Feasibility of Omitting Sentinel Lymph Node Biopsy in an Under-screened Cohort of Breast Cancer Patients With a Premastectomy Diagnosis of Ductal Carcinoma In Situ.

BACKGROUND: Nodal involvement in ductal carcinoma in situ (DCIS) is rare. In patients with DCIS diagnosis prior to mastectomy, a sentinel lymph node biopsy (SLNB) is usually performed during mastectomy, to avoid the risk of reoperation and the non-identification of SLN subsequently, should there be an upgrade to invasive cancer. We aimed to study the feasibility of omitting SLNB in an under-screened cohort, with mostly symptomatic patients and DCIS diagnosis before mastectomy, by determining the upgrade rate to invasive cancer/ DCIS microinvasion (DCISM) and its associated risk factors. METHODS: Patients with pure DCIS diagnosis premastectomy were reviewed retrospectively. Patients with known DCISM or invasive cancer before mastectomy and bilateral cancers were excluded. Patients' demographics, radiological and pathological data premastectomy were analyzed. RESULTS: A total of 189 patients were included. The mean age was 53.8 (range: 29-85) years old. About 64.4% presented with symptoms. 36.0% and 15.3% upgraded to invasive cancer and DCISM on mastectomy respectively. Palpable tumor (P = .0036), large size on ultrasound (P = .0283), tumor seen on mammogram and ultrasound (P = .0082), ultrasound-guided biopsy (P < .0001), high-grade DCIS on biopsy (P = .0350) and no open biopsy/lumpectomy before mastectomy (P < .0001) were associated with the upgrade, with the latter factor remaining significant after multivariable analysis. Nodal involvement was 8.47% and was associated with invasive cancer (P < .0001). CONCLUSION: In a cohort who had DCIS diagnosis before mastectomy and were mostly symptomatic, the upgrade rate was 51.3%. Despite the high upgrade rate, nodal involvement remained comparable. Risk factors could select patients for omission of upfront SLNB, with a delayed SLNB planned if needed.

Clinical presentations and outcomes of young women aged <40 yrs with Ductal carcinoma in situ.

INTRODUCTION: Ductal carcinoma in situ (DCIS) in young women is rare and not well studied. Since they do not qualify for mammographic screening, they are more likely to present with symptoms. Young women have also been associated with poorer outcomes, but it is unknown whether presentation mode affects outcome. We aimed to compare characteristics of DCIS patients <40 years of age presenting with symptoms versus those without, and determine whether presentation mode affects recurrence. METHODS: Pure DCIS patients aged <40 years were retrospectively analyzed. Clinical presentation, pathology and recurrence data were collected. Statistical analysis was performed to investigate the correlation of presentation mode with outcomes. RESULTS: 40 patients with 41 cases were included. The mean age at diagnosis was 32.3 years (range 17-39). 73.2% and 26.8% presented with symptoms or abnormal imaging respectively. Of the cases who presented with symptoms, 86.7%, 10.0% and 3.3% had palpable lump, nipple discharge or breast pain, respectively. The average tumor size was 22.0 mm (range 2.0-86.9) and 12.2 mm (range 3-25) for patients who presented with symptoms and non-symptomatic group, respectively. Cases presenting with symptoms were statistically associated with higher grade (p = 0.0090). On median follow-up of 85 months, there were 3 (7.3%) recurrences, which were not statistically associated with presentation mode. CONCLUSION: Young women with DCIS tend to present with symptoms, with breast lump as the commonest symptom. Symptomatic patients tend to be associated with grade III tumours, compared to non-symptomatic patients. On long-term follow-up, mode of presentation was not statistically associated with recurrence.

Approach to the growing breast lump during lactation.

Physiological changes during pregnancy and lactation result in increased lumpiness of the breast. This makes the evaluation of the breast challenging. Although most self-detected lumps, during this period, tend to be benign, the priority in these patients is to exclude tumours that may require prompt management. We present a case of phyllodes tumour that occurred during lactation and discussed the resultant pitfalls that may occur during the triple assessment of a breast lump in a lactating mother.

Can the size of chest wall recurrence after mastectomy in breast cancer patients predict the presence of systemic metastasis?

Background: One of the manifestations of recurrence after mastectomy is the presentation of chest wall lesion. However, it is unclear if the size of the chest wall recurrence (CWR) is related to the presence of simultaneous systemic metastasis in these patients. We aimed to determine if the size of the CWR could affect the outcome in these patients. Methods: Stage I-III breast cancer patients who underwent mastectomy and developed invasive ipsilateral CWR were included. Patients with bilateral mastectomy were excluded. Demographic, radiologic and pathological data were analysed between patients with CWR and simultaneous systemic metastasis versus those with isolated CWR. Results: Of the 1,619 patients treated with mastectomy, 214 (13.2%) patients developed recurrences. 57/214 (26.6%) patients had invasive ipsilateral CWR. 48 patients were analysed after exclusion of patients with missing data. Mean age at diagnosis of first cancer and at recurrence were 55.2 years (32-84 years) and 58.5 years (34-85 years) respectively. 26/48 (54.2%) had CWR with simultaneous systemic metastasis. Mean CWR size was 30.7 mm (6-121 mm) and 21.4 mm (5.3-90 mm) for the patients with simultaneous systemic metastasis and those without respectively (P=0.441). Grade (P=0.0008) and nodal status (P=0.0009) at primary diagnosis, grade (P=0.0011) and progesterone receptor (PR) status (P=0.0487) at recurrence were statistically significant for systemic metastasis in patients with CWR. Conclusions: Biologic factors such as grade of primary and recurrent cancer, PR status of recurrent cancer and nodal status at primary diagnosis, instead of CWR size, were associated with simultaneous systemic metastasis in patients with CWR.

Axillary management of breast cancer patients with isolated chest wall recurrence after mastectomy.

Background: National Comprehensive Cancer Network (NCCN) guidelines on the axillary management of breast cancer patients with isolated chest wall recurrence after mastectomy are unclear. Though sentinel lymph node biopsy (SLNB) is possible and may be considered, there is limited data on its usefulness. We aimed to determine if axillary restaging surgery was required in this cohort of patients who developed operable isolated chest wall recurrences after mastectomy. Methods: Breast cancer patients treated at a tertiary institution from 1st September 2005 to 31st October 2017 and developed isolated chest wall invasive recurrences after mastectomy were retrospectively reviewed. We excluded patients with bilateral cancers, concurrent regional or distant metastases, patients without surgery for their chest wall recurrences and patients who were lost to follow-up. The demographics, pathological data and second recurrences were collected from a prospectively maintained database and compared between patients with axillary lymph node dissection (ALND), SLNB and no axillary operation. Results: Of the 1,841 patients who underwent mastectomy, 26 (1.4%) patients developed isolated chest wall recurrences. Twenty two eligible patients were analysed. The mean age at diagnosis of the recurrence was 54.7 years (range, 37-84 years). 1, 2 and 19 patients had ALND, SLNB and no axillary operation respectively. On mean follow-up of 38.3 months, no axillary recurrences were noted. Conclusions: In breast cancer patients with isolated chest wall recurrences after mastectomy, axillary restaging surgery can be safely omitted with no increased axillary recurrences on medium term follow-up. This finding could refine existing guidelines in the management of the axilla for patients with chest wall recurrences after mastectomy.

Preparation of lignin nanoparticles via ultra-fast microwave-assisted fractionation of lignocellulose using ternary deep eutectic solvents.

Lignin separation from natural lignocellulose for the preparation of lignin nanoparticles (LNPs) is often challenging owing to the recalcitrant and complex structure of lignocellulose. This paper reports a strategy for the rapid synthesis of LNPs via microwave-assisted lignocellulose fractionation using ternary deep eutectic solvents (DESs). A novel ternary DES with strong hydrogen bonding was prepared using choline chloride, oxalic acid, and lactic acid in a 1:0.5:1 ratio. Efficient fractionation of rice straw (0.5 × 2.0 cm) (RS) was realized by the ternary DES under microwave irradiation (680 W) within only 4 min, and 63.4% of lignin could be separated from the RS to prepare LNPs with a high lignin purity (86.8%), an average particle size of 48-95 nm, and a narrow size distribution. The mechanism of lignin conversion was also investigated, which revealed that dissolved lignin aggregated into LNPs via π-π stacking interactions.

The interaction of ZnO nanoparticles, Cr(VI), and microorganisms triggers a novel ROS scavenging strategy to inhibit microbial Cr(VI) reduction.

Cr(VI) contaminated water usually contains other contaminants like engineered nanomaterials (ENMs). During the process of microbial treatment, the inevitable interaction of Cr(VI), ENMs, and microorganisms probably determines the efficiency of Cr(VI) biotransformation, however, the corresponding information remains elusive. This study investigated the interaction of ZnO nanoparticles (NPs), Cr(VI), and Pannonibacter phragmitetus BB (hereafter BB), which changed the process of microbial Cr(VI) reduction. ZnO NPs inhibited Cr(VI) reduction, but had no effect on bacterial viability. In particular, Cr(VI) induced BB to produce organic acids and to drive Zn2+ dissolution from ZnO NPs inside and outside of cells. The dissolved Zn2+ not only promoted Cr(VI) reduction to Cr(V)/Cr(IV) by strengthening sugar metabolism and inducing increase in NAD(P)H production, but also hindered Cr(V)/Cr(IV) transformation to Cr(III) through down-regulating Cr(VI) reductase genes. A novel bacterial driven ROS scavenging mechanism leading to the inhibition of Cr(VI) reduction was elucidated. Specifically, the accumulated Cr(VI) and Cr(V)/Cr(IV) formed a redox dynamic equilibrium, which triggered the disproportionation of superoxide radicals mimicking superoxide dismutase through the flip-flop of Cr(VI) and Cr(V)/Cr(IV) in bacterial cells. This study provided a realistic insight into design the applicability of biological remediation technology for Cr(VI) contaminant and evaluating environmental risks of ENMs.

Internal electric field induced photocarriers separation of nickel-doped pyrite/pyrite homojunction with rich sulfur vacancies for superior Cr(VI) reduction.

Improving the separation efficiency and transfer ability of photoinduced electrons/holes in pyrite (FeS2)-based photocatalytic materials is significant for the photoreduction of hexavalent chromium (Cr(VI)) but still remains a challenge. Herein, a novel homojunction was prepared through in-situ growth of nickel (Ni) doped FeS2 nanoparticles on FeS2 nanobelts (denoted as Ni-FeS2/FeS2). Systematical characterizations revealed that Ni doped FeS2 nanoparticles have been successfully in situ grown along the lattice of FeS2 nanobelts. Photoreduction experiments demonstrated that the Ni-FeS2/FeS2 homojunction with 2 mmol Ni doping contents (denoted as 2Ni-FeS2/FeS2) exhibited the optimum Cr(VI) reduction efficiency among the studied catalysts. Density Functional Theory (DFT) calculated results verified that Ni doping could not only be advantageous for the formation of sulfur vacancies but also modify the band gap and band structure of FeS2 nanoparticles. Moreover, several doping energy levels caused by Ni doping have also appeared near the Fermi level of FeS2 nanoparticles. The migration paths of electrons and the existence of internal electric field (IEF) in homojunction were further verified by the calculation of work function. To sum up, the doping energy levels and IEF that produced by homojunction played important roles in accelerating the separation efficiency of its photogenerated carriers.

Patterns of breast cancer second recurrences in patients after mastectomy.

INTRODUCTION: Little is known about second recurrences in breast cancer patients, especially in patients with mastectomy. We aimed to determine the risk factors, prevalence and patterns of second recurrence in mastectomy patients after first recurrence. METHODS: Stage I-III breast cancer patients treated at a tertiary institution from 1st September 2005 to 31st October 2017 and developed first and second recurrences after mastectomy were retrospectively reviewed. We excluded patients with bilateral cancers and patients who were lost to follow-up. The demographics, pathological and recurrence data were collected from a prospectively maintained database and analysed. RESULTS: Of the 1619 mastectomy patients, 214 (13.2%) patients developed recurrences at a mean 39.9 months from primary cancer diagnosis. 23, 8 and 183 had isolated chest wall recurrences (CWR), regional and systemic metastases, respectively. Excluding 2 CWR patients without surgery, second recurrences occurred in 3/21 (14.3%) and 3/8 (37.5%) in patients with CWR and regional metastasis at 27.7 months (range: 5-42) and 32 months (range: 18-40), respectively. In both groups, systemic metastasis as second recurrence occurred within 2 years after first recurrence, whilst locoregional second recurrences occurred later. No risk factors for second recurrence were identified. CONCLUSION: In patients with mastectomy, second recurrences occurred in 20.7% of patients with treated locoregional first recurrence, with no risk factors identified. Systemic metastases manifesting as second recurrence occurred in the first 2 years after first recurrence. Continued clinical surveillance and restaging patients in the first 2 years after first locoregional recurrence may enable early prognostication and treatment with the newer metastatic drugs.

Determining the benefit of neoadjuvant chemotherapy in reduction of axillary dissection rates in Z0011 trial cohort with high nodal burden.

Background: In breast cancer patients fulfilling the Z0011 trial criteria, axillary lymph node dissection (ALND) is reserved for patients with a high nodal burden of ≥3 metastatic nodes. In this group of patients, to avoid an ALND, neoadjuvant chemotherapy (NACT) could be given instead to achieve nodal pathological complete response (pCR). However, the benefit of NACT in achieving nodal pCR and avoiding ALND in this group of patients is unknown. We aimed to determine the nodal pCR rate in this group of patients who otherwise would have needed an ALND. Methods: cT1-2N0 breast cancer patients, with histologically proven nodal metastasis, who underwent NACT were identified from a prospectively maintained database. The sonographic criteria of ≥3 abnormal nodes, which has been reported as highly predictive of high nodal burden, was then used to identify the high nodal burden group. Nodal pCR was determined based on the ALND following NACT. Results: Twenty-four patients with high nodal burden were identified. Mean age was 55.2 years. 91.7% had invasive ductal carcinoma and 29.2% had grade III cancer. 54.2% achieved nodal pCR which was associated with ypT (P=0.006). Nodal pCR was 75%, 70% and 30% in the triple negative, human epidermal growth factor receptor2 (HER2) positive and ER/PR+HER2- tumors, respectively. Conclusions: In the postulated T1-2 breast cancer patients with high nodal burden, needing an upfront ALND, NACT could result in nodal pCR of 54.2%, with higher pCR in certain subtypes. Hence, to minimize ALND risk, NACT should be offered in this high nodal burden group.

Primary Eccrine Porocarcinoma of the Breast: A Case Report and Review of Literature.

Eccrine porocarcinoma (EPC) is a rare cutaneous neoplasm, with less than 500 reported cases worldwide since it was first described in 1963. EPC tends to affect the elderly and most commonly affects the head and neck. The mainstay of EPC treatment is surgery, with lymphadenectomy in the case of nodal involvement or presence of unfavourable characteristics. No evidence exists to guide the use of adjuvant chemotherapy or radiation. EPC is prone to misdiagnosis given its multiple clinical and histopathological mimics, especially in uncommon sites of presentation such as the breast. Herein, we report the case of a 59-year-old woman who presented with a left breast skin lump. The biopsied specimen revealed an infiltrative carcinoma involving the dermis and epidermis with positive IHC staining for P63 and CK5/6 and negative staining for ER, PR, and HER2. The tumour was resected and diagnosed as EPC with atypical features as overlapping characteristics of squamous cell carcinoma (SCC) were detected on histopathological analysis. In our case, a simple mastectomy with broad margins and axillary lymph node dissection with adjuvant radiotherapy to a dose of 60 Gy failed to achieve loco-regional control with nodal recurrence occurring 4 months postsurgery-a testament to the aggressive course of this rare malignancy.

Overlap of high-risk individuals predicted by family history, and genetic and non-genetic breast cancer risk prediction models: implications for risk stratification.

BACKGROUND: Family history, and genetic and non-genetic risk factors can stratify women according to their individual risk of developing breast cancer. The extent of overlap between these risk predictors is not clear. METHODS: In this case-only analysis involving 7600 Asian breast cancer patients diagnosed between age 30 and 75 years, we examined identification of high-risk patients based on positive family history, the Gail model 5-year absolute risk [5yAR] above 1.3%, breast cancer predisposition genes (protein-truncating variants [PTV] in ATM, BRCA1, BRCA2, CHEK2, PALB2, BARD1, RAD51C, RAD51D, or TP53), and polygenic risk score (PRS) 5yAR above 1.3%. RESULTS: Correlation between 5yAR (at age of diagnosis) predicted by PRS and the Gail model was low (r=0.27). Fifty-three percent of breast cancer patients (n=4041) were considered high risk by one or more classification criteria. Positive family history, PTV carriership, PRS, or the Gail model identified 1247 (16%), 385 (5%), 2774 (36%), and 1592 (21%) patients who were considered at high risk, respectively. In a subset of 3227 women aged below 50 years, the four models studied identified 470 (15%), 213 (7%), 769 (24%), and 325 (10%) unique patients who were considered at high risk, respectively. For younger women, PRS and PTVs together identified 745 (59% of 1276) high-risk individuals who were not identified by the Gail model or family history. CONCLUSIONS: Family history and genetic and non-genetic risk stratification tools have the potential to complement one another to identify women at high risk.

Aesthetic breast surgery: putting in context-a narrative review.

OBJECTIVE: This review article summarises the latest evidence for commonly undertaken procedures in aesthetic breast surgery with a focus on key principles of breast augmentation, reduction, and mastopexy. The paper also outlines various approaches and controversies as well as complications such as breast implant associated anaplastic large cell lymphoma (BIA-ALCL) and breast implant illness (BII) which are increasingly being recognised and becoming a challenge to manage. BACKGROUND: Changing trends of aesthetic breast surgery over the decades has warranted a continuous evolution of this field. The ability to deliver safe and appropriate care is dependent upon sound reconstructive principles and proper training. The lack of uniformity in either is a cause of concern. The impact of social media and changing perception of body image can also no longer be overlooked in the field of aesthetics and reconstruction. METHODS: Review of literature including recent journals, textbook chapters, online databases like PubMed, and current government and surgical society guidelines. CONCLUSIONS: Breast reconstruction is based on sound surgical principles and it is imperative to follow these for the practice of this speciality. There are two important issues that revolve around this aspect of surgery. First relates to the urgent need to invest time and effort in improving regulations and outcomes in the cosmetic surgery industry. Second, it is crucial to promote and prioritize the development and training in this field as the principles of aesthetic breast surgery underpins oncoplastic breast surgery for management of cancer.

Cohort profile: The Singapore Breast Cancer Cohort (SGBCC), a multi-center breast cancer cohort for evaluation of phenotypic risk factors and genetic markers.

This article aims to provide a detailed description of the Singapore Breast Cancer Cohort (SGBCC), an ongoing multi-ethnic cohort established with the overarching goal to identify genetic markers for breast cancer risk, prognosis and treatment response, as well as to understand the ethnic differences in disease risk and outcome in an Asian setting. The cohort comprises of breast cancer patients aged 21 years and above from six public hospitals which diagnose and treat nearly 76% breast cancer cases in Singapore. Self-reported data on sociodemographic and lifestyle, reproductive risk factors, medical history and family history of breast or ovarian cancer is collected using a structured questionnaire. Clinical data on tumour characteristics, and treatment modalities are obtained through medical record. Bio-specimens (blood or saliva) is collected at recruitment. Follow-up on survival information is done through routine linkage with the Registry of Births and Deaths. As of 31 December 2016, 7,768 subjects have been recruited to the study with 76% subjects contributed bio-specimens. The SGBCC provides a valuable platform which offers a unique, large and rich resource for new research ideas on breast cancer related phenotypic risk factors and genetic markers.

DNA methylation and breast cancer-associated variants.

BACKGROUND: A breast cancer polygenic risk score (PRS) comprising 313 common variants reliably predicts disease risk. We examined possible relationships between genetic variation, regulation, and expression to clarify the molecular alterations associated with these variants. METHODS: Genome-wide methylomic variation was quantified (MethylationEPIC) in Asian breast cancer patients (1152 buffy coats from peripheral whole blood). DNA methylation (DNAm) quantitative trait loci (mQTL) mapping was performed for 235 of the 313 variants with minor allele frequencies > 5%. Stability of identified mQTLs (p < 5e-8) across lifetime was examined using a public mQTL database. Identified mQTLs were also mapped to expression quantitative trait loci (eQTLs) in the Genotype-Tissue Expression Project and the eQTLGen Consortium. RESULTS: Breast cancer PRS was not associated with DNAm. A higher proportion of significant cis-mQTLs were observed. Of 822 significant cis-mQTLs (179 unique variants) identified in our dataset, 141 (59 unique variants) were significant (p < 5e-8) in a public mQTL database. Eighty-six percent (121/141) of the matched mQTLs were consistent at multiple time points (birth, childhood, adolescence, pregnancy, middle age, post-diagnosis, or treatment). Ninety-three variants associated with DNAm were also cis-eQTLs (35 variants not genome-wide significant). Multiple loci in the breast cancer PRS are associated with DNAm, contributing to the polygenic nature of the disease. These mQTLs are mostly stable over time. CONCLUSIONS: Consistent results from DNAm and expression data may reveal new candidate genes not previously associated with breast cancer.

The Impact of Radiotherapy and Histological Risk Factors on Outcomes in Malignant Phyllodes Tumors.

PURPOSE: Breast phyllodes tumors (PT) are classified into benign, borderline, and malignant grades based on histopathologic characteristics. Specific to malignant PT (MPT), surgery is the mainstay yet relapse rates are high and knowledge gaps in the literature exist regarding adjuvant radiotherapy (RT). We aimed to investigate the outcomes of patients with MPT treated in a tertiary Asian institution. METHODS AND MATERIALS: Patients with nonmetastatic MPT treated from February 1992 to June 2019 were analyzed retrospectively. RT details and relapse fields were studied. Outcomes of patients with and without RT were compared and hazard ratios were calculated using Cox proportional hazard test. Multivariable analysis was performed. RESULTS: Twenty-two of 89 patients received adjuvant RT and the median dose was 60 Gy. In the no-RT group, 4 patients received RT on relapse and had no further recurrences; a further 2 received RT for fungating relapses with good symptomatic relief. RT was only increasingly prescribed after 2004. Median follow-up in the RT group was 3.31 years, compared with 6.17 years in the no-RT group. In the RT group, 15 patients (68.2%) underwent mastectomy, versus 39 (58.2%) in the no-RT group. One patient in the RT group developed an infield local relapse, compared with 21 of 67 patients in the no-RT group. Multivariate model showed that RT decreased risk of locoregional failure (hazard ratio 0.12, 95% confidence interval [CI] 0.02-0.92, P = .04). Three-year locoregional recurrence-free survival was higher in the RT group, 92.3% (95% CI, 78.9-100) versus 73.3% (95% CI, 63.1-85.1) in the no-RT group (P = .03). There were no differences in 3-year survival. CONCLUSIONS: We recommend that adjuvant radiotherapy be discussed for malignant PT for local control, even after mastectomy.

Would Removal of All Ultrasound Abnormal Metastatic Lymph Nodes Without Sentinel Lymph Node Biopsy Be Accurate in Patients with Breast Cancer with Neoadjuvant Chemotherapy?

LESSONS LEARNED: Removal of sonographically abnormal (up to 3) metastatic clipped nodes, without sentinel lymph node biopsy, could accurately predict axillary status in breast cancer patients receiving neoadjuvant chemotherapy. ypT and the first clipped node status were statistically significant factors for nodal pathologic complete response. This novel approach requires validation in larger studies. BACKGROUND: In patients who have node-positive breast cancer, neoadjuvant chemotherapy could result in nodal pathologic complete response (pCR) and avoid an axillary lymph node dissection (ALND). Axillary staging, in such cases, can be performed using targeted axillary dissection (TAD) with a low false negative rate. However, identification of sentinel lymph nodes (SLNs) after chemotherapy can be difficult, and currently, it is the standard to remove only one clipped node in TAD. We aimed to determine if removal of all sonographically abnormal metastatic clipped nodes, without SLN biopsy, could accurately predict the axillary status post neoadjuvant chemotherapy. METHODS: Patients with breast cancer with one to three sonographically abnormal metastatic axillary nodes were prospectively recruited. Each abnormal node had histology and clip insertion before neoadjuvant chemotherapy. After chemotherapy, the patients underwent removal of clipped nodes using the Skin Mark clipped Axillary nodes Removal Technique (SMART) and ALND. RESULTS: Fourteen patients were recruited, having a total of 21 sonographically abnormal metastatic nodes, with nine, three, and two patients having 1, 2, and 3 malignant nodes clipped, respectively. Mean age was 55.5 years; 92.9% and 57.1% of patients had invasive ductal carcinoma and grade III tumors, respectively; and 35.7% patients achieved nodal pCR. The first clipped node predicted the axillary status with a false negative rate of 7.1%. Adding to this another second clipped node, the false negative rate was 0%. Pathologic tumor staging after neoadjuvant chemotherapy (ypT) (p = .0390) and the first clipped node pathological response status (p = .0030) were statistically significant predictors for nodal pCR. CONCLUSION: Removal of sonographically abnormal metastatic clipped nodes using SMART, without sentinel lymph node biopsy, could accurately predict axillary status. This finding needs validation in larger studies.

Diagnostic dilemma of micropapillary variant of mucinous breast cancer.

An elderly woman presented with an enlarging left breast lump. Breast imaging revealed a large suspicious mass associated with cystic components. Core biopsy however was non-diagnostic and only revealed necrotic papillary tissue. The patient then underwent excision of the lesion that revealed a large area of intracystic papillary ductal carcinoma in situ with a focus of micropapillary variant of mucinous cancer. This case describes how this rare subtype could present as necrotic papillary tissue on core biopsy, resulting in a diagnostic dilemma, which had not been previously reported. A literature review of this rare subtype was performed too.