De-escalation of surgery for occult breast cancer with axillary metastasis.

Occult breast cancer presenting as axillary metastasis is rare and remains a diagnostic and therapeutic challenge. Evidence to guide clinical management is limited, and locoregional treatment remains nonstandardized and highly varied nationally. Historically, occult breast cancer was managed with modified radical mastectomy ± radiotherapy; however, equivalent local control and survival are observed with breast preservation and adjuvant whole breast radiotherapy. Axillary lymph node dissection remains the standard surgical approach to the axilla for occult breast cancer patients. De-escalating axillary surgery in a subset of occult breast cancer patients treated with neoadjuvant chemotherapy with good response to treatment may be appropriate, similar to the management of clinically node-positive patients in a known primary setting. As in other clinically node-positive breast cancer cases, thoughtful integration and tailoring of axillary surgery and regional nodal radiotherapy (for the varying extent of nodal burden) is an area of continued controversy and active investigation.

SAVI SCOUT® localization of metastatic axillary lymph node prior to neoadjuvant chemotherapy for targeted axillary dissection: a pilot study.

PURPOSE: In clinically node-positive breast cancer, axillary staging after neoadjuvant chemotherapy (NAC) is optimized with targeted axillary dissection (TAD), which includes removal of the biopsy-proven metastatic lymph node (LN) in addition to sentinel lymph nodes (SLN). Localization of the clipped node is currently performed post-NAC; however, technical limitations can make detection and localization of the treated LN challenging. We prospectively evaluated the feasibility of localizing the metastatic LN with a SAVI SCOUT® reflector (SAVI) prior to NAC for targeted removal at surgery. METHODS: Twenty-five patients with stage 2/3 breast cancer underwent ultrasound-guided localization of the biopsy-proven LN with SAVI prior to NAC. After NAC, patients with clinical response underwent TAD. Primary outcome measures were rate of successful localization, days between insertion of SAVI and axillary surgery, frequency of retrieval of clipped node, and frequency of SAVI-LN as SLN. RESULTS: After NAC, 23/25 (92%) had clinical axillary down-staging and underwent TAD. Two patients with persistent palpable axillary disease underwent ALND for initial staging. Axillary surgery was performed at an average of 141 days post-SAVI insertion and the SAVI was successfully retrieved in all cases. Among 23 patients undergoing TAD, the SAVI was retrieved within a LN in all patients, whereas clip migration was observed in two patients. The median SLN removed was 4, and SAVI-LN was SLN in 22/23 patients. Axillary pCR rate was 44%. CONCLUSION: Localizing a metastatic LN with SAVI reflector prior to NAC for targeted removal at surgery is feasible and may provide technical and logistical advantages over axillary localization post-NAC. CLINICAL TRIAL REGISTRY: Clinical trials.gov identifier: NCT03411070.

Updates on treating ductal carcinoma in situ: what's to know in 2021.

PURPOSE OF REVIEW: Ductal carcinoma in situ (DCIS) is a noninvasive stage of disease but understood to be a nonobligate precursor to invasive breast cancer. As such, women with DCIS are routinely recommended for standard breast cancer treatment to prevent progression to invasive disease. DCIS, however, represents a heterogeneous group of lesions that differs in its biologic behavior and risk of progression. Thus, optimal treatment is unclear. This review presents the clinical trials evaluating the de-escalation of therapy, attempts at risk stratification, and future directions in the management of this disease. RECENT FINDINGS: The de-escalation of therapy for patients with DCIS is being actively explored. Although no group of patients based on clinicopathologic features has yet been identified as suitable for omission of therapy, molecular tests appear better able to stratify patients at low risk for whom omission of radiation may be considered. Trials considering omission of surgery are ongoing, and the use of Herceptin and vaccine therapy are also being explored. SUMMARY: The current review provides a centralized summary enabling the clinician to better understand the complexity of DCIS and the controversies over the optimal management of this disease. It highlights the need for better risk stratification to individualize patient care. VIDEO ABSTRACT: http://links.lww.com/COOG/A77.

Can Women With HER2-Positive Metastatic Breast Cancer Be Cured?

Breast cancer that is characterized by amplification or over expression of human epidermal growth factor receptor 2 (HER2) accounts for 15% to 20% of all forms of the disease. Although HER2 amplification has been associated with aggressive disease behavior and poor prognosis, the development and availability of a number of HER2-targeted agents has led to improved outcomes for patients with HER2-positive metastatic breast cancer, with data suggesting that overall survival has substantially improved in the past 2 decades. An increasing proportion of HER2-positive metastatic breast cancer is diagnosed as de novo stage IV disease. Patients with de novo metastases are traditionally classified in the general category of metastatic breast cancer and not analyzed as a distinct subgroup, though response to therapy and disease outcomes may differ from that of disease that recurred after early stage disease. Among patients with HER2+ de novo metastatic breast cancer, those who achieve a complete response have a prolonged progression-free survival and overall survival. Moreover, the fact that some patients achieve a prolonged durable response has raised interest and renewed discussion about whether cure is feasible in the complex context of metastatic breast cancer. In this review, available data associated with the possibility of cure in the population of patients with HER2+ de novo metastatic breast cancer are presented and discussed in detail.

Methodology of motor evoked potentials in a rabbit model.

Spinal cord ischemia (SCI) is a devastating complication of aortic operations. Neuromonitoring using motor evoked potentials (MEPs) is a sensitive modality to detect SCI in humans. We describe a leporine SCI model using MEPs to test pharmaceutical therapeutics and other neuroprotective adjuncts. In 80 rabbits, methods to obtain MEPs in normotensive and ischemic rabbits were developed. The effects of isoflurane, propofol, apnea, and hypotension on lower extremity MEPs were studied. Lower extremity MEPs disappear upon SCI induction in 78 of 78 (100 %) rabbits. Prior to SCI induction and during apneic episodes, lower extremity MEPs were lost in all (100 %) and upper extremity MEPs in one (25 %). Isoflurane was used in four experiments, with loss of lower extremity MEPs in all four (100 %) and loss of upper extremity MEPs in zero. With propofol upper extremity, MEPs were obtainable in 80 of 80 rabbits (100 %) and lower extremity MEPs in 78 of 80 rabbits (97.5 %) prior to SCI induction. The presence of these lower extremity MEPs prior to SCI induction was not correlated with systolic or diastolic blood pressure. Disappearance of MEPs occurred in all 45 rabbits with postoperative lower extremity impairment. MEPs in the leporine model correlate closely with paraplegia. MEPs are influenced by inhaled anesthetics and apnea but not by hypotension alone. Propofol anesthesia provides reliable MEPs. This study provides the basis for a reproducible model of SCI to be used for novel therapeutic drug development.

Central Corneal Thickness in Highly Myopic Eyes: Inter-device Agreement of Ultrasonic Pachymetry, Pentacam and Orbscan II Before and After Photorefractive Keratectomy.

PURPOSE: To determine inter-device agreement for central corneal thickness (CCT) measurement among ultrasound pachymetry, rotating Scheimpflug imaging (Pentacam, Oculus, Wetzlar, Germany), and scanning slit corneal topography (Orbscan II, Bausch & Lomb, Rochester, NY, USA) in highly myopic eyes before and after photorefractive keratectomy (PRK). METHODS: This prospective comparative study included 61 eyes of 32 patients with high myopia who underwent PRK. Six month postoperative CCT values were compared to preoperative values in 27 patients (51 eyes) who completed the follow up period. To determine the level of agreement, Pentacam and Orbscan II readings were compared to ultrasonic pachymetry measurements as the gold standard method. RESULTS: Mean CCT measurements with ultrasound, Pentacam, and Orbscan II before PRK were 557µm, 556µm, and 564µm, respectively; and 451µm, 447µm, and 438µm 6 months after surgery in the same order. Preoperatively, the 95% limits of agreement (LoA) with ultrasound measurements were -20µm to 17µm for Pentacam and -21µm to 33µm for Orbscan II. Six months postoperatively, the 95% LoA were -30µm to 23µm for Pentacam and -69µm to 43µm for Orbscan II. CONCLUSION: Preoperatively, CCT measurements were higher with Orbscan II as compared to ultrasound. Postoperatively, both Pentacam and Orbscan II measurements were lower than those obtained with ultrasound, but Pentacam had better agreement. The use of ultrasound, as the gold standard method, or Pentacam both appear to be preferable over Orbscan II among patients with high myopia.