Additional Workups Recommended During Preoperative Breast MRI: Methods to Gain Efficiency and Limit Confusion.

BACKGROUND: Preoperative breast MRI is indicated for staging but can lead to complex imaging workups. This study reviewed imaging recommendations made on preoperative MRI exams, to simplify management approaches for patients with newly diagnosed breast cancer. METHODS: This retrospective single-institution review was restricted to women with breast cancer who underwent staging MRI. Additional breast lesions, separate from index tumors, recommended for additional workup or surveillance were assessed to see which were detected and which characteristics predicted success in detection. Univariate mixed-effects logistic modeling predicted the likelihood of finding lesions using MRI-directed ultrasound (US), with odds ratios reported. Tests were two-sided, with a p value lower than 0.05 considered significant. RESULTS: In this study, 534 (39.6%) patients had recommendations for additional workup after preoperative MRI. MRI detected additional malignancy in 178 patients (33.3%). Half of the 66 patients who refused an additional workup and opted for mastectomy had additional malignancies at mastectomy. MRI-directed US was 14 times more likely to detect masses than nonmass enhancement (NME) (p < 0.001). NME was detected on US in only 16% of cases, with one third of subsequent biopsy results considered discordant. Probably benign assessments were given to 35 patients, with 23% not returning for follow-up evaluation and 7% returning at least 6 months later than recommended. CONCLUSION: Use of preoperative breast MRI has increased. Although it can add value, institutions should establish indications and expectations to prevent unnecessary workups. Limiting MRI-directed US to masses, avoiding probably benign assessments, and consulting with patients after MRI but prior to workups can prevent unnecessary exams and confusion.

Residual Cancer Burden Class Associated with Survival Outcomes in Women with Different Phenotypic Subtypes of Breast Cancer After Neoadjuvant Chemotherapy.

BACKGROUND: The residual cancer burden class informs survival outcomes after neoadjuvant chemotherapy. We evaluated the prognostic ability of the RCB for survival outcomes in women with different phenotypic subtypes of breast cancer treated with neoadjuvant chemotherapy. Additional variables were assessed for inclusion with the RCB to further improve the model's discriminative ability. PATIENTS AND METHODS: We conducted a retrospective review of patients completing at least 75% of the recommended cycles of neoadjuvant chemotherapy between 1 January 2010 and 31 December 2016. Phenotypic subtypes were defined by hormone receptor and human epidermal growth factor receptor 2 (HER2) status at diagnosis, classified as HR+/HER2-, HER2+, or triple-negative breast cancer (TNBC). The RCB class was calculated and survival endpoints of overall survival, recurrence-free survival, and distant recurrence-free survival were analyzed using Kaplan-Meier and Cox proportional hazards methods. The discriminative ability of the models was quantified by Harrell's C-index. RESULTS: Overall, 532 women met the inclusion criteria. Median follow-up was 65 months. In univariate models, RCB was significantly associated with OS, RFS, and DRFS. The RCB class had good discriminative ability for OS, RFS, and DRFS survival, with Harrell's C-indices of 0.68, 0.67, and 0.68, respectively. The RCB class discriminated well for each survival endpoint within HER2+ and TNBC, but did not discriminate well for HR+/HER2- (OS Harrell's C-indices of 0.77, 0.75, and 0.52, respectively). CONCLUSIONS: The RCB class was prognostic for OS, RFS, and DRFS after neoadjuvant chemotherapy, but prognostic discrimination between patients with subtype HR+/HER2- was not observed during the follow-up period for which the overall event rate was low.

Outcomes for forearm and upper arm arteriovenous fistula creation with the transposition technique.

OBJECTIVE: To study the outcomes of three different types of arteriovenous fistula (AVF) transpositions (forearm cephalic vein transposition [FACVT], upper arm cephalic vein transposition [UACVT], and upper arm basilic vein transposition [UABVT]) for dialysis patients in a single center. METHODS: A 6-year retrospective review, from 2006 to 2012, was conducted at a single institution in which the surgical outcomes for three different types of AVF transposition were reviewed. Preoperative duplex vein mapping was obtained in all patients to choose the best vein for access. RESULTS: There were 165 patients identified with 77 FACVTs, 52 UACVTs, and 36 UABVTs. Primary access maturation rates for the FACVT, UACVT, and UABVT groups were 86%, 90%, and 97%, respectively (P = .19). All transposed, matured primary AVFs were used after a mean of 9.9 weeks, without additional intervention. Primary 1-year patency for the FACVT, UACVT, and UABVT groups were 63%, 61%, and 70%, respectively (P = .71). Primary assisted 1-year patency for the FACVT, UACVT, and UABVT groups were 93%, 93%, and 100%, respectively (P > .999). Mean operating room times and time to intervention were not significantly different between the groups. The postoperative hematoma rate was 2% and wound infection rate was 2%. Multivariate analysis indicated no significant predictors of time to failure (P > .05). CONCLUSIONS: With low primary failure rates, reduced need for secondary interventions before maturation, and 1-year primary assisted patency rates in excess of 93%, our study showed that the transposition technique, in our experience, is superior to previously published literature in hemodialysis access creation.

Institutional Analysis of Metaplastic Breast Cancer.

Triple-negative breast cancer (TNBC) is typically managed with neoadjuvant chemotherapy (NAC). Metaplastic breast cancer (MBC), a subtype of TNBC, demonstrates different histologic characteristics and less responsiveness to NAC. We performed this study to achieve a better understanding of MBC, including the impact of neoadjuvant chemotherapy. We identified patients diagnosed with MBC from January 2012 to July 1, 2022. A control group of TNBC breast cancer patients from 2020 who did not meet the criteria for MBC was identified. Demographic data, tumor and nodal characteristics, management strategies employed, response to systemic chemotherapy, and treatment outcomes were recorded and compared between groups. A total of 22 patients were included in the MBC group and demonstrated a 20% response to NAC compared to an 85% response rate in the 42 patients in the TNBC group (P = .003). Five patients have recurred (23%) in the MBC group compared to none in the TNBC group (P = .013).

Multidisciplinary Breast Cancer Clinic: A Novel Approach to Decrease Time to Intervention.

Multidisciplinary clinics (MDCs) were created at high-volume surgical oncology centers to optimize breast cancer care, in which patients are seen by multiple subspecialists at one visit. We aim to evaluate our experience with this novel approach. We examined 492 patients with newly diagnosed invasive breast cancer from January 1, 2020, to September 1, 2022. Patients seen at our MDC had a decreased time to intervention across all measured intervals: 3 days faster (10 vs 13 days) from biopsy to clinic visit [t Sat 2.09 > t critical two tail 1.99], 5 days faster (23 vs 28 days) from diagnosis to initiation of neoadjuvant chemotherapy [t Sat 5.12 > t critical two tail 2.019], and 21 days faster (24 vs 45 days) from surgery clinic visit to operation [t Sat 5.12 > t critical two tail 2.019]. Although early in our experience, we have initiated a strategy for improved breast cancer care.

Recalibrating the decision for MRI-directed breast ultrasound in patients with newly diagnosed breast cancer, factors predicting sonographic success.

OBJECTIVE: Evaluate utilization of MRI-directed breast ultrasound (US) in patients with newly diagnosed breast cancer and refine practices to increase success of sonographic lesion detection. METHODS: This retrospective single-institution review was restricted to women with breast cancer who underwent MRI from November 2006 to January 2017. Enhancing breast lesions, separate from the index tumor, recommended for MRI-directed US were assessed to see which were detected and which characteristics predicted success in detection. Univariate mixed-effects logistic modeling predicted likelihood of finding breast lesions with US, with odds ratios reported. All tests were two-sided with p < 0.05 considered significant. RESULTS: A total of 275 patients underwent MRI-directed US for 361 breast lesions, of which 187 (51.8%) were found on US. Of those detected, 171 (91.4%) were masses and 16 (8.6%) were nonmass enhancement (NME), with masses 14 times more likely to be seen (p < 0.001). Size alone was not a significant predictor but achieved significance when associated with lesion type (mass size, p < 0.001). Masses with irregular shapes or margins and invasive carcinomas were more frequently detected. Patient age, internal enhancement pattern, and distribution of NME were not significant predictors in sonographic detection. A presumed sonographic correlate for NME was found for 16 (16.2%) of 99 attempted lesions. CONCLUSION: As MRI access expands, utilization of MRI-directed US should be scrutinized to avoid downstream practice inefficiencies. Sonographic detection rates for NME remain low for women undergoing MRI for disease extent, with NME often better suited for MRI-guided biopsy.