Management of pregnant women with breast cancer.

Pregnancy complicates the diagnosis and treatment of breast cancer. Surgical treatment options of mastectomy or breast-conservation can be used as for non-pregnant patients. Sentinel lymph node biopsy can be safely used with lymphoscintigraphy. Chemotherapy is appropriate in the second and third trimesters, however, radiation therapy should be delayed until after delivery. Multidisciplinary care, including High-Risk Obstetrics, remains the best approach to managing this complex patient population.

Expansion of a cell population expressing stem cell markers in parathyroid glands from patients with hyperparathyroidism.

OBJECTIVE: We sought to examine abnormal parathyroid glands for the presence of stem cells. SUMMARY BACKGROUND DATA: Cancer stem cells have been identified in cancers from a variety of tissues as a CD44/CD24 cell population. We hypothesize that stem cells (SC) may also be involved in the pathogenesis of benign clonal expansion characteristic of hyperparathyroidism (HPT). METHODS: Under institutional review board approval, parathyroid tissue was obtained from 20 patients with HPT and analyzed by fluorescence-activated cell sorting (FACS) for the CD44/CD24 cell population. Immunohistochemistry (IHC) with CD44 antibody was correlated with FACS results. RESULTS: Parathyroid tissue was obtained for FACS analysis from 25 enlarged parathyroid glands from 20 patients, 17 with primary HPT, and 3 with secondary HPT. The average percent of SC defined as CD44/CD24 population was 10.93% for enlarged parathyroid glands. IHC using CD44 antibody was performed on 27 abnormal parathyroid glands and 7 normal parathyroid gland biopsies from the same patients. Although IHC was not as sensitive as FACS, comparison of IHC and FACS results for 24 abnormal glands gave a correlation coefficient of 0.52, which was statistically significant (P = 0.01, Spearman rank). By IHC, 13 of 27 abnormal glands stained 1+ to 3+ (average, 0.93) compared with no CD44 staining in normal glands, which was statistically different (mean IHC of 0 vs. 0.93, P = 0.03, Wilcoxon). CONCLUSIONS: These novel findings demonstrate expansion of a resident cell population that expresses SC markers in abnormal parathyroid glands from patients with HPT. Our results suggest that clonal expansion of a resident SC population occurs in the pathogenesis not only of cancer, but also in benign parathyroid tumors occurring in HPT.

Sampling of secondary margins decreases the need for re-excision after partial mastectomy.

BACKGROUND: We analyzed factors that influenced the need for re-excision after partial mastectomy. METHODS: We conducted a retrospective study of 470 breast cancer patients treated with partial mastectomy with main outcome measures of re-excision, conversion to mastectomy, and recurrence. RESULTS: Of 470 patients, 146 (31%) underwent re-excision for inadequate margins and 42 (8.9%) required mastectomy. Twelve (2.6%) patients had local recurrence of disease with a mean follow-up of 4.2 years. Factors found on multivariate analysis increasing the likelihood of re-excision include wire localization (2.4-fold), tumor or ductal carcinoma in situ (DCIS) close to the margins (<0.2 cm; 12.5-fold), margins involved with tumor or DCIS (25.3-fold), and seen by a non-breast specialist (2.25-fold). Taking secondary margins at initial operation reduced odds ratio of re-excision by 52% (P = .006) without a difference in volume of breast tissue removed (P = .33). Inadequate margins without re-excision had 12.% overall recurrence compared with a 6% recurrence with adequate margin and no re-excision (P = .069). CONCLUSION: One third of patients treated with partial mastectomy required re-excision, but 89% avoided the need for mastectomy. Taking secondary margins during the initial procedure decreased the need for re-excision by half. The recurrence rate was identical whether clear margins were obtained after primary partial mastectomy or re-excision.

The use of touch preparation for the evaluation of sentinel lymph nodes in breast cancer.

BACKGROUND: This study was undertaken to evaluate the accuracy of touch preparation (touch prep) in the evaluation of sentinel lymph nodes (SLNs). METHODS: We performed a retrospective review of 402 breast cancer patients who underwent SLN biopsy. RESULTS: A SLN was identified in 381 patients. Of 61 patients with a true positive result, 59 underwent axillary node dissection, and in 22 the SLN was the only node with metastases. Thirty-six (9.44%) had at least 1 false negative result. Twenty-five with a false negative results were due to macrometastases, with 17 (2.4%) false negatives occurring in patients with invasive ductal and 6 (5.5%) in those with invasive lobular histology, P = .04. Touch prep had an overall sensitivity of 62.89% and specificity of 98.94%. CONCLUSIONS: Touch prep for the evaluation of SLNs in breast cancer compares favorably to reported results for frozen section. False negative findings are more likely with micrometastases and invasive lobular histology.

A single institutional experience of factors affecting successful identification of sentinel lymph node in breast cancer patients.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients. We hypothesized that certain clinical parameters are associated with failure to identify a SLN. METHODS: We performed an institutional review board-approved, retrospective analysis of 402 consecutive breast cancer patients who underwent SLNB from 2000 to 2007. RESULTS: Of 402 patients, 399 had lymphoscintigraphy (LSG) performed at the time of radiocolloid injection. No significant differences in successful identification of a SLN were found with respect to patient age, histology, or pathologic status of the SLN. Thirteen of 27 patients with no nodes imaged on LSG failed to have a SLN identified at surgery, whereas only 8 of 372 patients with positive imaging on LSG failed to have a SLN identified at surgery (P < .0001). Patients with a body mass index (BMI) > or =40 had a significantly higher rate of failure to detect a SLN by LSG (5/29 patients) compared with patients with a normal BMI (4/145 patients; P < .01). There was a trend for association with increasing BMI and failure to identify a SLN at surgery. The rate of failure to identify a SLN demonstrated a significant improvement in LSG after 200 patients and in surgical success after 100 patients (P < .001). CONCLUSION: Successful identification of a SLN was influenced by BMI, institutional experience, and successful imaging by LSG. After gaining appropriate experience, the probability of successfully identifying a SLN at the time of surgery in a patient with BMI <40 who imaged on LSG was 99.7%.