Pre-treatment MRI tumor features and post-treatment mammographic findings: may they contribute to refining the prediction of pathologic complete response in post-neoadjuvant breast cancer patients with radiologic complete response on MRI?

PURPOSE: Radiologic complete response (rCR) in breast cancer patients after neoadjuvant chemotherapy (NAC) does not necessarily correlate with pathologic complete response (pCR), a marker traditionally associated with better outcomes. We sought to verify if data extracted from two important steps of the imaging workup (tumor features at pre-treatment MRI and post-treatment mammographic findings) might assist in refining the prediction of pCR in post-NAC patients showing rCR. METHODS: A total of 115 post-NAC women with rCR on MRI (2010-2016) were retrospectively assessed. Pre-treatment MRI (lesion morphology, size, and distribution) and post-treatment mammographic findings (calcification, asymmetry, mass, architectural distortion) were assessed, as well as clinical and molecular variables. Bivariate and multivariate analyses evaluated correlation between such variables and pCR. Post-NAC mammographic findings and their correlation with ductal in situ carcinoma (DCIS) were evaluated using Pearson's correlation. RESULTS: Tumor distribution at pre-treatment MRI was the only significant predictive imaging feature on multivariate analysis, with multicentric lesions having lower odds of pCR (p = 0.035). There was no significant association between tumor size and morphology with pCR. Mammographic residual calcifications were associated with DCIS (p = 0.009). The receptor subtype remained as a significant predictor, with HR-HER2 + and triple-negative status demonstrating higher odds of pCR on multivariate analyses. CONCLUSIONS: Multicentric lesions on pre-NAC MRI were associated with a lower chance of pCR in post-NAC rCR patients. The receptor subtype remained a reliable predictor of pCR. Residual mammographic calcifications correlated with higher odds of malignancy, making the correlation between mammography and MRI essential for surgical planning. Key Points • The presence of a multicentric lesion on pre-NAC MRI, even though the patient reaches a radiologic complete response on MRI, is associated with a lower chance of pCR. • Molecular status of the tumor remained the only significant predictor of pathologic complete response in such patients in the present study. • Post-neoadjuvant residual calcifications found on mammography were related to higher odds of residual malignancy, making the correlation between mammography and MRI essential for surgical planning.

Papillomas of the breast: factors associated with underestimation.

The distinction between benign and malignant papilloma of the breast through percutaneous needle biopsy can be difficult because of limited samples; the underestimation rate can be up to 25%. The aim of this study is to identify clinical and histological factors associated with underestimation, invasive ductal carcinoma, or ductal in-situ carcinoma (DCIS) of the breast found in surgical specimens from papillary lesions. This may contribute toward selection of patients for a follow-up strategy without the need for surgical excision. From a database of 3563 patients, we identified 85 with intraductal papilloma between 2007 and 2013 who had undergone breast-imaging studies, percutaneous needle biopsy, and surgical resection of the lesion. Central papillomas normally present with a palpable mass, whereas peripheral papillomas generally do not have clinical manifestations (microcalcifications); both central and peripheral papillomas were related to atypical lesions, 13.5 and 15.4%, respectively. Among the 59 cases of central papillomas, there were four cases of underestimation, three DCIS and one invasive ductal carcinoma (6.8%). Among the 26 cases of peripheral papillomas, there was one case of DCIS (3.8%), with a total underestimation rate of 5.8%; all underestimated lesions measured more than 1 cm. The median size was 11 mm at mammography and 19 mm at ultrasound. Our data suggest that lesions less than 1 cm in size, without atypia and concordant imaging and clinical findings, may not require surgical resection.

Axillary Lymph Node Sonographic Features and Breast Tumor Characteristics as Predictors of Malignancy: A Nomogram to Predict Risk.

The purpose of this study was to build a mathematical model to predict the probability of axillary lymph node metastasis based on the ultrasonographic features of axillary lymph nodes and the tumor characteristics. We included 74 patients (75 axillae) with invasive breast cancer who underwent axillary ultrasonography ipsilateral to the tumor and fine-needle aspiration of one selected lymph node. Lymph node pathology results from sentinel lymph node biopsy or surgical dissection were correlated with lymph node ultrasonographic data and with the cytologic findings of fine-needle aspiration. Our mathematical model of prediction risk of lymph node metastasis included only pre-surgical data from logistic regression analysis: lymph node cortical thickness (p = 0.005), pre-surgical tumor size (p = 0.030), menopausal status (p = 0.017), histologic type (p = 0.034) and tumor location (p = 0.011). The area under the receiver operating characteristic curve of the model was 0.848, reflecting an excellent discrimination of the model. This nomogram may assist in the choice of the optimal axillary approach.

Predictive factors for positive surgical margins in the treatment of breast ductal carcinoma in situ.

CONTEXT: Surgery is the main form of treatment for ductal carcinoma in situ (DCIS) of the breast. Among other factors, treatment success requires that the surgical margins are free of disease, to reduce the risk of recurrence. AIMS: The purpose of this study was to analyze factors that might be associated with positive margins in patients diagnosed with DCIS. SETTINGS AND DESIGN: A retrospective analysis was performed of hospital databases from the year 2006 to 2014, to identify patients with an initial diagnosis of DCIS made by percutaneous biopsy. SUBJECTS AND METHODS: Age, the presence of disease symptoms, lesion size on mammogram, and the presence of estrogen receptors, and their relationship to the surgical margins were evaluated in 249 patients. STATISTICAL ANALYSIS USED: Shapiro and Wilcoxon-Mann-Whitney tests were used to verify that the data were normally distributed. Chi-squared test was used to verify the independence of the variables. RESULTS: Lesions measuring 1.55 cm or greater had a relative risk of positive margins after conservative surgery of 1.39 (95% confidence interval [95% CI]: 1.02-1.90). The presence of symptoms had a relative risk of positive margins after conservative surgery of 1.54 (95% CI: 1.17-2.02). CONCLUSION: Lesions measuring 1.55 cm or greater and the presence of symptoms are risk factors for positive margins in the treatment of ductal carcinoma in situ. Therefore, these patients need a better surgical planning in order to reduce the risk of positive margins. There is a clear need for large prospective studies to validate our findings and define other factors that might contribute to the success of surgical resection for ductal carcinoma in situ.

Immediate reconstruction following breast-conserving surgery: management of the positive surgical margins and influence on secondary reconstruction.

The efficacy of breast-conserving surgery for the local control of early breast cancer has been repeatedly evidenced. Although immediate reconstruction following breast-conserving surgery has been described, little information is available regarding surgical management in reoperative settings due to positive margins. We studied the influence of intraoperatively assessed and postoperatively controlled surgical margin status on the type of breast-conserving surgery and report our results regarding complications in a reoperative breast reconstruction scenario. All patients were seen by a multidisciplinary team who recommended breast-conserving surgery. According to the breast volume, ptosis and tumor size/location, the patients were also evaluated by a plastic surgeon, who recommended reconstruction with the appropriate technique. Intraoperative assessment of surgical margins was determined by histological examination of frozen sections. The mean follow-up time was 48 months. Two hundred and eighteen patients (88.5%) underwent breast-conserving surgery and immediate reconstruction. Twelve (5.5%) patients had a positive tumor margin after review of the permanent section. All patients underwent re-exploration. In 1.3%, a second reconstructive technique was indicated and in 2.2% a skin-sparing mastectomy with total reconstruction was performed. Our findings support the important role of the intraoperative assessment of surgical margins and its interference in the selection of reconstruction techniques and negative margins; however, it will not guarantee complete excision of the tumor. Success depends on coordinated planning with the oncologic surgeon and careful intraoperative management.

Câncer de vulva na Clínica ginecológica da Faculdade de Medicina da Universidade de Säo Paulo / Vulvar cancer in the clínica Ginecológica da Faculdade de Medicina da Universidade de Säo Paulo

Estudamos 58 casos de câncer da vulva (1974/1990). O tipo histológico mais comum foi o carcinoma (91,3 por cento); a idade média foi 59,5 anos (30 a 91); o sintoma mais assíduo foi prurido; o local mais freqüente da neoplasia foi o pequeno lábio Ó direita; e o aspecto mais encontradiçäo a ulceraçäo. Em 12 por cento dos casos a forma era in situ, nessas, o tamanho da lesäo era menor que 2cm em 85,7 por cento e eram mais freqüentes áreas discrómicas e a multicentricidade. Nos invasores, em 51,7 por cento havia linfonodos suspeitos e em 22 por cento bilateralidade dos mesmos. Em 51,7 por cento havia outras vulvopatias associadas; a mais freqüente das quais eram as distrofias hiperplásicas. O exame subsidiário mais útil foi o teste de Collins (azul de toluidina). Os estádios 0 = 12,1 por cento; microinvasor = 3,4 por cento; I = 27, 5 por cento; II = 20,7 por cento; III = 31 por cento e IV = 5,2 por cento. O tratamento nas formas in situ, foi ou vulvectomia simples ou exerese nas formas nÒo multicêntricas. Nas invasoras efetuamos vulvectomia radical em 46,6 por cento das ocasiöes. A reconstruçäo com recursos de cirurgia plástica tem sido cada vez mais utilizada. A complicaçäo mais comum foi a necrose de retalho. A radioterapia pós-operatória foi indicada quando havia linfonodos metastáticos. A sobrevida foi de 85 por cento nos estádios I; 66,7 por cento no II; 36,8 por cento no III e 0 no IV.