The importance of tattoo pigment in sentinel lymph nodes.

BACKGROUND: The presence of pigment in axillary lymph nodes (LN) secondary to migration of tattoo ink can imitate the appearance of a blue sentinel lymph node (SLN) on visual inspection, causing the operator to either miss the true SLN or excise more than is needed. OBJECTIVE: We present patients with tattoos ipsilateral to an early stage breast cancer who underwent a SLN biopsy. METHODS: Patients were retrospectively reviewed from medical records and clinicopathologic data was collected. A total of 52 LNs were retrieved from 15 patients for sentinel mapping and 29 of them had tattoo pigmentation on pathologic evaluation. RESULTS: Of those 29 SLNs, 2 of them (6.9%) were pigmented, but did not contain either blue dye or Tc-99m (pseudopigmented SLN). Two (3.8%) SLNs were positive for metastasis; both of these had either blue dye or Tc99m uptake, and 1 demonstrated tattoo pigment in the node. CONCLUSIONS: In this cohort of patients with ipsilateral tattoos, removed more LNs lead to unnecessary excision which may important for increasing the risk of arm morbidity from SLN biopsy. However, the presence of tattoo pigment did not interfere with understaging for axillary mapping and it did not effect of pathological identification of SLNs positivity.

A Prospective Study of Nausea and Vomiting After Breast Cancer Surgery.

PURPOSE: Postoperative nausea and vomiting (PONV) and post-discharge nausea and vomiting (PDNV) continue to be common and disturbing complications experienced after surgery, particularly in women and especially in women undergoing breast cancer surgery. The purpose of this study was to assess the incidence and risk factors associated with PONV and PDNV from preoperative to 48 hours postoperatively in 97 women scheduled for breast cancer surgery. DESIGN: Prospective, comparative design. METHODS: After informed consent was obtained, women scheduled for breast cancer surgery were evaluated for incidence of vomiting, as well as the presence and severity of nausea from the preoperative holding area for 48 hours following surgery. Vomiting was assessed as both a nominally scaled, binary variable (Yes/No) and as a continuous variable to measure separate emetic events. Nausea was measured on an 11point verbal numeric scale with 0 being the absence of nausea and 10 representing the highest level of nausea ever experienced. RESULTS: Twenty-nine (29.8%) women experienced nausea, and nine (9%) women experienced nausea and vomiting while in the post-anesthesia care unit despite close attention to the need for prophylactic antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experience PONV. Women who received intravenous acetaminophen did not experience less PONV in this study. PDNV occurred more frequently than PONV, with 34 women (35%) reporting occurrence after discharge. About 13 women who did not experience PONV while in the PACU subsequently experienced PDNV after leaving the hospital, evidence for the importance of patient discharge teaching regarding these symptoms. Although clinical guidelines are necessary, our observation is that nurses in the PACU setting continuously challenge themselves to individualize the combination of medications and activities for each patient to reduce PONV after surgery.

Magee Equation 3 predicts pathologic response to neoadjuvant systemic chemotherapy in estrogen receptor positive, HER2 negative/equivocal breast tumors.

Magee Equations were derived as an inexpensive, rapid alternative to Oncotype DX. The Magee Equation 3 utilizes immunohistochemical and FISH data for estrogen receptor (ER), progesterone receptor (PR), HER2 and Ki-67 for its calculation (24.30812+ERIHC × (-0.02177)+PRIHC × (-0.02884)+(0 for HER2 negative, 1.46495 for equivocal, 12.75525 for HER2 positive)+Ki-67 × 0.18649). We hypothesize that Magee Equation 3 scores from pre-therapy core biopsy can predict response to neoadjuvant systemic chemotherapy. A prospectively-maintained database of patients who received neoadjuvant systemic therapy from 2010 to 2014 at a single institution was retrospectively reviewed. Pathologic complete response was defined as absence of invasive tumor in the breast and regional lymph nodes. Of the 614 cases, tumors with missing immunohistochemical results and those that were ER negative or HER2 positive were excluded. This resulted in 237 ER positive, HER2 negative/equivocal tumors that formed the basis of this study. Magee Equation 3 scores were divided into 3 categories similar to Oncotype DX, ie, 0 to <18 (low), 18 to <31 (intermediate), and 31 or higher (high) scores. The pathologic complete response rate for low, intermediate and high Magee Equation 3 scores was 0%, 4%, and 36%, respectively. Patients with high Magee Equation 3 scores were 13 times more likely to achieve pathologic complete response compared to those with Magee Equation 3 scores less than 31 (95% CI 5.09-32.87, P<0.0001). For patients that did not achieve pathologic complete response, high Magee Equation 3 correlated with higher recurrence rate, with the majority occurring in patients with positive lymph nodes in the resection specimen. Magee Equation 3 score ≥31 predicts pathologic complete response in the neoadjuvant setting and for tumor recurrence, when pathologic complete response is not achieved. These results show the utility of Magee Equation 3 in predicting patients who will benefit from chemotherapy but warrant prospective multi-institutional validation.

Breast Tumor Resembling Tall Cell Variant of Papillary Thyroid Carcinoma: A Solid Papillary Neoplasm With Characteristic Immunohistochemical Profile and Few Recurrent Mutations.

OBJECTIVES: Breast tumor resembling tall cell variant of papillary thyroid carcinoma (BTRPTC) is a rare breast lesion that is unrelated to thyroid carcinoma. Morphologically, it shows a solid papillary lesion with bland cytology, eosinophilic/amphophilic secretions, nuclear grooves, reversal of nuclear polarity (recently described), and nuclear inclusions. Clinical course is often uneventful with few exceptions reported in the literature. Herein, we report three additional cases. METHODS: Immunohistochemical staining and next-generation sequencing was performed on all three cases. RESULTS: The lesional cells on all cases were positive for cytokeratin 5 and S100, with weak expression/lack of estrogen receptor. No staining was observed for myoepithelial markers (p63 and myosin heavy chain) around the lesion. IDH2 mutations were identified in two cases at nucleotide 172 (cases 1 and 3). ATM gene mutation was identified in cases 2 and 3 and PIK3CA mutation in case 3. All patients are currently without disease. CONCLUSIONS: BTRPTC is a slow-growing neoplastic lesion that needs to be distinguished from other papillary lesions for optimizing therapy.

Exploring the multifactorial nature of postoperative nausea and vomiting in women following surgery for breast cancer.

BACKGROUND: Postoperative nausea and vomiting (PONV) are two of the most frequent and distressing complications following surgical procedures, with as many as 80% of patients considered to be at risk. Despite recognition of well-established risk factors and the subsequent use of clinical guidelines, 20-30% of women do not respond to antiemetic protocols, indicating that there may be a genetic risk. OBJECTIVE: The purpose of this pilot study was to describe the incidence and explore the risk factors associated with PONV after surgery in women diagnosed with early stage breast cancer. METHODS: A prospective cohort design was employed to measure PONV in women recruited prior to surgery. DNA was extracted from saliva samples collected prior to discharge. Polymorphisms for seven candidate genes with a known role in one of the neural pathways associated with PONV were included in this study; serotonin receptor (HTR3A), serotonin transport (SLC6A4), tryptophan (TPH), dopamine receptors (DRD2/ANKK and DRD3), catechol-O-methyltransferase (COMT) and histamine (H1). RESULTS: Twenty-nine (29.8%) women experienced nausea and 10 (11%) experienced nausea and vomiting while in the PACU despite administration of multiple antiemetic medications. Women who experienced PONV had higher levels of pain and received more opioids than those women who did not experienced PONV. Odds ratios demonstrated that alleles for the COMT, DRD3, and TPH genes were associated with decreased PONV. CONCLUSION: The understanding of the multifactorial nature of PONV and the recognition of genetic risk will ultimately lead to the development of personalized interventions to manage these frequent and often debilitating symptoms.

The impact of Oncotype DX® recurrence score of paraffin-embedded core biopsy tissues in predicting response to neoadjuvant chemotherapy in women with breast cancer.

BACKGROUND: Oncotype DX® test is beneficial in predicting recurrence free survival in estrogen receptor positive (ER+) breast cancer. Ability of the assay to predict response to neoadjuvant chemotherapy (NCT) is less well-studied. OBJECTIVE: We hypothesize a positive association between the Oncotype DX® recurrence score (RS) and the percentage tumor response (%TR) after NCT. METHODS: Pre-therapy RS was measured on core biopsies from 60 patients with ER+, HER2- invasive breast cancer (IBC) who then received NCT. Pre-therapy tumor size was measured using imaging. %TR, partial response (PR; >50%), pathologic complete response (pCR) and breast conserving surgery (BCS) rates were measured. RESULTS: Median RS was 20 (2-69). Median %TR was 42 (0-97)%. PR was observed in 43% of patients. There was no association between %TR and pre-NCT tumor size, age, Nottingham score or nodal status (p > 0.05). No statistically significant association with %TR was seen with RS as a categorical or continuous variable (p = 0.21 and 0.7, respectively). Response to NCT improved as ER (p = 0.02) by RT-PCR decreased. Lower ER expression by IHC correlated with response (p = 0.03). CONCLUSIONS: In patients with ER+ IBC receiving NCT, RS did not predict response to NCT using %TR. The benefit of the assay prior to NCT requires further study.

Predictive value of axillary nodal imaging by magnetic resonance imaging based on breast cancer subtype after neoadjuvant chemotherapy.

BACKGROUND: Magnetic resonance imaging (MRI) is commonly used to determine residual breast disease after neoadjuvant chemotherapy (NCT) for cancer. Few studies have assessed its role in predicting nodal response, by cancer subtype. METHODS: A retrospective review was completed using our institutional cancer registry. Patients who started NCT from 2005 to 2010 with clinically node positive disease were evaluated. Those who underwent post-NCT breast MRI were selected. Radiologic response was determined by an independent review. Nodal involvement was confirmed pathologically after surgery. RESULTS: A total of 135 patients underwent post-NCT breast MRI. The positive and negative predictive values of MRI are 93% and 26%, respectively. A subset analysis by cancer phenotype demonstrates triple negative cancers have the highest sensitivity (68%) and luminal cancers have the highest positive predictive value (100%). CONCLUSIONS: This study demonstrates that MRI post-NCT, even by cancer subtype, cannot reliably predict residual nodal disease because of high false-negative rates (low negative-predictive value).

Axillary Staging After Neoadjuvant Chemotherapy for Breast Cancer: A Pilot Study Combining Sentinel Lymph Node Biopsy with Radioactive Seed Localization of Pre-treatment Positive Axillary Lymph Nodes.

BACKGROUND: Neoadjuvant chemotherapy (NAC) downstages axillary disease in 55 % of node-positive (N1) breast cancer. The feasibility and accuracy of sentinel lymph node biopsy (SLNB) after NAC for percutaneous biopsy-proven N1 patients who are clinically node negative (cN0) by physical examination after NAC is under investigation. ACOSOG Z1071 reported a false-negative rate of <10 % if ≥3 nodes are removed with dual tracer, including excision of the biopsy-proven positive lymph node (BxLN). We report our experience using radioactive seed localization (RSL) to retrieve the BxLN with SLNB (RSL/SLNB) for cN0 patients after NAC. METHODS: We performed a retrospective review of a single-institution, prospectively maintained registry for the years 2013 to 2014. Patients with BxLN who received NAC and had RSL/SLNB were identified. All BxLNs were marked with a radiopaque clip before NAC to facilitate RSL. RESULTS: Thirty patients with BxLN before NAC were cN0 after NAC and underwent RSL/SLNB. Median age was 55 years. Disease stage was IIA-IIIB. Twenty-nine of 30 had ductal cancer (12 triple negative and 16 HER-2 positive). One to 11 nodes were retrieved. Twenty-nine of 30 BxLN were successfully localized with RSL. Note was made of the BxLN-containing isotope and/or dye in 22 of 30. Nineteen patients had no residual axillary disease; 11 had persistent disease. All who remained node positive had disease in the BxLN. CONCLUSIONS: RSL/SLNB is a promising approach for axillary staging after NAC in patients whose disease becomes cN0. The status of the BxLN after NAC predicted nodal status, suggesting that localization of the BxLN may be more accurate than SLNB alone for staging the axilla in the cN0 patient after NAC.

Factors affecting cosmesis after breast conserving surgery without oncoplastic techniques in an experienced comprehensive breast center.

We aimed to study the factors affecting cosmetic outcome (CO) in breast conserving surgery (BCS) without oncoplastic techniques in our center with a BCS rate higher than 60% in more than 1000 breast cancer surgeries a year. In this study 284 patients who underwent BCS without oncoplastic techniques were included. Surgeries were performed by two experienced breast surgeons with more than 25 years of experience. These patients were followed in our established Wellness Clinic postoperatively. The CO is evaluated according to the "Harvard Breast Cosmesis Grading Scale" by a breast surgeon who did not participate in the patient's surgery. The correlation among patient factors (age, breast volume, menopausal status), tumor factors (size, location, distance to areola) and treatment factors (excision volume, breast skin excision, axillary surgery, adjuvant therapy) and CO were evaluated. The mean age was 57.6 [33-98] years in the successful CO group and 58.1 [34-85] years in the unsuccessful CO group (p > 0.05). The mean follow-up time was 37.9 [24-84] months. The CO was successful in 88.7% (n:252) of the patients. Tumor size, retroareolar location of the tumor, adjuvant chemotherapy administration and whole breast radiation therapy (WBRT) were correlated with a poorer CO (p < 0.05). We were able to attain a successful CO in approximately 90% of our patients. Adding oncoplastic techniques to the surgical management of larger tumors and retroareolar tumors, may increase the percentage of good CO. In selected patients choosing balloon brachytherapy instead of WBRT, may also have positive effects on CO.

Decision making and factors influencing long-term satisfaction with prophylactic mastectomy in women with breast cancer.

PURPOSE: Studies demonstrate an increasing rate of contralateral prophylactic mastectomy (CPM). The purpose of this study is to evaluate decision making and factors influencing women's long-term satisfaction with CPM. Descriptive analysis is used to analyze the results of our designed questionnaire approved by our Institutional Review Board. METHODS: We searched our institutional cancer registry for patients diagnosed with breast cancer between 2000 and 2010. The studied time frame is of significance as this study is the first to measure response rate in questions examining patient satisfaction for >1 year after undergoing CPM. The questionnaire was mailed to all consented participants to examine factors contributing to the choice of CPM and postoperative satisfaction. RESULTS: Of the 206 women included in the study, 147 were aged up to 50 years. Majority of women who underwent CPM in this cohort was with a bachelor's degree or higher, married or partnered women, and women earning >$60,000/y. Almost all women were "happy with overall surgery" and would recommend CPM to other patients. Psychological factors, such as fear of recurrence, were more commonly associated with the decision for CPM in patients with invasive carcinoma. Opinions of partners, relatives, friends, and physicians further contributed to the decision to undergo surgery. The availability of reconstruction was also an influential factor in the overall decision. CONCLUSIONS: The majority of our study participants experienced long-term satisfaction with the surgical procedure of CPM. From our analysis, we can confidently say that fear of cancer recurrence and the opinions of others, among other factors, were influencing contributors toward the decision of undergoing CPM.

The importance of detection of subclinical lymphedema for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection; a prospective observational study.

PURPOSE: Early detection and timely intervention have potential to reduce late-stage lymphedema (LE) in patients with breast cancer undergoing axillary lymph node dissection (ALND). This study aims to determine if detection and early treatment of subclinical LE by using prospective monitoring with bioimpedance spectroscopy (BIS) can lead to reduced development of clinical LE. METHODS AND RESULTS: Subclinical LE was prospectively detected using an L-Dex(®) U400 analyzer to measure BIS in 186 patients who underwent ALND between 2010 and 2013 through our LE monitoring program. Baseline measurements were obtained and at 3-6 month intervals for 5 years. Patients diagnosed with subclinical LE received short-term physical therapy, compression garments, and education about exercise, elevation, infection precautions, BMI, and hand usage. The control group had a preoperative baseline L-Dex(®) measurement, but had only clinical follow-ups with circumferential arm measurements. Mean age and BMI were 56 years and 28.3 kg/m(2), respectively. The majority of the women underwent mastectomy (61%) and received chemotherapy (89%) and radiotherapy (77%). Thirty-three percent patients who had repeated L-Dex measurements were diagnosed with subclinical LE and received early intervention. Progression to clinical lymphedema occurred in 4.4% over an average of 20 months follow-up. In the control group, the incidence of clinical LE was 36.4%. CONCLUSION: Periodic monitoring of women at high risk for LE with BIS allows early detection and timely intervention for LE, which reduces the incidence of clinical LE from 36.4% to 4.4%. This may have implications for quality of life and health care costs.

Localizing high-risk lesions for excisional breast biopsy: a comparison between radioactive seed localization and wire localization.

BACKGROUND: Improved resolution and utilization of screening breast imaging has increased identification of nonpalpable high-risk lesions (HRL) and subsequent excisional breast biopsies (EBBs). Wire localization (WL), used most commonly for EBBs, may have shortcomings, including wire displacement, patient discomfort, limitations with incision planning and scheduling logistics. Radioactive seed localization (RSL) may overcome these drawbacks. The purpose of this study was to compare WL and RSL for EBBs for HRLs. METHODS: All single-site EBBs for HRL performed by four breast surgeons were retrospectively reviewed over two consecutive 1-year periods. Patients with cancer on percutaneous core biopsy (CB) were excluded. Clinicopathologic information, operative time, targeted lesion retrieval rate, and upstage rate were collected. RESULTS: A total of 324 EBBs for HRL were performed: 196 using WL and 128 using RSL. CB pathology was atypical hyperplasia in 56 % of WLs and 62 % of RSLs. The remaining pathologies were radial scar, papilloma, atypical papilloma or lobular carcinoma in situ. Mean age was 54 years. OR time was 27 ± 8 min for WL and 27 ± 7 min for RSL (p = 0.9). Upstage rate was 6 and 5 % for WLs and RSLs, respectively (p = 0.5). Targeted lesions were retrieved in 98 % of WL and 99 % of RSL (p = 0.5). SV was 37.2 ± 32.8 cm(3) and 25.7 ± 22.3 cm(3) for WL and RSL, respectively (p = 0.001). CONCLUSIONS: RSL is comparable to WL for EBB of HRLs with similar OR times and upstage rates. SV is significantly decreased with RSL and may translate into improved cosmetic outcomes without sacrificing the diagnostic accuracy of the EBB.

Association between serotonin transport polymorphisms and postdischarge nausea and vomiting in women following breast cancer surgery.

PURPOSE/OBJECTIVES: To examine the association of the serotonin transport gene and postdischarge nausea and vomiting (PDNV) in women following breast cancer surgery. DESIGN: A cross-sectional study. SETTING: A comprehensive cancer center in Pittsburgh, PA. SAMPLE: 80 post-menopausal women treated surgically for early-stage breast cancer. METHODS: Data were collected using standardized instruments after surgery but before the initiation of chemotherapy. Blood or saliva were used for DNA extraction and analyzed following standardized protocols. Data were analyzed using descriptive statistics and logistic regression. MAIN RESEARCH VARIABLES: Serotonin transport gene (SLC6A4), nausea, vomiting, pain, and anxiety. FINDINGS: Women who inherited the LA/LA genotypes were at greater risk for nausea and vomiting when compared to women who carried any other combination of genotypes. Twenty-one percent of women reported nausea and vomiting an average of one month following surgery and prior to initiation of adjuvant therapy. Those women who experienced PDNV reported significantly higher anxiety and pain scores. CONCLUSIONS: Findings of this study suggest that variability in the genotypes of the serotonin transport gene may help to explain the variability in PDNV in women following breast cancer surgery and why 20%-30% of patients do not respond to antiemetic medications. IMPLICATIONS FOR NURSING: Nurses need to be aware that women who do not experience postoperative nausea and vomiting following surgery for breast cancer continue to be at risk for PDNV long after they have been discharged from the hospital, and this frequently is accompanied by pain and anxiety.

Rationale of excisional biopsy after the diagnosis of benign radial scar on core biopsy: a single institutional outcome analysis.

BACKGROUND: Radial scar (RS) is characterized by a fibroelastic core with entrapped ducts and lobules. Association with carcinoma is not uncommon. There is some dilemma as to the need for excisional biopsy or follow-up after RS diagnosis on core biopsy. AIM: To determine the necessity of excisional biopsy after the diagnosis of benign RS by core biopsy. STUDY DESIGN: A total of 67 RS specimens associated with benign findings on core biopsy obtained between 2003 and 2008 were reviewed. They were grouped by their accompanying histopathologic features found upon subsequent surgical excision: benign, high-risk lesion (HRL), or carcinoma. Demographic features, radiologic findings, and needle gauge were compared within subgroups. RESULTS: After surgical excision, 15 (22.4%) patients in the benign group were upgraded to a HRL, 4 (5.9%) patients were upgraded to carcinoma, and 48 (71.6%) remained benign. We found that malignancy is associated with RS more frequently if the patient is older and postmenopausal. Other variables such as symptoms at presentation, presence and type of abnormality on mammography (Breast Imaging Reporting and Data System score), breast density, size of biopsy needle used, and number of core samples retrieved did not help to predict the presence of carcinoma. CONCLUSIONS: The HRL and cancer upgrade rate of RS, requiring further intervention such as surgery or chemoprevention, is 28% in this study. However, we found that age and menopausal status may be taken into consideration when making the decision to follow up or excise the RS diagnosed on core biopsy. There is insufficient data to support the predictive value of any variables. Therefore, RS associated with benign findings on core biopsy should be excised.

Atypical hyperplasia on core biopsy: is further surgery needed?

INTRODUCTION: Percutaneous core needle biopsy (CNB) has been widely performed as a standard technique for initial histological diagnosis of suspicious breast lesions. There have been an increased number of atypical lesions diagnosed on CNB as a consequence of the advances in breast imaging techniques. The authors aim to identify if any of the radiological and histopathological criteria evaluated in this study can predict the presence of malignancy associated with atypical hyperplasia (AH) diagnosed on CNB. METHODS: The authors retrospectively reviewed the medical records of 450 patients diagnosed with AH. Surgical excision was then performed and pathology revealed carcinoma or benign lesions. Patient age, imaging features, number of CNB samples taken, biopsy needle gauge, presence of additional proliferative diseases and calcification on CNB or excision were evaluated in both groups. RESULTS: Fifty-one (11.3%) patients were found to have malignancy on surgical excision; 74.5% had ductal carcinoma in situ only and 25.6% had invasive cancer. In subgroup analysis, pure atypical ductal hyperplasia lesions were upgraded in 11.5%, pure atypical lobular hyperplasia lesions were upgraded in 8.1% and mixed lesions were upgraded in 17.6% (P > 0.05) of patients. The majority of the patients were older than 50 years, and calcification was the main reason for biopsy in both groups. The presence of additional proliferative lesions and needle gauge were not found to be statistically significant (P > 0.05). CONCLUSION: Upgrade rate to cancer after surgical excision was 11.3% of AH patients diagnosed on CNB. However, none of the variables are significant in determining the presence of malignancy associated with AH diagnosed by CNB.

MRI staging after neoadjuvant chemotherapy for breast cancer: does tumor biology affect accuracy?

BACKGROUND: A discrepancy often exists between the post-neoadjuvant chemotherapy (NAC) breast tumor size on magnetic resonance imaging (MRI) and pathologic tumor size. We seek to quantify this MRI/pathology discrepancy and determine if the accuracy of MRI post NAC varies with tumor subtype. METHODS: The University of Pittsburgh Medical Center (UPMC) Cancer Registry and radiology database were searched for patients with breast cancer who underwent NAC and MRI staging between 2004 and 2009. We compared radiologic to pathologic staging and stratified differences based on tumor biology using univariate, multivariate, and receiver operating characteristic (ROC) analysis. RESULTS: Two hundred three of 592 patients undergoing surgery after NAC for breast cancer had MRI staging pre and post chemotherapy. All patients had intact tumors prior to the initiation of chemotherapy. Average tumor size by MRI was 4.0 cm pre chemotherapy and 1.2 cm post chemotherapy. The average pathologic tumor size was 1.7 cm (range 0-13 cm). The difference between MRI and pathologic tumor size was greatest in luminal (1.1 cm) and least in triple-negative (TN) and human epidermal growth factor receptor 2 (HER2)-positive tumors (<0.1 cm) (p = 0.015). MRI was a good discriminator for pathologic complete response (pCR) [area under the curve (AUC) 0.777]. Its predictive value for pCR was much greater in TN and estrogen receptor(ER)-/HER2+ than in luminal tumors (73.6 vs. 27.3%). CONCLUSIONS: MRI is an effective tool for predicting response to NAC. The accuracy of MRI in estimating postchemotherapy tumor size varies with tumor subtype. It is highest in ER-/HER2+ and TN and lowest in luminal tumors. Knowledge of how tumor subtype affects MRI accuracy can guide recommendations for surgery following NAC.

Can nomograms predict non-sentinel lymph node metastasis after neoadjuvant chemotherapy in sentinel lymph node-positive breast cancer patients?

BACKGROUND: The predictive probability of breast cancer nomograms for non-sentinel node metastases (NSLNM) after neoadjuvant chemotherapy (NCT) in patients with a positive sentinel lymph node (SLN) biopsy is unknown. The aim of this study was to evaluate the accuracy of 3 different nomograms in patients receiving NCT. PATIENTS AND METHODS: Between 1999 and 2007, 54 patients presented with clinically N0 disease received NCT. Nomograms developed by Memorial Sloan-Kettering Cancer Center (MSKCC), Stanford University, and Tenon Hospital were used to calculate the probability of NSLNM by using tumor size at presentation and after NCT for the same patient. The discrimination of the nomograms was assessed by calculating the area under (AUC) the receiver operating characteristic curve, and it was accepted that AUC values 0.7-0.8 represent considerable discrimination. RESULTS: The median patient age was 50.9 years (range, 29-67 years). Twenty-two patients (38.8%) had positive NSLNM. The MSKCC and the Stanford nomograms yielded similar AUC regardless of whether initial or post-NCT tumor size was used to determine predicted probability of NSLNM (AUCs were < 0.70). AUC was 0.74 for the Tenon model using tumor size at presentation. After NCT, the AUCs were 0.64, 0.57, and 0.78 for the MSKCC, the Stanford, and the Tenon nomograms, respectively. CONCLUSION: Although the AUC of the Tenon model was acceptable for accuracy, we found a lower rate for predicting negative NSLNM in our group than in the Tenon Hospital report. All of the nomograms developed for use in the non-NCT population need to be used with caution in the NCT population.

Predicting likelihood of having four or more positive nodes in patient with sentinel lymph node-positive breast cancer: a nomogram validation study.

PURPOSE: Katz suggested a nomogram for predicting having four or more positive nodes in sentinel lymph node (SLN)-positive breast cancer patients. The findings from this formula might influence adjuvant radiotherapy decisions. Our goal was to validate the accuracy of the Katz nomogram. METHODS AND MATERIALS: We reviewed the records of 309 patients with breast cancer who had undergone completion axillary lymph node dissection. The factors associated with the likelihood of having four or more positive axillary nodes were evaluated in patients with one to three positive SLNs. The nomogram developed by Katz was applied to our data set. The area under the curve of the corresponding receiver operating characteristics curve was calculated for the nomogram. RESULTS: Of the 309 patients, 80 (25.9%) had four or more positive axillary lymph nodes. On multivariate analysis, the number of positive SLNs (p < .0001), overall metastasis size (p = .019), primary tumor size (p = .0001), and extracapsular extension (p = .01) were significant factors predicting for four or more positive nodes. For patients with <5% probability, 90.3% had fewer than four positive nodes and 9.7% had four or more positive nodes. The negative predictive value was 91.7%, and sensitivity was 80%. The nomogram was accurate and discriminating (area under the curve, .801). CONCLUSION: The probability of four or more involved nodes is significantly greater in patients who have an increased number of positive SLNs, increased overall metastasis size, increased tumor size, and extracapsular extension. The Katz nomogram was validated in our patients. This nomogram will be helpful to clinicians making adjuvant treatment recommendations to their patients.

Predictive probability of four different breast cancer nomograms for nonsentinel axillary lymph node metastasis in positive sentinel node biopsy.

BACKGROUND: Although completion axillary lymph node dissection (CALND) is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN) in breast cancer, almost 40% to 70% of SLN-positive patients will have negative non-SLNs. To predict non-SLN metastases (NSLNM) in patients with a positive SLN biopsy, four different nomograms have been created. The aim of this study was to evaluate the accuracy of four different nomograms in our SLN-positive breast cancer patients. STUDY DESIGN: We identified 319 patients who had a positive SLN biopsy and CALND at our hospital during an 8-year period. Breast cancer nomograms developed by Memorial Sloan-Kettering Cancer Center, Tenon Hospital, Cambridge University, and Stanford University were used to calculate the probability of NSLNM. The area under the receiver operating characteristics curve was calculated for each nomogram, and values greater than 0.70 were accepted as demonstrating considerable discrimination. RESULTS: One hundred seven of 319 patients (33.5%) had positive axillary NSLNM. The mean number of SLNs was 2.01 (range, 1 to 11 nodes), and the mean number of positive SLNs was 1.44 (range, 1 to 9 nodes). The area under the curve values were 0.70, 0.69, 0.69, and 0.64 for the Memorial Sloan-Kettering Cancer Center, Tenon, Cambridge, and Stanford models, respectively. CONCLUSIONS: We found that the Memorial Sloan-Kettering Cancer Center nomogram was more predictive than the other nomograms, but the Cambridge model and the Tenon model reached borderline values for accurate prediction. Nomograms developed at other institutions should be used with caution when counseling patients about the risk of additional nodal disease.

Does failure to visualize a sentinel node on preoperative lymphoscintigraphy predict a greater likelihood of axillary lymph node positivity?

BACKGROUND: Sentinel lymph node (SLN) mapping has become the standard of care for axillary staging in women with early-stage breast cancer. The purpose of the study was to investigate the hypothesis that nonvisualization of SLN on lymphoscintigraphy (LSG) predicts a subset of patients at risk of having a substantial burden of axillary tumor as evidenced by higher rate of lymph node involvement. STUDY DESIGN: We retrospectively reviewed the records of 1,500 patients who underwent dual-tracer SLN mapping for breast cancer between 1999 and 2004. LSG were reported as negative or positive. RESULTS: Ninety-one percent had axillary SLN(s) identified on LSG imaging. In 133 of 134 (99.3%) patients with a negative LSG, SLN(s) was identified intraoperatively either by blue dye or hand-held gamma detection. SLN was positive in 28.4% of LSG nonvisualized group and was positive in 29.1% of LSG visualized group (p>0.05). A significantly higher percentage of women older than 50 years of age had nonvisualization of SLN (p<0.0001). Body mass index (calculated as kg/m2) was >30 in 42.5% of LSG nonvisualized group and in 26.3% in LSG visualized group (p<0.0001). CONCLUSIONS: Failure to demonstrate axillary uptake by LSG appears to be related to technical factors and patient-related factors, such as body mass index and older age, but does not adversely affect SLN identification. The equivalent rate of positive SLNs in patients with a positive or negative LSG supports the null hypothesis that "failure to visualize" on LSG does not identify a subset of patients at higher risk of being axillary lymph node positive.