Nationwide Analysis of Locoregional Management for Ductal Carcinoma In Situ in Males: An NCDB Analysis of the Surgical Approach to DCIS in Males.

BACKGROUND: Limited data exist regarding the optimal locoregional approach for males with ductal carcinoma in situ (DCIS). This study examined trends in management and survival for males with DCIS. METHODS: The National Cancer Database (NCDB) was queried for males with a diagnosis of DCIS from 2006 to 2017. Patients were categorized by locoregional management. Continuous variables were evaluated by Kruskal-Wallis and categorical variables by chi-square or Fisher's exact test. Univariable and multivariable logistic regressions were performed to evaluate for predictors of patients receiving partial mastectomy (PM) with radiation. Survival was analyzed by Kaplan-Meier. RESULTS: Between 2006 and 2017, 711 males with DCIS were identified. Most received mastectomy alone (57.1%). No change was observed in management approach from 2006 to 2017. Patients who underwent mastectomy alone were mostly hormone-positive (95.9% were estrogen-positive, 90.9% were progesterone-positive), although this cohort was least likely to receive hormone therapy (17.2%). Among those who underwent PM with radiation, only 61% of those who were hormone-positive received hormone therapy. Univariable analysis demonstrated that those of black race had lower odds of receiving PM with radiation (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.36-0.84), which persisted in the multivariable analysis with control for age and tumor size (OR, 0.32; 95% CI, 0.15-0.67). Overall survival did not differ significantly between the four treatment methods (p = 0.08). CONCLUSIONS: The management approach to male DCIS did not change from 2006 to 2017. Survival did not differ between treatment methods. Demographic and clinicopathologic features, including race, may influence locoregional treatments received, and further studies are needed to further understand this.

National trends for axillary lymph node dissection and survival outcomes for clinical T3/T4 node-negative breast cancer patients undergoing mastectomy with positive lymph nodes.

PURPOSE: Previous studies have suggested axillary lymph node dissection (ALND) can be omitted in early breast cancer patients undergoing mastectomy with positive lymph nodes (LNs). We assessed the national utilization of ALND and overall survival (OS) for larger, locally advanced tumors in patients undergoing mastectomy with positive LNs. METHODS: The National Cancer Database from 2006 to 2016 was queried for mastectomy patients with clinical T3/T4, N0 tumors, and 1-2 positive LNs. Trends and outcomes for ALND were compared to sentinel lymph node biopsy (SLNB) alone. RESULTS: Thousand nine hundred and seventeen women were included. The proportion of ALND decreased from 70% pre-Z0011 to 52% post-Z0011. On Kaplan-Meier analysis, ALND had better OS compared to SLNB alone (p < 0.01). On multivariate analysis, age (p < 0.01), chemotherapy (p < 0.01), and hormonal therapy (p < 0.01) were associated with better OS. In patients who received adjuvant radiation therapy (ART) ALND improved OS on multivariate analysis (p < 0.01). CONCLUSION: This is the first large database study to demonstrate a national trend to forego ALND in mastectomy patients with large or locally advanced tumors (T3/T4abc) and 1-2 positive lymph nodes. This study suggests a survival benefit for ALND, particularly in patients receiving ART. Careful consideration and further investigations should be performed prior to omitting ALND this patient population.

National Trend of Axillary Management in Clinical T3/T4 N0 Patients Having Breast Conserving Therapy.

BACKGROUND: The ACOSOG Z0011 trial has essentially eliminated axillary lymph node dissection (ALND) in breast conserving therapy (BCT) patients with clinical T1/T2 and 1-2 positive sentinel lymph nodes (SLNs). Currently, ALND is recommended for positive SLNs unless ACOSOG Z0011 criteria are applicable. We aimed to assess the national trends and axillary management before and after the publication of ACOSOG Z0011 for larger tumors. METHODS: An IRB-approved study evaluated the National Cancer Database from 2006 to 2016. Women with clinical T3/T4, N0 who otherwise fit ACOSOG Z0011 criteria were included. Neoadjuvant systemic therapy or known nodal disease was excluded. Clinicopathologic data were compared between two timeframes based on ACOSOZ Z0011 publication and by axillary management. Patients were categorized into SLNB alone (1-5 lymph nodes examined) and ALND (≥10 lymph nodes examined) groups. RESULTS: A total of 230 women fit inclusion criteria, of whom 36% underwent ALND. ALND use decreased from 54% in 2006 to 14% in 2016 (P < 0.01). Comparing ALND to SLNB alone within the pre-Z0011 era, comprehensive community cancer programs had higher proportions of ALND, whereas academic centers had higher rates of SLND alone (P = 0.03). Comparing similar axillary management between eras, SLNB-alone patients in the post-Z0011 era had higher pT and pN stages, were less likely to be Her2 positive, and were more likely to receive systemic treatment. CONCLUSIONS: There is a national trend to forgo ALND in women who have tumors larger than those included in the Z0011 criteria without any clear clinicopathologic indications.

Evaluation of the SmartClip™ Nonradioactive Seed, a Novel Wireless Localization Method for the Breast: Initial Clinical Experience and Surgical Outcome.

INTRODUCTION: Wire localization has been the gold standard for breast localization of non-palpable lesions for decades. This technique remains robust but has disadvantages relative to scheduling, complications of vasovagal reactions in placement, wire migration, or transection. With more modern technologies available, several implantable markers have been developed to allow uncoupling of localization by radiology and the surgical procedure on the same day. This study summarizes our experience with the EnVisio Navigation System™ utilizing SmartClip™ as the implantable tissue localization marker. METHODS: An IRB-approved retrospective database of benign and malignant breast disease was used to perform a review of 100 consecutive patients who underwent SmartClip™ localized breast and axillary procedures in 2021. Demographic information, localization accuracy, associated surgical procedure(s) with resultant pathology findings, margin status for malignancies, and re-excision rate were collected. RESULTS: The localized breast lesion or lymph node was excised and SmartClip™ retrieved in all cases, confirmed by intraoperative specimen radiograph. The distribution of gender and race/ethnicity among the patients who underwent surgery reflects the community population and frequency of breast cancer development among men versus women. 45.1% of the cases involved malignancy, as determined pre-operatively. Positive margins requiring re-excision constituted 18.2% of cases. In twenty-six patients, two or three SmartClips™ were placed per case for either a bracketed lesion, two separate breast lesions, and/or a breast lesion and lymph node. CONCLUSION: Although this study is limited in patient number, it demonstrates safety of this technique and its reliability in guiding the surgeon directly to the lesion(s) of concern.

Axillary management in breast cancer after neoadjuvant chemotherapy in the modern era: A national cancer database analysis.

BACKGROUND: Axillary management for node-positive breast cancer continues to evolve. Data further supporting targeted axillary dissection after neoadjuvant chemotherapy was published in 2016 and may have induced changes in practice. METHODS: Patients included in the National Cancer Database from 2014 to 2017 with clinical T1 to T4 and node-positive disease who underwent neoadjuvant chemotherapy before surgical axillary management were evaluated. Patients were divided into the following 3 groups: selective axillary dissection, minimal axillary dissection, and maximal axillary dissection, according to surgical axillary management and pathological node status. RESULTS: Patients who underwent selective axillary dissection were younger (52.4 years ± 12.4, P < .0001) compared to maximal axillary dissection (55.1 ± 12.7) and minimal axillary dissection (54.6 ± 12.7). Patients with higher clinical stage more frequently underwent maximal axillary dissection, and those with lower tumor grade more frequently underwent minimal axillary dissection (P < .0001). Community cancer programs were more likely to perform maximal axillary dissection compared to all other types of programs and had the slowest rate of adoption of selective axillary dissection. Integrated Network Cancer Programs had the lowest proportion of maximal axillary dissection performed and the highest proportion of selective axillary dissection. Uninsured patients were more likely to receive maximal axillary dissection, and those with private insurance were more likely to undergo selective axillary dissection (P < .0001). Selective axillary dissection rates increased from 29.8% of procedures in 2016 to 41.5% in 2017, and MaxAD rates decreased from 62.4% in 2016 to 47.9% in 2017. CONCLUSION: Utilization of selective axillary dissection has increased since 2016; however, discrepancies in surgical axillary management after neoadjuvant chemotherapy still exist.

Incidence and predictors of neuropathic pain following breast surgery.

PURPOSE: Neuropathic pain (NPP) following breast surgery extends morbidity in the postoperative period. The incidence and etiology of postoperative NPP remains unclear and under-reported in literature. This study aims to define the incidence of neuropathic pain following breast surgery and to identify patient characteristics that are predictors for developing postoperative NPP. METHODS: Consecutive female patients undergoing breast resection surgery over a 5-year period (2008-2012) with 1-year minimum follow-up were included in this single-center study. Retrospective chart review was performed to identify patient specific characteristics including the development of post-operative NPP. Data was analyzed using univariate and multivariate logistic regression. RESULTS: A total of 470 patients were identified for study inclusion. The incidence of postoperative NPP was 14.7 % (69 of 470). Significant predictors for the development of postoperative NPP in the univariate analyses included history of diabetes mellitus, diabetic neuropathy, or fibromyalgia, concomitant axillary surgery, axillary node dissection, and taxane-based chemotherapy regimen. Multivariate analysis identified African American race [odds ratio (OR) = 1.78; 95 % CI = 1.01-3.17; p = 0.05), history of diabetes mellitus (OR = 1.98; 95 % CI = 1.0-3.74; p = 0.01) or fibromyalgia (OR = 2.75; 95 % CI = 1.13-6.69; p = 0.03), and taxane-based chemotherapy regimen (OR = 2.85; 95 % CI = 1.23-6.58; p = 0.01) as being independently associated with the development of postoperative NPP. CONCLUSIONS: NPP is a significant risk following breast surgery. African American race, history of either diabetes mellitus or fibromyalgia, and treatment with taxane-based chemotherapy regimens are all associated with an increased risk of NPP.

Lessons from other fields of medicine, Part 1: Breast cancer.

Through the understanding of multiple etiologies, pathologies, and disease progression trajectories, breast cancer shifted historically from a singular malignancy of the breast to a complex of molecular/biological entities, translating into individualized disease-modifying treatments. As a result, this led to various de-escalations of treatment compared with the gold standard in the era preceding systems biology: radical mastectomy. Targeted therapies have minimized morbidity from the treatments and mortality from the disease. Biomarkers further individualized tumor genetics and molecular biology to optimize treatments targeting specific cancer cells. Landmark discoveries in breast cancer management have evolved through histology, hormone receptors, human epidermal growth factor, single-gene prognostic markers, and multigene prognostic markers. Relevant to the reliance on histopathology in neurodegenerative disorders, histopathology evaluation in breast cancer can serve as a marker of overall prognosis rather than predict response to therapies. This chapter reviews the successes and failures of breast cancer research through history, with focus on the transition from a universal approach for all patients to divergent biomarker development and individualized targeted therapies, discussing future areas of growth in the field that may apply to neurodegenerative disorders.

Comparison of Male and Female Surgeons' Experiences With Gender Across 5 Qualitative/Quantitative Domains.

Importance: A growing body of literature has been developed with the goal of attempting to understand the experiences of female surgeons. While it has helped to address inequities and promote important programmatic improvements, work remains to be done. Objective: To explore how practicing male and female surgeons' experiences with gender compare across 5 qualitative/quantitative domains: career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change. Design, Setting, and Participants: This national concurrent mixed-methods survey of Fellows of the American College of Surgeons (FACS) compared differences between male and female FACS. Differences between female FACS and female members of the Association of Women Surgeons (AWS) were also explored. A randomly selected 3:1 sample of US-based male and female FACS was surveyed between January and June 2020. Female AWS members were surveyed in May 2020. Exposure: Self-reported gender. Main Outcomes and Measures: Self-reported experiences with career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative). Results: A total of 2860 male FACS (response rate: 38.1% [2860 of 7500]) and 1070 female FACS (response rate: 42.8% [1070 of 2500]) were included, in addition to 536 female AWS members. Demographic characteristics were similar between randomly selected male and female FACS, with the notable exception that female FACS were less likely to be married (720 [67.3%] vs 2561 [89.5%]; nonresponse-weighted P < .001) and have children (660 [61.7%] vs 2600 [90.9%]; P < .001). Compared with female FACS, female AWS members were more likely to be younger and hold additional graduate degrees (320 [59.7%] were married; 238 [44.4%] had children). FACS of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting, including shared experiences of gender-based harassment, discrimination, and blame. Female FACS were less likely to have had gender-concordant mentors. They were more likely to emphasize the importance of gender when determining career aspirations and prioritizing future mentor-mentee relationships. Moving forward, female FACS emphasized the importance of avoiding competition among female surgeons. They encouraged male surgeons to acknowledge gender bias and admit their potential role. Male FACS encouraged male and female surgeons to treat everyone the same. Conclusions and Relevance: Experiences with gender are not limited to supportive female surgeons. The results of this study emphasize the importance of recognizing the voices of all stakeholders involved when striving to promote workforce diversity and the related need to develop quality improvement/surgical education initiatives that enhance inclusion through open, honest discourse.

Assessment of the impact of CYP3A polymorphisms on the formation of α-hydroxytamoxifen and N-desmethyltamoxifen in human liver microsomes.

Tamoxifen, an antiestrogen used in the prevention and treatment of breast cancer, is extensively metabolized by cytochrome P450 enzymes. Its biotransformation to α-hydroxytamoxifen (α-OHT), which may be genotoxic, and to N-desmethyltamoxifen (N-DMT), which is partially hydroxylated to 4-hydroxy-N-DMT (endoxifen), a potent antiestrogen, is mediated by CYP3A enzymes. However, the potential contribution of CYP3A5 and the impact of its low-expression variants on the formation of these metabolites are not clear. Therefore, we assessed the contributions of CYP3A4 and CYP3A5 and examined the impact of CYP3A5 genotypes on the formation of α-OHT and N-DMT, by using recombinant CYP3A4 and CYP3A5 and human liver microsomes (HLM) genotyped for CYP3A5 variants. We observed that the catalytic efficiency [intrinsic clearance (CL(int))] for α-OHT formation with recombinant CYP3A4 was 5-fold higher than that with recombinant CYP3A5 (0.81 versus 0.16 nl · min⁻¹ · pmol cytochrome P450⁻¹). There was no significant difference in CL(int) values between the three CYP3A5-genotyped HLM (*1/*1, *1/*3, and *3/*3). For N-DMT formation, the CL(int) with recombinant CYP3A4 was only 1.7-fold higher, relative to that with recombinant CYP3A5. In addition, the CL(int) for N-DMT formation by HLM with CYP3A5*3/*3 alleles was approximately 3-fold lower than that for HLM expressing CYP3A5*1/*1. Regression analyses of tamoxifen metabolism with respect to testosterone 6ß-hydroxylation facilitated assessment of CYP3A5 contributions to the formation of the two metabolites. The CYP3A5 contributions to α-OHT formation were negligible, whereas the contributions to N-DMT formation ranged from 51 to 61%. Our findings suggest that polymorphic CYP3A5 expression may affect the formation of N-DMT but not that of α-OHT.

Characteristics of General Surgery Social Media Influencers on Twitter.

BACKGROUND: The influence of social media and Twitter in general surgery research, mentorship, networking, and education is growing. Limited data exist regarding individuals who control the dialogue. Our goal was to characterize influencers leading the discussion in general surgery. METHODS: Right Relevance Insight API was searched for "general surgery," and individual influencers were ranked by a comprehensive assessment of connections (followers/following) and engagement (likes, retweets, and comments). Profession, specialty, gender, and location were collected utilizing Twitter, Doximity, LinkedIn, ResearchGate, and institutional websites. American Board of Surgery and Royal College of Physicians and Surgeons of Canada were queried for board certification and academic h-index scores were acquired from Scopus. RESULTS: Eighty-eight individual influencers in general surgery were identified, with 73 holding positions in general surgery. Attending level general surgeons comprised 50%, of which 91% are board certified, and 94% completed a fellowship (surgical oncology, laparoscopic surgery, critical care/trauma, and colorectal surgery). Residents comprised 31%; 11% were nonsurgeons and 3% were not physicians. The majority of residents and fellow influencers were female (72%). Many general surgery influencers were international (51%), particularly Canadian (28% overall). The academic h-indices for these influencers (n = 73) ranged from 0 to 73 (mean 14.5 ± 8.2; median 9.5). DISCUSSION: Our data describe the positions, backgrounds, and research contributions of the top Twitter influencers in general surgery. Those engaged in social media should consider the background, expertise, and motivation of these influencers as the utilization and impact of this platform grows.

Flat epithelial atypia and the risk of sampling error: Determining the value of excision after image-guided core-needle biopsy.

BACKGROUND: We determined the sampling error rate of flat epithelial atypia (FEA) and evaluated current guidelines recommending excisional biopsy. METHODS: A retrospective review of consecutive excisional biopsies after image-guided core-needle biopsy identified patients with isolated FEA diagnosed between 2014 and 2018. Clinical and pathologic parameters were evaluated. RESULTS: Twenty-five women with 27 biopsies were included. Based on pathologic review of original core specimens, 44.4% (N = 12) were accurately diagnosed as FEA. Upon excision, lesions were upgraded to ductal carcinoma in situ (N = 2) or invasive ductal carcinoma (N = 1) in 11.1% of cases. Older age, black race, hormone replacement, and calcifications in the image-guided biopsy specimen were associated with the presence of high-risk or malignant lesions in the excisional biopsy (all p ≤ 0.05). CONCLUSIONS: In this study, FEA was frequently overcalled. However, lesions suspicious for FEA warrant excision due to their association with malignancy or high-risk lesions, which may necessitate further surgical management and/or risk-reducing strategies.

The F-domain of estrogen receptor-alpha inhibits ligand induced receptor dimerization.

The role of the carboxyl terminal F-domain of estrogen receptor (ERalpha) is uncertain, but evidence suggests that this region may impart internal restraint on ER dimerization in the presence of 17beta-estradiol (E2). To identify the C-terminal residues affecting human ERalpha activation, we created a series of deletions and examined E2 induced receptor dimerization and transactivation. Deletion of the final 24 C-terminal amino acids of the F-domain (Delta7b) yielded a fivefold increase in dimerization, when compared to wild type (wt) ERalpha in the presence of 2nM E2, utilizing a yeast two-hybrid assay. This increase in dimerization is similar to that observed when the entire F-domain was deleted. Measurement of mutant:mutant homodimer formation yielded similar increases compared to mutant:wt interactions. Interestingly, a point mutation at the C-terminus (mut 3) showed increases in dimerization comparable to that of Delta7b in the presence of nanomolar amounts of E2. However, at sub-nanomolar levels of E2, mut 3 behaved similarly to wt ERalpha, whereas Delta7b maintained striking increases in dimerization. Determination of E2 binding affinity (Kd) constants revealed only marginal differences for wt and F-domain mutants, suggesting that the F-domain affects dimerization directly. We also observed enhanced interaction of F domain mutants with p160 family coactivator SRC1. Finally, transcriptional regulation of estrogen responsive reporters, 2XERE-LacZ and 3XERE-Luc in yeast and mammalian cells, respectively, reflected the increased propensity for dimerization by F domain mutants. Together, these data indicate that the C-terminal amino acids of ERalpha are critical for attenuation of E2 induced receptor dimerization and transcriptional activity.

Characteristics and diagnosis of pregnancy and lactation associated breast cancer: Analysis of a self-reported regional registry.

BACKGROUND: Pregnancy-associated breast cancer (PABC) is the most common malignancy in pregnancy. However due to its infrequent occurrence, PABC continues to be poorly understood. METHODS: We performed a retrospective study using self-reported data from 1079 eligible women in a regional breast cancer registry. RESULTS: The PABC cases were more likely than non-PABCs to be younger than age 35 and have nodal involvement at diagnosis. Despite diagnosis at a young age, there was not an association between PABC and family history. For method of diagnosis, PABC was found on self-exam, while non-PABCs were found on mammography. CONCLUSION: In conclusion, PABC is rarely detected by mammography and diagnosis is highly dependent on detection during self-breast exam. Women who are or recently were pregnant should be encouraged to perform regular self-breast exams to report any changes for further evaluation. Patient and clinician education regarding risk and realities of PABC is essential.

A Proposed Model for Perinatal Palliative Care.

Perinatal palliative care allows for an active partnership among a pregnant woman, her family, and her multidisciplinary treatment team and addresses her specialized medical care, emotional, social, and familial needs when a life-limiting fetal diagnosis is confirmed. The purpose of this article is to highlight the multidisciplinary care model used within a perinatal palliative care program. A case study provides a unique perspective on support needed for parents who anticipate that their newborn may die before or shortly after birth.

Lobular neoplasia at 11-gauge vacuum-assisted stereotactic biopsy: correlation with surgical excisional biopsy and mammographic follow-up.

OBJECTIVE: The objective of our study was to evaluate the outcome of lobular neoplasia diagnosed at 11-gauge stereotactic vacuum-assisted biopsy (SVAB). MATERIALS AND METHODS: Retrospective review of 1,819 lesions sampled with 11-gauge SVAB yielded 27 patients with lobular neoplasia as the most severe pathologic entity diagnosed. Patients with lobular neoplasia associated with atypical ductal hyperplasia (ADH), ductal carcinoma in situ (DCIS), or infiltrating carcinoma were excluded. Twenty patients underwent surgical excisional biopsy, and seven patients were followed mammographically for a mean of 52 months (range, 14-67 months). Mammographic lesion type, number of specimens obtained per lesion, and specific histologic features related to lobular carcinoma in situ (LCIS) were assessed. Results were compared with histologic findings at surgery or mammographic follow-up. RESULTS: Nineteen lesions presented mammographically as microcalcifications, four as masses, three as masses with associated microcalcifications, and one as architectural distortion. A mean of 13 specimens were obtained per lesion. Carcinoma was found at surgical excision in 19% of the lesions (5/27). Lesions were upgraded to DCIS (n = 2), invasive lobular carcinoma (n = 2), and mixed invasive ductal and lobular carcinoma (n = 1). In addition to the diagnosis of lobular neoplasia at SVAB, one patient presented with synchronous infiltrating ductal carcinoma in the contralateral breast, and two patients developed metachronous infiltrating ductal carcinoma in a different quadrant of the ipsilateral breast. Twelve of the 27 lesions included LCIS. These lesions were evaluated pathologically to distinguish the classic (10/12) from the pleomorphic (2/12) form of this entity. Ten of the 12 LCIS cases underwent surgical excisional biopsy with four of the five upgrades occurring in these patients. Only one of these patients was shown to have the pleomorphic type of LCIS. Lesions in seven patients who underwent mammographic follow-up remained stable. CONCLUSION: The known association of lobular neoplasia with high-risk and malignant lesions at surgical biopsy requires careful consideration when lobular neoplasia is diagnosed as the most severe histologic entity at SVAB. The diagnosis of lobular neoplasia at 11-gauge SVAB is not reliable in view of the 19% upgrade rate at the time of surgical excisional biopsy in our study. No predictive mammographic features allowed distinction between the patients with lesions that were upgraded at the time of surgery from those whose lesions were not upgraded.

Excellent outcomes with adjuvant toremifene or tamoxifen in early stage breast cancer.

BACKGROUND: Fareston (toremifene) and tamoxifen, both selective estrogen receptor modulators, are therapeutically equivalent treatments for metastatic breast cancer. We hypothesized that toremifene as compared with tamoxifen given as adjuvant therapy for early stage breast cancer would result in equivalent survival with an improved side effect profile, therefore, providing superior therapeutic efficacy. METHODS: The North American Fareston versus Tamoxifen Adjuvant trial assigned 1813 perimenopausal or postmenopausal women with hormone receptor (HR)-positive invasive breast cancer to adjuvant treatment with either tamoxifen or toremifene. The primary outcomes evaluated were disease-free survival (DFS) and overall survival (OS). RESULTS: Median follow-up was 59 months. The baseline characteristics of the 2 treatment groups were well-balanced. On the basis of intent-to-treat, 5-year actuarial DFS was not significantly different between tamoxifen and toremifene (91.2% [standard error of the mean [SE] 1.2%] vs 91.2% [SE 1.1%], respectively). Similarly, 5-year actuarial OS was not significantly different between tamoxifen and toremifene (92.7% [SE 1.1%] vs 93.7% [SE 1.0%], respectively). Controlling for patient age, tumor size, and tumor grade, a Cox multivariate survival analysis found no difference between patients randomized to toremifene versus tamoxifen in terms of OS (OR = 0.951; 95% confidence interval [CI], 0.623-1.451, P = .951) or DFS (OR = 1.037; 95% CI, 0.721-1.491, P = .846). Adverse events were similar in the 2 groups. CONCLUSIONS: Women treated with adjuvant hormonal therapy enjoyed excellent DFS and OS. No significant differences were found between treatment with either tamoxifen or toremifene. Treatment of HR-positive patients with either tamoxifen or toremifene is appropriate.

Forequarter amputation for recurrent breast cancer: a case report and review of the literature.

Axillary recurrence of breast cancer is an uncommon event that can lead to debilitating pain, lymphedema, and paralysis of the upper extremity. Multimodality therapy including surgery is usually used to control local recurrence. In a subset of patients, the extent of disease is such that local excision of the recurrence is not possible. In the absence of metastatic disease, forequarter amputation may be used as an effective means of surgical salvage and palliation for locally recurrent breast cancer. In this report, we describe management of a patient with advanced axillary recurrence treated with forequarter amputation and review the current literature on the use of this operation in breast cancer patients.

Bilateral synchronous breast cancer and HER-2/neu overexpression.

Bilateral synchronous breast cancer appears to have a worse prognosis than comparable unilateral breast cancer. HER-2/neu expression in bilateral breast cancer has not been reported. The purpose of this study was to review the characteristics of patients with bilateral synchronous breast cancer and to report the incidence of HER-2/neu overexpression. Between 1984 and 1998, 58 patients were diagnosed with bilateral synchronous breast cancer (defined as both cancers diagnosed within 3 months). The paraffin blocks from both breast specimens were available and immunostained in 21 patients. Of 42 breast specimens, there were 31 invasive carcinomas and 11 noninvasive carcinomas. Of the 21 paired specimens immunostained for HER-2/neu, 11 were invasive cancers in both breasts, nine were invasive cancers in one breast and noninvasive cancers in the other breast, and one was noninvasive cancers in both breasts. Of the 31 invasive carcinomas, HER-2/neu was overexpressed (2-3+) in 22 (71%) and negative (0-1+) in nine (29%). In contrast, 35 of 101 (34.7%) consecutive unilateral invasive breast cancer specimens from our institution overexpressed HER-2/neu. The difference in HER-2/neu overexpression between patients with bilateral synchronous breast cancer and unilateral breast cancer (22/31 v.s. 35/101) was statistically significant (chi square = 11.3, p < 0.001). In cases where both breasts had invasive carcinoma, HER-2/neu overexpression could be either in one (six patients) or both breasts (four patients). The increased mortality of patients with bilateral synchronous breast cancer may be due to the higher incidence of HER-21neu overexpression.