Contrast-Enhanced Ultrasound Biopsy of Sentinel Lymph Nodes in Patients with Breast Cancer: Implications for Axillary Metastases and Conservation.

BACKGROUND: In breast cancer patients, sentinel lymph nodes (SLN) can be identified in the breast clinic using contrast-enhanced ultrasound (CEUS). This study aimed to characterize and compare the extent of axillary metastases in patients with either a benign or malignant SLN core biopsy at the end of surgical treatment. METHODS: Between 2009 and 2014, prospective data were collected on consecutive patients who underwent targeted core biopsy of SLN identified using CEUS in the breast clinic. Patients with abnormal lymph nodes (LN) detected on grey-scale ultrasound were not included. Patients whose initial SLN core biopsy was benign were compared with those who had a malignant SLN core biopsy. RESULTS: 555 patients with invasive breast cancer had SLN successfully identified and core biopsied. 487 had a benign SLN core biopsy and 427 (88 %) did not have metastases found in surgically excised SLN. Only 2 % of patients with an initial benign SLN core biopsy were found to have 2 or more LN macrometastases. 68 patients had a malignant SLN core biopsy and 52 % had 2 or more LN macrometastases. The total volume of LN metastases was higher in the group of patients who had an initial malignant SLN core biopsy (P < 0.001). CONCLUSIONS: Patients with a normal grey-scale ultrasound and benign SLN core biopsy are unlikely to have extensive axillary disease and may be ideally suited for axillary conservation. The decision to omit axillary LN dissection for patients with a malignant SLN core biopsy must be carefully considered because many will have undetected high-volume metastases.

Breast microcalcification: diagnostic value of calcified and non-calcified cores on specimen radiographs.

To determine if the specimen without calcification, as depicted on specimen radiography, made any contribution to the final histopathological diagnosis in comparison to the specimen with calcification. The records of 1312 stereotactic vacuum-assisted biopsies for breast microcalcifications between February 2000 and December 2010 were reviewed retrospectively. Following specimen x-ray the biopsy tissues with and without microcalcifications were sent in two separate pots (pot 1 and pot 2 respectively). The number of cores in each pot and the number of calcium specks within the cores were recorded. In 1135 of the 1312 (86%) cases the histopathological findings were similar for pot 1 and pot 2. In 165 cases (13%) the diagnosis was made solely on pot 1 while cores in pot 2 did not reveal any additional pathology. In 12 biopsies (1%) the significant pathology was only present in the specimen without any calcification. For "microcalcification only" breast lesions the specimen containing calcium will yield a correct diagnosis in 99% of cases. Cores containing no calcification rarely contribute to the diagnosis on their own, but in 87% of cases an accurate diagnosis would still have been made even if the targeted calcification had been missed.

Percutaneous removal of sentinel lymph nodes in a swine model using a breast lesion excision system and contrast-enhanced ultrasound.

OBJECTIVES: To investigate the feasibility of percutaneous removal of the entire sentinel lymph node (SLN) in an animal model using a breast lesion excision system after identifying these nodes using contrast-enhanced ultrasound (CEUS) and intradermal microbubbles. METHODS: Animal studies approval was obtained. SLNs were identified using CEUS and intradermal injection of microbubbles in two young pigs. Microbubbles were mixed with blue dye and injected around the mammary papillae to access lymphatic drainage to the superficial inguinal lymph nodes. When enhancing nodes were identified, the breast lesion excision system (BLES) was used to remove these nodes percutaneously. Both animals then underwent surgical lymph node dissection. Histopathological examination of all the samples was performed. RESULTS: Removal of the entire SLN was successful in three groins in the pigs. All three nodes were stained with blue dye. No other stained nodes were observed in the node dissection specimens. The nodal architecture of removed lymph nodes was well preserved on microscopy. There were no signs of excess trauma within the biopsy bed. CONCLUSION: The results obtained from the swine model demonstrated that it is feasible to remove the entire SLN percutaneously under the guidance of CEUS and microbubbles. KEY POINTS: Intradermal injection of microbubbles and CEUS can identify sentinel lymph nodes • Ultrasound could then guide percutaneous removal of intact and complete SLNs • We have shown this was feasible in pigs but not yet in humans • This technique may eventually have the potential to reduce futile SLN biopsies.

A case of unilateral keloid after bilateral breast reduction.

Keloid scar is a manifestation of abnormal wound healing in predisposed individuals. Many treatment modalities have been tried with varying degrees of success. Radiotherapy is one such modality that is widely recognised. We present a case report and literature review based on a patient who developed unilateral keloid scarring following bilateral breast reduction surgery. Some 4 years previously, she had undergone breast conserving surgery followed by adjuvant radiotherapy for breast cancer. After her breast reduction surgery, she developed keloid scarring on the non-irradiated breast only. This case highlights a possible 'preventative' effect of radiotherapy in keloid formation.

Radiotherapy and wound healing.

This review article discusses basic radiation physics and effects of radiation on wounds. It examines various postulated hypothesis on the role of circulatory decrease and radiation-induced direct cellular damage. The new concept related to the radiation pathogenesis proposes that there is a cascade of cytokines initiated immediately after the radiation. Sustained activation of myofibroblasts in the wound accounts for its chronicity. Recent advances highlight that transforming growth factor beta1 is the master switch in pathogenesis of radiation fibrosis. This articles overviews its role and summarises the available evidences related to radiation damage. The goal of this article was to provide its modern understanding, as future research will concentrate on antagonising the effects of cytokines to promote wound healing.

An oncoplastic technique to reduce the formation of lateral 'dog-ears' after mastectomy.

BACKGROUND: Lateral skin folds or 'dog-ears' are frequent following mastectomy, particularly in patients with large body habitus. METHODS: We describe a method of modifying the mastectomy incision and suturing to eliminate these lateral 'dog-ears'. CONCLUSION: This surgical technique, as compared to others described in the literature, is simple, does not require additional incisions and is cosmetically acceptable to the patient.

Current management of the axilla in patients with clinically node-negative breast cancer: a nationwide survey of United Kingdom breast surgeons.

BACKGROUND: Precise knowledge of axillary lymph node status is essential in the treatment of operable carcinoma of the breast. For many years, axillary nodal clearance (ANC) has been an integral part of the conventional management of early-stage breast cancer. During the last few decades the trend of these surgical procedures has been one of decreasing invasiveness in order to try and achieve a much lower level of morbidity. To help reach this improved level of treatment the concept of the sentinel lymph node (SLN) was utilized. Recent studies have shown that SNB can provide an accurate assessment of the axillary nodal status in clinically node negative patients, negating the need to remove the majority of the axillary contents and thus reducing morbidity. A recent meta-analysis of all the literature to date appears to reveal that the dual technique (blue dye and technetium-labelled sulfur) is the gold-standard for successful identification of the SLN in the context of early-stage breast cancer. We aim to highlight the on-going wide range of differing methods employed, and compare this to the gold-standard recommended guidelines. METHODS: A questionnaire was devised to provide a snapshot overview of the current management of the axilla in patients with clinically node-negative T1 invasive breast cancer amongst UK beast surgeons in August 2006. RESULTS: Of the 271 UK surgeons, 74 (27.3%) performed ANC as the initial management of the axilla in patients with clinically node negative T1 invasive breast cancer, 56 (20.7%) used axillary node sampling (not directed by sentinel node mapping) and a total of 141 (52.0%) used the technique of SNB, of which 50 (18.5%) used blue dye alone and 91 (33.6%) used a combination of blue dye and radioisotope. CONCLUSION: Despite the obvious advantages, our survey has revealed that the procedure is only used by 52% of British breast surgeons in this subgroup of patients (clinically node negative, tumour equal of smaller than 2 cm) most of whom have no disease within the axilla. The reasons for this include limited hospital resources and lack of surgeons training and accreditation and ARSAC license (nuclear medicine license).

The competent sentinel node: an association with an axillary presentation and an occult or a small primary invasive breast carcinoma.

The concept of the sentinel node describes a primary or sentinel lymph node (SLN), which exists and through which tumour cells from a primary tumour in a particular location must first travel to spread to a particular regional lymph node group. In this series we present three patients presenting with a pathological axillary node associated with either an occult or very small primary breast cancer. In each case the primary tumour was found to have metastasised to the palpable node, however despite the significant enlargement of this node, no other axillary nodes were found to be affected on axillary node clearance. This has led us to postulate that the SLN in some cases contains unique characteristics that enable it to prevent further spread of the tumour up the lymphatic chain. Hence the term the competent sentinel node.

Predictive factors for invasive cancer in surgical specimens following an initial diagnosis of ductal carcinoma in situ after stereotactic vacuum-assisted breast biopsy in microcalcification-only lesions.

PURPOSE: The aim of this study was to determine the incidence of invasive breast carcinoma in patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by stereotactic vacuum-assisted biopsy (SVAB) performed for microcalcification-only lesions, and to identify the predictive factors of invasion. METHODS: From 2000 to 2010, the records of 353 DCIS patients presenting with microcalcification-only lesions who underwent SVAB were retrospectively reviewed. The mammographic size of microcalcification cluster, presence of microinvasion within the cores, the total number of calcium specks, and the number of calcium specks within the retrieved core biopsy specimen were recorded. Patients were grouped as those with or without invasion in the final pathologic report, and variables were compared between the two groups. RESULTS: The median age was 58 years (range, 34-88 years). At histopathologic examination of the surgical specimen, 63 of 353 patients (17.8%) were found to have an invasive component, although SVAB cores had only shown DCIS preoperatively. The rate of underestimation was significantly higher in patients with microcalcification covering an area of 40 mm or more, in the presence of microinvasion at biopsy, and in cases where less than 40% of the calcium specks were removed from the lesion. CONCLUSION: Invasion might be underestimated in DCIS cases diagnosed with SVAB performed for microcalcification-only lesions, especially when the mammographic size of calcification is equal to or more than 40 mm or if microinvasion is found within the biopsy specimen and less than 40% of the calcifications are removed. At least 40% of microcalcification specks should be removed from the lesion to decrease the rate of underestimation with SVAB.

Factors that impact the upgrading of atypical ductal hyperplasia.

PURPOSE: The purpose of this study was to identify the factors that may have an impact on upgrading atypical ductal hyperplasia (ADH) lesions to malignancy. MATERIALS AND METHODS: Between February 1999 and December 2010, the records of 150 ADH lesions that had been biopsied were retrospectively reviewed. The biopsy types included 11-gauge stereotactic vacuum-assisted biopsy (SVAB) (n=102) and ultrasonography (US)-guided 14-gauge automated biopsy (n=48). The patients were divided into two groups: those who had cancer in the final pathology and those who did not. Variables associated with underestimation of ADH lesions were compared between the groups. RESULTS: The underestimation rates according to the biopsy types were 41.7% (20/48) for the US-guided 14-gauge automated biopsy and 20.6% (21/102) for the 11-gauge SVAB (P = 0.007). The rate of underestimation was significantly higher in lesions greater than 7 mm than it was in smaller lesions, with both US-guided 14-gauge automated biopsy and 11-gauge SVAB (P = 0.024 and P = 0.042, respectively). The rate of underestimation was significantly higher with the 11-gauge SVAB (P = 0.025) in lesions that were suspicious (R4) and highly suggestive of malignancy (R5) than in those that were probably benign (R3). CONCLUSION: The underestimation rate in ADH lesions was significantly higher with US-guided 14-gauge automated biopsy compared to the 11-gauge SVAB. The underestimation rate was also significantly higher in lesions greater than 7 mm regardless of the biopsy type, and in lesions biopsied using SVAB that were regarded as suspicious (R4) or highly suggestive of malignancy (R5) on imaging.

Causes of failure in removing calcium in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy.

PURPOSE: The aim of this study was to determine the causes and rate of failure in removing calcification in microcalcification-only lesions using 11-gauge stereotactic vacuum-assisted breast biopsy. MATERIALS AND METHODS: In total, 1365 microcalcification-only lesions were included in this study. The breast biopsy database was reviewed retrospectively. The biopsies were divided into two groups based on whether the specimen X-ray showed calcium within the cores. Breast composition, lesion size, calcification distribution, density on mammography, and the number of specimens were compared between the two groups. RESULTS: In 11 (0.8%) biopsies, no calcium in the specimen radiography could be identified. Re-biopsy was performed in five cases. The initial biopsy result was unchanged at the second biopsy in three cases containing calcium, while in the other two cases, a benign biopsy result was upgraded to atypical ductal hyperplasia and ductal carcinoma in situ, respectively. In six cases, the biopsy was not repeated despite the absence of calcium in the specimen X-ray. In three of these cases, calcifications were reported histopathologically and deemed to be too small to be identified on specimen X-ray. In two of six patients, sufficient information was found in the cores without microcalcification to indicate the need for surgery. One patient refused re-biopsy. A statistically significant higher failure rate was observed in low-density calcification compared with intermediate or high-density calcification on mammography. CONCLUSION: The failure to retrieve microcalcification is uncommon when an 11-gauge vacuum-assisted breast biopsy is used. Low-density calcifications have a higher rate of failure. In cases in which no calcium is observed in specimen radiography, repeated biopsy is recommended.

How does knowledge of three-dimensional excision margins following breast conservation surgery impact upon clinical target volume definition for partial-breast radiotherapy?

BACKGROUND AND PURPOSE: To compare partial-breast clinical target volumes generated using a standard 15 mm margin (CTV(standard)) with those generated using three-dimensional surgical excision margins (CTV(tailored 30)) in women who have undergone wide local excision (WLE) for breast cancer. MATERIAL AND METHODS: Thirty-five women underwent WLE with placement of clips in the anterior, deep and coronal excision cavity walls. Distances from tumour to each of six margins were measured microscopically. Tumour bed was defined on kV-CT images using clips. CTV(standard) was generated by adding a uniform three-dimensional 15 mm margin, and CTV(tailored 30) was generated by adding 30 mm minus the excision margin in three-dimensions. Concordance between CTV(standard) and CTV(tailored 30) was quantified using conformity (CoI), geographical-miss (GMI) and normal-tissue (NTI) indices. An external-beam partial-breast irradiation (PBI) plan was generated to cover 95% of CTV(standard) with the 95% isodose. Percentage-volume coverage of CTV(tailored 30) by the 95% isodose was measured. RESULTS: Median (range) coronal, superficial and deep excision margins were 15.0 (0.5-76.0)mm, 4.0 (0.0-60.0)mm and 4.0 (0.5-35.0)mm, respectively. Median CoI, GMI and NTI were 0.62, 0.16 and 0.20, respectively. Median coverage of CTV(tailored 30) by the PBI-plan was 97.7% (range 84.9-100.0%). CTV(tailored 30) was inadequately covered by the 95% isodose in 4/29 cases. In three cases, the excision margin in the direction of inadequate coverage was