Overuse of Chest CT in Patients With Stage I and II Breast Cancer: An Opportunity to Increase Guidelines Compliance at an NCCN Member Institution.

Background: The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) recommend that patients with clinical stage I/II breast cancer undergo advanced imaging for staging only when symptomatic. Regardless, many asymptomatic patients undergo chest CT. The goal of this study was to assess the use and results of chest CT in these patients at an NCCN Member Institution. Methods: Patients with breast cancer diagnosed between 1998 and 2012 were identified in a prospectively maintained database. All patients with clinical stage I/II disease who did not receive neoadjuvant chemotherapy were included. Data collected included demographics, tumor size, node status, chest CT within 6 months of diagnosis, imaging findings, need for additional workup, and identification of metastatic disease. Appropriate statistical tests were used for analysis. Results: From 1998 to 2012, 3,321 patients were diagnosed with early-stage breast cancer. Of these, 2,062 (62.1%) had clinical stage I breast cancer at diagnosis and 1,259 (37.9%) had stage II; 227 patients (11%) with stage I and 456 (36.2%) with stage II breast cancer received staging chest CT. Of patients undergoing CT, 184 (26.9%) were found to have pulmonary nodules, which measured ≤5 mm for 128 patients (69.6%), 5 to 10 mm for 46 patients (25.0%), 11 to 20 mm for 6 patients (3.2%), and ≥20 mm for 4 patients (2.2%). Patients undergoing chest CT for staging subsequently underwent a mean of 2.34 (range, 0-16) additional CTs in follow-up. Of all patients undergoing chest CT for staging, only 9 (1.3%) were ultimately diagnosed with pulmonary metastases at an average of 25 months (range, 0-97) after initial staging chest CT. Conclusions: A significant percentage of patients with stage I/II breast cancer underwent unnecessary chest CT as part of their initial workup. Nearly one-third of these patients were found to have pulmonary nodules, but only 1.3% were ever diagnosed with pulmonary metastases. Adherence to NCCN Guidelines will reduce the excessive use of CT chest imaging.

Staging studies have limited utility for newly diagnosed stage I-II breast cancer.

BACKGROUND: For stage I-II breast cancer, routine radiologic staging in the absence of symptoms suggesting distant metastasis is not recommended. This study aims to determine the yield of these studies at a National Comprehensive Cancer Network member institution. METHODS: Patients presenting with clinical stage I-II breast cancer between 1998 and 2012 were identified in a prospective database. Charts were reviewed to document staging studies (computed tomography, bone scan, and positron emission tomography) performed within 6 mo of diagnosis. Results and additional diagnostic procedures were recorded. Appropriate statistical tests were used for the analysis. RESULTS: A total of 3291 patients were included (2044 stage I and 1247 stage II). Eight hundred eighty-two patients (27%) received computed tomography, bone scan, or positron emission tomography within 6 mo of diagnosis. Three hundred twelve patients were stage I (15% of the stage I cohort) and 570 patients were stage II (46% of the stage II cohort). Patients receiving staging studies were more often younger and had estrogen receptor/progesterone receptor-negative or HER2/neu-positive tumors. Of the 882 patients, 194 (22%) required additional imaging and/or biopsies to further evaluate abnormalities. Only 11 of those (5%) were confirmed to have metastasis (1.2% of the imaged patients, 0.3% of the total cohort). Of these, 1 was stage I at presentation and 10 were stage II. CONCLUSIONS: Identification of distant metastasis among stage I-II patients was rare. Even among patients judged appropriate for staging, only 1.2% were diagnosed with metastatic disease. These findings suggest that even at a National Comprehensive Cancer Network member institution staging studies are overused and lead to additional testing in over 20% of patients.

Nipple-sparing mastectomies: Clinical outcomes from a single academic institution.

Nipple-sparing mastectomies (NSMs) are increasingly used in the surgical treatment of patients with breast cancer and for prevention of breast cancer. The present study was performed to review the outcomes of patients undergoing NSMs at a single large university setting. A retrospective chart review was performed on all patients undergoing NSMs from 2008-2014. Charts were reviewed for demographic data and patient characteristics. Tumor and breast size, cancer recurrence and complications were also evaluated. Descriptive statistics were utilized to summarize the findings. From 2008-2014, 110 patients underwent 197 NSMs. The mean patient age was 44.4 years (range, 20-77). The average body mass index was 24 (range, 18-47). Breast weight was available for 106 specimens, with a mean weight of 475.5 g (range, 124.1-1,625.0 g). Seventy-three NSMs were performed for cancer and 124 were performed prophylactically. The mean tumor width was 1.38 cm (range, 0-6.0 cm), with an average nipple to tumor distance of 5.87 cm (range, 2.93-10.0 cm). Three (4%) patients required removal of the nipple areolar complex (NAC) due to pathological extension of the tumor. A total of 34 (17.2%) complications occurred, including infections, hematomas and nipple necrosis, with 9 requiring removal of the NAC and 13 requiring removal of the tissue expander or implant. Smokers had a 36.0% (9/25) complication rate, compared with 14.5% (25/172) of nonsmokers (P<0.05). During follow-up, one recurrence was noted, located on the chest wall. There were no recurrences in the NAC group. Therefore, NSMs may safely be performed without compromising oncologic outcomes or increasing complication rates in properly selected patients.

Influence of root-bed size on the response of tobacco to elevated CO2 as mediated by cytokinins.

The extent of growth stimulation of C3 plants by elevated CO2 is modulated by environmental factors. Under optimized environmental conditions (high light, continuous water and nutrient supply, and others), we analysed the effect of an elevated CO2 atmosphere (700 ppm, EC) and the importance of root-bed size on the growth of tobacco. Biomass production was consistently higher under EC. However, the stimulation was overridden by root-bed volumes that restricted root growth. Maximum growth and biomass production were obtained at a root bed of 15 L at ambient and elevated CO2 concentrations. Starting with seed germination, the plants were strictly maintained under ambient or elevated CO2 until flowering. Thus, the well-known acclimation effect of growth to enhanced CO2 did not occur. The relative growth rates of EC plants exceeded those of ambient-CO2 plants only during the initial phases of germination and seedling establishment. This was sufficient for a persistently higher absolute biomass production by EC plants in non-limiting root-bed volumes. Both the size of the root bed and the CO2 concentration influenced the quantitative cytokinin patterns, particularly in the meristematic tissues of shoots, but to a smaller extent in stems, leaves and roots. In spite of the generally low cytokinin concentrations in roots, the amounts of cytokinins moving from the root to the shoot were substantially higher in high-CO2 plants. Because the cytokinin patterns of the (xylem) fluid in the stems did not match those of the shoot meristems, it is assumed that cytokinins as long-distance signals from the roots stimulate meristematic activity in the shoot apex and the sink leaves. Subsequently, the meristems are able to synthesize those phytohormones that are required for the cell cycle. Root-borne cytokinins entering the shoot appear to be one of the major control points for the integration of various environmental cues into one signal for optimized growth.

Management of the axilla.

Status of the axillary lymph nodes is one of the most important factors impacting overall prognosis and treatment for breast cancer. The sentinel lymph node (SLN) concept for breast cancer has been validated and SLN biopsy should be considered standard of care for axillary staging in patients with clinically node-negative axilla given the decreased morbidity when compared with axillary lymph node dissection. Ongoing controversy includes use of SLN in patients with ductal carcinoma in situ, prior axillary surgery, multicentric breast cancer, and large breast cancers. Determining the optimal timing of SLN in patients undergoing neoadjuvant chemotherapy and the prognostic and clinical significance of micrometastases remain areas of research.

Surgical management of retroperitoneal leiomyosarcoma arising from the inferior vena cava.

Retroperitoneal leiomyosarcomas are uncommon tumors, with approximately 300 documented cases in the literature. Management necessitates complete surgical resection in order to offer patients a chance at long-term cure. Resection often presents a challenge as these tumors are often large, involving adjacent structures, and may require reconstruction of the inferior vena cava (IVC). In this article, we will present background information on retroperitoneal leiomyosarcomas and the technical aspects of surgical resection and vascular reconstructive options of the IVC.