant chemotherapy (NAC). Recently, various forms of conservative axillary surgery have been developed in order to minimize arm lymphedema without increasing axillary recurrence. In the era of effective multimodality therapy, conventional ALND may not be necessary in either cN0 or cN+ patients. Further studies with a longer follow-up period are needed to determine the safety of conservative axillary surgery.

Axillary Reverse Mapping in Clinically Node-Positive Breast Cancer Patients.

BACKGROUND: Axillary reverse mapping (ARM) nodes are involved in a significant proportion of clinically node-positive (cN+) breast cancer patients. However, neoadjuvant chemotherapy (NAC) is effective at decreasing the incidence of nodal metastases in cN+ patients. PATIENTS AND METHODS: One hundred forty-five cN+ patients with confirmed nodal involvement on ultrasound-guided fine needle aspiration cytology were enrolled in this study: one group underwent axillary lymph node dissection (ALND) without NAC (upfront surgery group), and the other group underwent ALND following NAC (NAC group). The patients underwent 18F-FDG-positron emission tomography/computed tomography (18F-FDG-PET/CT) before surgery, as well as an ARM procedure during ALND. RESULTS: the rates of involvement of ARM nodes in the NAC group were significantly lower than those of the upfront surgery group (36.6% vs. 62.2%, p < 0.01). Notably, involvement was significantly decreased after NAC in non-luminal-type tumors as compared to the luminal-type (18.4% vs. 48.5%: p < 0.01). Moreover, there was a significant difference in ARM node involvement after NAC between patients with or without axillary uptake of 18F-FDG (61.5% vs. 32.5%: p < 0.01). CONCLUSIONS: NAC significantly decreased the risk of ARM node metastases in cN+ patients, but 18F-FDG-PET/CT was not suitable to detect residual metastatic disease of the axilla after NAC.

Axillary reverse mapping using a fluorescence imaging system in breast cancer.

BACKGROUND: The axillary reverse mapping (ARM) procedure is based on the hypothesis that the lymphatic drainage from the upper arm is different from that of the breast. However, the oncologic safety of the procedure has not yet been determined. METHODS: The ARM nodes were identified using a fluorescence imaging system. Axillary lymph node dissection (ALND) was performed in patients with clinically involved nodes, and the ARM nodes were removed separately during ALND. Sentinel lymph node (SLN) biopsy was performed in patients with clinically uninvolved nodes. If the SLN was positive, ALND was performed with removal of ARM nodes. Otherwise, the identified ARM nodes were preserved unless they were the same as the SLN. RESULTS: ARM nodes were identified in 29 (85%) of 34 patients who underwent ALND, and 11 had tumor involvement. The ARM node was identified in 42 (43%) of 97 patients who underwent SLN biopsy, and it was the same as the SLN in 27 patients. However, in 15 patients with a positive SLN who subsequently underwent ALND, ARM nodes were tumor-free when they were not the same as the positive SLN. CONCLUSIONS: It may be feasible to spare ARM nodes during ALND in patients with positive SLN.

Local therapy and survival in breast cancer with distant metastases.

This review article presents an evaluation of the effects of local therapy on survival of breast cancer patients with distant metastases along with a discussion of their relevance. Primary and recurrent breast cancers with distant metastases are systemic diseases with poor prognosis. However, several retrospective studies have demonstrated that surgical removal of the primary breast tumor has a favorable impact on the prognosis of stage IV breast cancer patients. Similarly, it has been reported that surgical resection of metastatic lesions in the lung as well as the liver yields unexpectedly promising results. The interaction of local treatment and systemic therapy may be important, because surgery and radiotherapy are only local treatments. However, it remains uncertain whether these encouraging findings are due to the surgical procedure itself or preoperative patient selection. Only a randomized prospective study can definitively show whether local treatment can prevent death from stage IV disease or recurrent breast cancer with distant metastases. Until data from prospective studies are available, clinicians must weigh retrospective experiences and clinical judgment in deciding whether to offer surgery or radiotherapy to these patients.

[Recurrent breast cancer obtained long-term survival with local treatment(surgery and stereotactic body radiotherapy)and systemic therapy].

A 52-year-old woman developed right breast cancer and underwent modified radical mastectomy in 1994. Histologically, the tumor was invasive ductal carcinoma. She was positive for estrogen receptor (ER) but negative for progesterone receptor(PgR), while her human epidermal growth factor receptor type 2(HER2) status was not examined. Although she received adjuvant hormone therapy and chemotherapy[cyclophosphamide+doxorubicin+5-fluorouraci(l CAF), 6 courses ], she underwent partial pulmonary resection on both sides with right oophorectomy in 1997. Subsequently, she was treated with weekly doses paclitaxel(12 courses). However, she developed a pulmonary metastasis in the left breast. In 2002, she underwent a partial left pulmonary resection (ER-positive and HER2 3+) and treatment with an aromatase inhibitor. Subsequently, she was treated with trastuzumab because of repeated lung metastasis. A complete response was obtained after the administration of trastuzumab. In 2008, she developed bone metastasis in the sternum and the left seventh rib, and subsequently underwent stereotactic body radiotherapy (SBRT). She was treated with trastuzumab and aromatase inhibitor. At present, she is free of pain and is still living 15 years after breast cancer recurrence. This case suggests that the interaction of local treatment(surgery and SBRT) and systemic therapy(chemotherapy, hormonal therapy, and monoclonal therapy) may improve the survival of patients with recurrent breast cancer.

[A case of port site recurrence after thoracoscopic resection for lung metastasis of cecal cancer].

We experienced a case of port site recurrence after thoracoscopic resection for lung metastasis of cecal cancer. The patient was a 57-year-old woman who underwent right hemicolectomy at the age of 51 following a diagnosis of cecal carcinoma. She underwent video-assisted thoracic surgery for pulmonary metastasis 2 years after the first surgery. She underwent local resection for a retroperitoneal pelvic wall recurrence 3.5 years after the first surgery. Chest wall port site recurrence occurred 5.5 years after the first surgery, and she underwent partial resection of the left lung and chest wall. Subsequent treatment has been performed with adjuvant chemotherapy, and she is healthy with no evidence of recurrence 7 years and 11 months after the initial surgery. In this case, a good prognosis was obtained by frequent local resection and adjuvant chemotherapy for metachronous multiple metastases.

Oncological and cosmetic outcome in breast cancer patients undergoing "moving window" operation.

An inappropriate skin incision on the breast reduces the cosmetic benefit of breast-conserving surgery (BCS). To improve the cosmetic outcome, we have performed "moving window" operation in which BCS can be performed via a periareolar incision (periareolar approach) and/or axillary incision (axillary approach) under direct visualization. Axillary lymph node dissection is also performed via an axillary incision. The periareolar and axillary approaches were used in 65 and 43 patients, respectively. Average operation time was 130 min in periareolar approach and 131 min in axillary approach. Average blood loss was 37 and 50 ml, respectively. Postoperatively, the surgical margin of breast tissue was histologically confirmed to be negative in 107 (99%) of 108 patients, one patients underwent subsequently reoperation because of positive surgical margin. Fifty-two patients (85%) in periareolar approach and 37 patients (86%) in axillary approach had excellent or good cosmetic results. With a mean follow-up of 36 months, four patients developed in-breast recurrence, but three of them had neoadjuvant chemotherapy before surgery. The moving window operation can improve cosmetic outcome of BCS without compromising oncological safety. Moreover, it can reduce operation time and blood loss in comparison to endoscope-assisted BCS.

Axillary surgery for breast cancer: past, present, and future.

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.

Axillary reverse mapping for breast cancer.

The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. Identification rates of ARM nodes were insufficient using blue dye. Although this was improved using radioisotopes, radioisotopes alone do not permit visual mapping of ARM lymphatics. Fluorescence imaging may be useful to improve the identification rate of ARM nodes and lymphatics. On the other hand, the ARM nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases. Moreover, the SLN draining the breast may be the same as the ARM node draining the upper extremity in a minority of patients. These issues represent important drawbacks of the ARM procedure. The success of ARM in reducing lymphedema has not yet been determined. Further studies are needed before this can be accepted as a standard procedure in surgical management of breast cancer.

Axillary reverse mapping with indocyanine fluorescence imaging in patients with breast cancer.

BACKGROUND: The ARM technique was proposed to prevent arm lymphedema after ALND and/or SLN biopsy. However, several problems remain to be resolved in the practical application of this technique. METHODS: The fluorescent ARM nodes and/or lymphatics were identified using a fluorescence imaging system with subdermal injection of indocyanine green into the upper limb. ALND was performed in patients with clinically involved nodes, and the ARM nodes were separately removed during ALND. SLN biopsy was performed in patients with clinically uninvolved nodes. If SLN was positive, ALND was performed with removal of ARM nodes. Otherwise, identified ARM nodes were preserved unless they were the same as SLN. RESULTS: ARM nodes and/or lymphatics were identified in 7 (88%) of 8 patients who underwent ALND, whereas they were identified in 9 (75%) of 12 patients who underwent SLN biopsy alone. ARM nodes were involved with tumors in 3 (43%) of the former patients, and SLN was the same as the ARM node in 2 (14%) of 14 patients who underwent SLN biopsy. CONCLUSIONS: Fluorescence imaging was sensitive for identification of ARM nodes and/or lymphatics. However, further studies are needed before efforts to preserve these nodes can be safely implemented.

Histopathological and immunohistochemical evaluations of breast cancer treated with radiofrequency ablation.

BACKGROUND: Although RF ablation is a promising non-surgical ablation technique for the treatment of breast cancer, assessment of the efficacy requires not only imaging of tumor necrosis but also histological confirmation. METHODS: Two series of patients were treated with RF ablation. In the first series, 17 patients underwent surgical resection immediately and 17 underwent delayed mammotome excision in the second series. The ablated tumor tissue was examined histologically with H&E staining and NADH-diaphorase staining. Furthermore, ssDNA was immunohistochemically stained in the specimen where tumor cells were histologically detected. RESULTS: In the first series, mild response was histologically seen in 14 of 17 patients (82%), whereas complete response was observed in 8 of 16 patients (50%) in the second series. However, NADH-diaphorase staining did not demonstrate any viable tumor tissues in any patient in either the first or the second series. ssDNA staining was positive (non-viable) in 13 of 16 cases in the first series, but it was positive in all 8 cases tested in the second series. CONCLUSION: Although NADH-diaphorase staining is essential to evaluate tumor cell viability immediately after RF ablation, ssDNA may be useful for the assessment of cell viability after some interval following RF ablation.

Axillary reverse mapping in patients undergoing axillary dissection -a short review of the literature.

Axillary lymph node dissection (ALND) can be avoided not only in patients with negative sentinel lymph nodes (SLNs) but also in those with one or two positive SLNs receiving breast or axillary radiation. However, ALND has remained the standard treatment for patients with clinically positive nodes (cN+). Although axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND, it could not be indicated for cN + patients because metastatic rate of ARM nodes is high. However, a new type of conservative ALND with ARM attempts to preserve ARM lymphatics and nodes except SLNs and other suspicious palpable nodes, including suspicious ARM nodes. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients received postoperative chemotherapy and high-risk patients underwent axillary radiation. Thus, a traditional full ALND may not be necessary for cN + patients in the era of effective multimodality therapy.

A case of recurrent malignant phyllodes tumor undergoing nipple-sparing mastectomy with immediate breast reconstruction.

BACKGROUND: Although the primary treatment for malignant phyllodes tumor (PT) is complete surgical excision with either breast-conserving surgery or total mastectomy, recent technical advances have led to the adoption of nipple-sparing mastectomy (NSM) with immediate breast reconstruction (IBR). CASE PRESENTATION: A 28-year-old woman noticed a mass in her left breast that was rapidly increasing in size. She underwent tumor excision and a histological diagnosis of marked degenerative and necrotic induration suggested benign PT. One year later, however, she was found to have recurrent masses in the left breast on follow-up mammography and sonography. Needle biopsy was performed and the tumor was diagnosed as borderline or malignant PT. She underwent NSM and sentinel lymph-node biopsy with IBR using a tissue expander. Histological examination of the mastectomy specimen showed multiple fibroepithelial tumors with marked stromal overgrowth, focal necrosis, and hemorrhage. Stromal cells showed pleomorphism and a maximal mitotic rate of approximately 25 per 10 high-power fields. The tumor was diagnosed as malignant PT. She did not receive adjuvant chemotherapy or radiation treatment. At 3-year follow-up, the patient remains free of disease and highly satisfied with the cosmetic results. CONCLUSIONS: NSM with IBR is not a contraindication for malignant PT. It is both curative and can offer an appealing cosmetic option for localized malignant PT.

Complement of peritumoral and subareolar injection in breast cancer sentinel lymph node biopsy.

BACKGROUND: The optimal site for injection of mapping tracers is controversial in sentinel lymph node (SLN) biopsy for breast cancer. We evaluated whether a combination of peritumoral (PT) injection and subareolar (SA) injection can improve the identification rate of SLN biopsy and decrease the false-negative rate. METHODS: Two hundred one patients underwent SLN biopsy with PT injection of radioisotope and SA injection of blue dye. RESULTS: The overall identification rate for blue and/or hot lymph nodes was 99.5%; the identification rate of blue-dyed lymph nodes was 98.0% and that of hot lymph nodes was 97.0%. However, no concordance between the hot node and the blue node was found in 17 patients (8.5%). Among SLN-positive 51 patients, 4 patients had blue-only positive SLN and 7 had hot-only positive SLN. Consequently, the false-negative rates were at least 7.8% for PT injection and 13.7% for SA injection, while axillary lymph node dissection was not performed in SLN-negative patients. However, a combination of both injections significantly decreased the false-negative rate. CONCLUSIONS: The success of SLN mapping is optimized not only by using dye and isotope in combination but also by using PT and SA injections in combination.