Management of High-Risk Breast Lesions.

High-risk breast lesions (HRLs) are a group of heterogeneous lesions that can be associated with a synchronous or adjacent breast cancer and that confer an elevated lifetime risk of breast cancer. Management of HRLs after core needle biopsy may include close imaging and clinical follow-up or excisional biopsy to evaluate for cancer. This article reviews histologic features and clinical presentation of each of the HRLs, current evidence with regard to management, and guidelines from the American Society of Breast Surgeons and National Comprehensive Cancer Network. In addition, imaging surveillance and risk-reduction strategies for women with HRLs are discussed.

Value of a short-term imaging follow-up after a benign result in a one-stop breast unit: Is it still useful?

INTRODUCTION: A short-term radiologic follow-up after a benign breast biopsy or fine needle aspiration (FNA) is recommended in many guidelines. However, the current trend is to reduce imaging investigations, radiation dose and costs. The objectives of this study were to evaluate the cancer detection rate at short-term follow-up and to estimate its cost. METHODS: We retrospectively assessed all consecutive patients referred to our 'one-stop' breast unit between 2004 and 2012, with a benign histological or cytological result and at least one short-term follow-up within 3-12 months after the initial diagnosis. We evaluated the number of cancers detected, as well as the mean cost to detect each cancer and per patient. RESULTS: About 1366 patients were eligible for this study. Ten patients were diagnosed with cancers (0.73%) at short-term follow-up; six of 10 were low-grade tumours or ductal carcinoma in situ. The cost for detecting one cancer was 19,043€, with mean cost per patient of 139€. CONCLUSION: The cancer detection rate at short-term follow-up after benign biopsy or FNA was low and was similar to that of most national screening programs. The cost of cancer detection appeared high, considering that most cancers were indolent. This suggests that radiologic follow-up could reasonably be carried out at a later point in time.

Double-Blind Randomized 12-Month Soy Intervention Had No Effects on Breast MRI Fibroglandular Tissue Density or Mammographic Density.

Soy supplementation by patients with breast cancer remains controversial. No controlled intervention studies have investigated the effects of soy supplementation on mammographic density in patients with breast cancer. We conducted a double-blind, randomized, placebo-controlled intervention study in previously treated patients with breast cancer (n = 66) and high-risk women (n = 29). We obtained digital mammograms and breast MRI scans at baseline and after 12 months of daily soy (50 mg isoflavones per day; n = 46) or placebo (n = 49) tablet supplementation. The total breast area (MA) and the area of mammographic density (MD) on the mammogram were measured using a validated computer-assisted method, and mammographic density percent (MD% = 100 × MD/MA) was determined. A well-tested computer algorithm was used to quantitatively measure the total breast volume (TBV) and fibroglandular tissue volume (FGV) on the breast MRI, and the FGV percent (FGV% = 100 × FGV/TBV) was calculated. On the basis of plasma soy isoflavone levels, compliance was excellent. Small decreases in MD% measured by the ratios of month 12 to baseline levels were seen in the soy (0.95) and the placebo (0.87) groups; these changes did not differ between the treatments (P = 0.38). Small decreases in FGV% were also found in both the soy (0.90) and the placebo (0.92) groups; these changes also did not differ between the treatments (P = 0.48). Results were comparable in patients with breast cancer and high-risk women. We found no evidence that soy supplementation would decrease mammographic density and that MRI might be more sensitive to changes in density than mammography.

The first case of breast cancer in thalassemic patient: case report and review of literature.

Thalassemias are genetic disorders characterized by decreased synthesis of one of the globin chains. Beta-thalassemia is caused by impairment in the production of beta-globin chains leaving the excess alpha chains unstable. With better treatment approaches and improvement in chelation therapy, thalassemic patients are living longer. As a consequence, new complications and associations with other conditions including malignancy have emerged. The occurrence of malignancies in thalassemia has rarely been reported, and our review of the literature revealed only few cases. We report the first case of a thalassemic patient developing breast cancer and discuss the possibility of a link between the two disease entities. This case is intended to alert physicians of the possibility of a malignancy in thalassemia patients.

Radioactive seed localization of nonpalpable breast lesions in an academic comprehensive cancer program community hospital setting.

Wire localized excision (WLE) has been a long-standing method for localization of nonpalpable breast lesions. Disadvantages of this method include difficulty locating the wire tip in relation to borders of the lesion, imprecise placement of the wire, and the need to place the wire shortly before scheduled surgery. These shortcomings may lead to a high positive margin rate requiring re-excision to obtain clear margins for breast cancer. Radioactive seed localized excision (RSLE) of nonpalpable breast lesions has been advocated as a safe and effective alternative to WLE. The primary endpoints of the study were to compare re-excision rates between WLE and RSLE of nonpalpable breast lesions and to determine if there were any differences in volume of tissue removed. One hundred three patients were included in a retrospective review of localized breast excisions done by a single surgeon. Forty-four patients underwent WLE between April 2007 and February 2009. Fifty-nine patients underwent RSLE between September 2009 and January 2012. Margins were considered to be clear if at least 1 mm of normal tissue was obtained from the circumferential periphery of the lesion in question. RSLE resulted in a re-excision rate of 17 versus 55 per cent re-excision rate for wire localization (P < 0.001). Excision volume was greater for patients having wire localization (P = 0.074). RSLE is an effective technique for excision of nonpalpable breast lesions in the community setting. This technique allows for accurate localization and appears to allow for smaller volume of tissue to be excised.

Variation in detection of ductal carcinoma in situ during screening mammography: a survey within the International Cancer Screening Network.

BACKGROUND: There is concern about detection of ductal carcinoma in situ (DCIS) in screening mammography. DCIS accounts for a substantial proportion of screen-detected lesions but its effect on breast cancer mortality is debated. The International Cancer Screening Network conducted a comparative analysis to determine variation in DCIS detection. PATIENTS AND METHODS: Data were collected during 2004-2008 on number of screening examinations, detected breast cancers, DCIS cases and Globocan 2008 breast cancer incidence rates derived from national or regional cancer registers. We calculated screen-detection rates for breast cancers and DCIS. RESULTS: Data were obtained from 15 screening settings in 12 countries; 7,176,050 screening examinations; 29,605 breast cancers and 5324 DCIS cases. The ratio between highest and lowest breast cancer incidence was 2.88 (95% confidence interval (CI) 2.76-3.00); 2.97 (95% CI 2.51-3.51) for detection of breast cancer; and 3.49 (95% CI 2.70-4.51) for detection of DCIS. CONCLUSIONS: Considerable international variation was found in DCIS detection. This variation could not be fully explained by variation in incidence nor in breast cancer detection rates. It suggests the potential for wide discrepancies in management of DCIS resulting in overtreatment of indolent DCIS or undertreatment of potentially curable disease. Comprehensive cancer registration is needed to monitor DCIS detection. Efforts to understand discrepancies and standardise management may improve care.

Nation-wide data on screening performance during the transition to digital mammography: observations in 6 million screens.

PURPOSE: To critically evaluate and confirm previous results regarding the diagnostic accuracy of digital mammography screening (DM), compared to screen-film mammography (SFM) in the whole Dutch screening programme, in the period of 2004-2010, during which a full transition from SFM to DM was made. MATERIALS AND METHODS: 1.5 million DM and 4.6 million SFM were read in the Dutch national breast cancer screening programme in the period of 2004-2010. We evaluated recall rate, detection rate, positive predictive value and tumour-size distribution for younger and older women, for first time participants and women having a timely subsequent screen. We compared DM screens read by radiologists reading DM and SFM (DM-group) to SFM screens read by these radiologists (SFM-group) and to SFM screens read by radiologists reading only SFM (SFMonly-group). RESULTS: Recall rate was 2.0% (95% confidence interval (C.I.): 2.0; 2.1) in the DM-group, compared to 1.6% (95% C.I.: 1.6; 1.6) in the SFM-group and 1.6% (95% C.I.: 1.5; 1.6) in the SFM only-group. The overall detection rates were 5.9/1000 screens (95% C.I.: 5.7; 6.0) in the DM-group, 5.1/1000 screens (95% C.I.: 5.0; 5.2) in the SFM-group and 5.0/1000 screens (95% C.I.: 5.0; 5.1) in the SFM only-group. Detection rate rose most markedly in younger women (age 49-54) from 4.0/1000 screens to 5.1/1000 screens (p-value<0.001). Positive predictive value (PPV) in DM rose from 18.4% (95% C.I.: 14.6; 23.1) in 2004 to 32.5% (95% C.I.: 31.7; 33.2) in 2010. Detection rate rose in SFM-group from 5.0/1000 screens (95% C.I.: 4.7; 5.3) in 2004 to 5.5/1000 screens (95% C.I.: 5.2; 5.7) in 2010. Detection rate in DM-group rose mostly due to ductal carcinoma in situ (DCIS) detection especially in younger women/first screens. The proportion of T1a tumours was significantly higher in DM-group; otherwise size distribution did not change significantly for invasive carcinoma. Recall rates were variable between different screening regions. CONCLUSION: In accordance to previous, smaller, studies, we can confirm that DM has a higher detection rate compared to SFM, at the cost of a higher recall rate and lower PPV. More DCIS and a higher fraction of very small tumours were detected with DM, which has positive consequences for the stage shift as a result of mass screening.

Breast cancer in Singapore: some perspectives.

Breast cancer is the commonest malignancy among Singapore women, accounting for 29.7% of all female cancers, with an age-standardized rate of 54.9 per 100,000 per year. It has been the most frequent cancer in Singapore women for the last 30 years, with the highest rates previously reported in those aged between 45 and 49 years, but with a more recent observation of a change in peak age group to women in their late 50s. About 1,100 new cases are diagnosed annually and approximately 270 women die in Singapore each year from breast cancer. In the multiethnic population of Singapore, it has been noted that rising breast cancer incidence is consistent across all three ethnic groups (Chinese, Malays, and Indians). Singapore has among the highest breast cancer incidence in Asia. Possible explanations include rapid urbanization, improvement in socio-economic status, and adoption of a western lifestyle. Our experience with the Singapore breast screening pilot project (1994-1997) and the national breast-screening program (BreastScreen Singapore) has led to increased understanding of this disease in the country. Data from the pilot project showed that breast screening is just as effective in a predominantly Asian population as in the west. Early breast cancer accounted for most breast cancers detected, with pre-invasive ductal carcinoma in situ (DCIS) comprising 26% of all screen-detected cancers in the pilot study. In the currently on-going BreastScreen Singapore, DCIS forms >30% of all breast cancers among pre-menopausal women, a relatively high proportion probably accounted for partially by the greater participation of women aged between 40 and 49 years. Despite the ready availability of subsidized mammographic screening, there are still women in Singapore who present with locally advanced breast cancer. Clinical management of an increasing number of women with breast cancer embraces a multidisciplinary team-based approach, with regular discussions of therapeutic strategies at tumor boards. In order to improve breast cancer diagnostics and therapeutics in our country, it is important that there are continual breast cancer and breast disease-related educational activities for medical professionals engaged in diagnosing and managing breast cancer. The role of public education in raising awareness is also essential.

Invasive ductal carcinoma associated with tubular adenoma of the breast.

We report an extremely rare case of the colocalization of a tubular adenoma and an invasive ductal carcinoma occurring in a 55-year-old woman. Following radiographical evaluation, fine-needle aspiration cytology of the left breast tumor was undertaken. Because cytological examination revealed malignancy, a partial mastectomy was performed. Histologically, the tumor (measuring 1.7 x 1.3 cm) comprised two distinct parts: tubular adenoma and invasive ductal carcinoma. The invasive ductal carcinoma showed a solid pattern, high nuclear and structural atypia and frequent mitotic figures, while the tubular adenoma consisted of a proliferation of small ducts lined by single layers of epithelial and myoepithelial cells with bland nuclei and inconspicuous nucleoli. The histological boundary was clearly defined between the tubular adenoma and the invasive ductal carcinoma, and between the tubular adenoma and the surrounding breast tissue. The current case might be a collision between separate tubular adenoma and invasive ductal carcinoma, but the malignant transformation of a tubular adenoma cannot be ruled out. Both the long-term observation of this case and analysis of more cases may enable us to determine the histological characteristics and clinical significance of invasive ductal carcinoma associated with tubular adenoma.

Prediction of treatment temperatures in clinical hyperthermia of locally advanced breast carcinoma: the use of contrast enhanced computed tomography.

PURPOSE: Nineteen patients with locally advanced breast carcinoma were subjected to computed tomography examinations prior to thermoradiotherapy. Pre- and postcontrast computed tomography images were obtained, and tumor contrast enhancement was studied in relation to tissue perfusion, PERF, and steady state temperature, TS, in an attempt to develop an assay for prediction of treatment temperatures in clinical hyperthermia of breast carcinoma. METHODS AND MATERIALS: PERF and TS were calculated from temperature data achieved during the first fraction of the heat treatment regimen. The computed tomography images were subjected to image analysis, and two parameters representing tumor contrast enhancement were calculated from the computed tomography numbers; the absolute increase in mean attenuation, delta N, and the fraction of the postcontrast attenuation values that was higher than the mean precontrast attenuation value, F+C. RESULTS: delta N and F+C were clearly correlated to each other. The two parameters differed considerably among the patients, showing that the accumulation of contrast medium was higher in some tumors than in others. Tumor contrast enhancement increased with increasing PERF, suggesting that the accumulation of contrast medium in the tumors was determined mainly by the effective tissue perfusion. There was also a clear correlation between tumor contrast enhancement and TS. The tumors showing a high accumulation of contrast medium were more difficult to heat than those showing a low accumulation. CONCLUSION: The results indicate that contrast enhanced computed tomography images may give information about the treatment temperatures that can be achieved in clinical hyperthermia of breast carcinoma. The computed tomography images may possibly be used to predict those tumors that can be heated to therapeutic temperatures.

Choice of anesthetic technique for needle localized breast biopsy.

General anesthesia has been recommended to increase the accuracy and safety of needle localized biopsy (NLB). The authors' NLB experience was reviewed to determine whether the method of anesthesia affected accuracy, yield, complication rate, or cost. All biopsies were performed in a standard operating room using either local anesthesia (Group 1, n = 14), local anesthesia with an anesthesiologist present (Group 2, n = 14), or general anesthesia (Group 3, n = 10). The mean operative times were 54, 59, and 56 minutes for Groups 1, 2, and 3, respectively. In groups 1 and 2, 100 per cent of the specimen radiographs showed the target lesion had been excised, although one biopsy was indeterminate. Among Group 3 two target lesions could not be identified on specimen radiographs and one was indeterminate. There was one malignancy in Group 1 compared with four malignancies in Group 2 and two in Group 3. The average hospital bill was $1,172 for Group 1, $1,418 for Group 2, and $1,488 for Group 3. Anesthesiologists' fees added an additional $224 to Groups 2 and 3. NLB can be performed using local anesthesia without sacrificing accuracy or yield, increasing operative time, or increasing complication rate; the cost is significantly less than with general anesthesia.

[Clinical x-ray and morphological changes in breast carcinomas during radiothermotherapy]. / Kliniko-rentgenologicheskie i morfologicheskie izmeneniia v kartsinomakh molochnoi zhelezy pri radiotermoterapii.

Clinico-roentgeno-morphological investigation established a marked regression of tumor in as many as 86.1% out of 230 patients with stage IIB and III breast cancer who had undergone radiothermotherapy. Morphologically confirmed complete regression was observed in 12.6% of patients with lesions smaller than 3 cm in diameter at presentation. Treatment was followed by massive necrosis, dystrophic changes and inhibition of mitotic activity of tumor cells in patients with stage III cancer and those with stage IIB who had presented with tumors larger than 3 cm in diameter. However, in all these cases viable tumor cells were still observed at the periphery of tumor.

[Galactography in the early detection of breast cancer]. / Galaktografiia v rannem dyiavlenii raka molochnoi zhelezy.

Pathologic discharge from the breast occurred in 308 out of 5000 (6.1%) apparently healthy women. Ductography was carried out in 237 such cases. The procedure revealed ductal ectasia in 96 patients (40.5%), ductal papillomatosis--38 (16.0%), intraductal papilloma--15 (6.8%) and cysts--in 16 cases. Cancer was suspected in 22 (9.3%) patients and in 14 (63.6%) of them tumor was diagnosed following excisional biopsy. On the whole, cancer was detected in 5.9% of the examined cases. In 13 out of 14 (92.9%), ductal carcinomas were either minimal (dia less than or equal to 1 cm) or noninvasive.