Lymphoscintigraphy and Single-Photon Emission Computed Tomography (SPECT)/CT to Determine Need for Second Sentinel Lymph Node Biopsy for Breast Cancer Recurrence Following Ipsilateral Breast/Axillary Surgery.

BACKGROUND For patients with cN0 breast cancer, sentinel node biopsy (SNB) is performed to confirm metastasis. When cancer recurs after a breast/axillary surgery, performing a second SNB is debatable in terms of its accuracy and significance. However, SNB is often performed because it is less invasive and can provide significant information. This report describes our experience of performing lymphoscintigraphy and single-photon emission computed tomography (SPECT)/CT to determine whether SNB is informative or not in patients who develop ipsilateral breast tumor recurrence (IBTR) following a breast/axillary surgery. CASE REPORT We included 9 patients with breast cancer and a history of ipsilateral breast/axillary surgery who underwent lymphoscintigraphy and SPECT/CT between April 2020 and July 2023. For lymphoscintigraphy, 20-25 MBq of 99mTc-phytate was injected subcutaneously in the areola, and planar images and SPECT/CT were taken at 15 min and 3 h after the injection. In lymphoscintigraphy, radioisotope accumulation was detected in 2 patients at 15 min and 8 patients at 3 h; it was not detected in 1 patient. The accumulation site was only the axilla in 3 patients; other sites including the axilla in 3, and sites outside the axilla in 2. CONCLUSIONS When a patient who previously underwent breast/axillary surgery develops IBTR, the initial surgery may have altered the lymphatic flow. The lymphatic flow varied between the contralateral or ipsilateral internal mammary lymph nodes, contralateral axilla, multidirectional flow, and the axilla alone. Lymphoscintigraphy and SPECT/CT may be useful for early determination of the need for another SNB.

Effectiveness of Changing the Class of Molecularly Targeted Agent after Disease Progression during Initial Molecularly Targeted Therapy for Luminal Advanced/Metastatic Breast Cancer.

BACKGROUND: The emergence of molecularly targeted agents (MTAs) has altered the treatment landscape for hormone receptor-positive (HR+), human epidermal growth factor 2-negative (HER2-) advanced breast cancer (ABC) /metastatic breast cancer (MBC). Multiple guidelines recommend molecularly targeted therapy as first-line treatment for HR+/HER2- ABC/MBC. However, optimal treatment for disease progression during MTA therapy remains undetermined. This study evaluated the suitability of different MTA types for this patient subgroup. METHODS: In this retrospective study, we analyzed the electronic health records of 56 patients with HR+/HER2- ABC/MBC receiving treatment with palbociclib, abemaciclib, or everolimus in our center between April 2014 and June 2021. RESULTS: Overall, 39, 14, and 35 regimens using palbociclib, abemaciclib, and everolimus, respectively, were identified. Three and 53 patients were premenopausal and postmenopausal, respectively. MTAs were included in the 1st-11th lines of treatment. Time to failure (TTF) was significantly different among the three MTAs. In contrast, TTF did not significantly differ among the 50 regimens that included CDK4/6 inhibitors, with/without prior mTOR inhibitor use, and the 35 regimens that included mTOR inhibitors, with/without prior CDK4/6 inhibitor use. CONCLUSIONS: The sequential use of different MTA classes did not affect the TTF of another MTA. mTOR inhibitor + exemestane is a favorable treatment option after CDK4/6 inhibitor + hormone therapy, and CDK4/6 inhibitor + hormone therapy is suitable for patients previously treated with mTOR inhibitor + exemestane. Although this study was retrospective and conducted at a single center, the present findings are useful for treatment selection in clinical practice.

Molecular Targeted Therapy for Hormone Receptor-Positive, Human Epidermal Growth Factor 2-Negative Metastatic Breast Cancer in Clinical Practice.

BACKGROUND: The emergence of molecular targeted therapies (MTTs) has altered the treatment landscape for hormone receptor-positive (HR+), human epidermal growth factor 2-negative (HER2-) metastatic breast cancer (MBC). The objective of this study was to describe treatment patterns, clinical outcomes, and safety profiles for patients with HR+/HER2- MBC treated with palbociclib, abemaciclib, or everolimus in clinical practice. METHODS: Forty-five patients with HR+/HER2- MBC were enrolled; 40 received MTT as the third line or later and 5 received MTT as the first/second line. The results were compared with those of clinical trials. RESULTS: Median overall progression-free survival (PFS) was 5.3 months (95% confidence interval [CI] 2.8-8.4), and PFS was similar for patients receiving first/second line (5.5 months, 95% CI 1.8-) and third line or later (5.1 months, 95% CI 2.8-9.4) treatments. Eleven patients continued with the same regimen for >1 year; treatment is ongoing for 15 patients. In 23 patients (51%), everolimus was administered before cyclin-dependent kinase (CDK) 4/6 inhibitors. The most frequent grade 3 or worse adverse event (AE) with CDK4/6 inhibitors was neutropenia, whereas grade 3 or worse AEs with everolimus were Pneumocystis pneumonia, sepsis, and stomatitis. CONCLUSIONS: MTT was mostly used in third or later lines, and PFS was similar for patients receiving first/second line and third or later line treatments. However, this study included heavily treated patients and a small number of cases. Treatment options should consider maximal patient benefit, as indicated by the results of clinical trials.

Breast cancer hormone receptor negativity, triple-negative type, mastectomy and not receiving adjuvant radiotherapy were associated with axillary recurrence after sentinel lymph node biopsy.

BACKGROUND: Axillary lymph node dissection (ALND) can be avoided in selected patients with positive sentinel lymph nodes (SLNs). However, regional lymph node recurrence may occur after SLN biopsy (SLNB). This study aimed to identify the risk factors for axillary recurrence to ensure safe axillary surgery. METHODS: Between June 2004 and December 2017, a total of 1056 women underwent SLNB without ALND. Patient data were prospectively entered into the breast cancer database at Kawaguchi Municipal Medical Center. From October 2012, we did not perform ALND in patients with (a) 1 or 2 positive SLNs, (b) positive SLNs that were unmatted or did not show gross extra nodal extension, (c) a clinical tumor size ≤5 cm, and in (d) those who received adjuvant endocrine therapy or chemotherapy and radiotherapy. Subsequently, appropriate adjuvant systemic and/or radiation treatment was administered. RESULTS: Of the 1056 patients included, 996 had negative SLNs, 49 had positive SLNs, and 11 had undetectable SLNs. The identification rate for SLNs was 99.0%, and the median number of removed SLNs was 2. During the median 6.9-year follow-up period, 10 patients (1.0%) showed axillary recurrence without SLNs metastasis. Hormone receptor negativity (p < 0.01), triple-negative type (0.047), mastectomy (<0.01) and not receiving adjuvant radiotherapy (<0.01) were significantly related to axillary recurrence. CONCLUSION: ALND can be safely avoided in selected patients with early breast cancer. Patients with hormone receptor-negative tumors, especially triple-negative breast cancer, patients who underwent mastectomy without ALND or those who did not receive adjuvant radiotherapy should be followed up carefully.

Differentiating vacuum-assisted breast biopsy from core needle biopsy: Is it necessary?

Needle biopsy has replaced excisional biopsy as a definitive diagnostic technique for breast tumours, although excisional biopsy is still used for complete tumour removal for therapeutic and/or diagnostic purposes. Many vacuum-assisted breast biopsy (VAB) systems have been made available by several manufacturers since the release of the Mammotome (MMT) by Johnson & Johnson in 1995. Several recent discussions have been conducted to identify whether core needle biopsy (CNB) or VAB, is more appropriate. However, currently available VAB systems differ from the conventional system (i.e. articulate arm type 11-gauge(G) MMT), and the characteristics of both CNB and VAB have been improved. In CNB, a 14-G needle is frequently used to obtain a larger sample. By contrast, VAB is considered easier to perform because it uses a thinner needle and a lighter, non-tethered system. When differentiating CNB from VAB, the type of VAB should also be defined. In this review, we discuss the characteristics of ultrasonography-guided VAB and CNB with a focus on practical issues such as the number of samples and volume of tissue obtained during ultrasonography-guided needle biopsy.

Spontaneous breast cancer remission: A case report.

INTRODUCTION: Spontaneous breast cancer remission is a rare phenomenon. We report the disappearance from the remaining breast of a new primary carcinoma that had been confirmed through cytology of a pathological specimen, in a case that is strongly suspected to be spontaneous remission. PRESENTATION OF CASE: A 44-year-old woman underwent breast-conserving surgery for a tumor located on the border between the upper-outer and lower-outer quadrants of the left breast (T2, N1, M0; Stage IIB). Eleven years after surgery, computed tomography indicated a mass in the upper-inner quadrant of the left breast. Excisional biopsy was initially planned for treatment following the definitive diagnosis because cytology revealed malignancy. The patient had noticed tumor regression one month after fine-needle aspiration and repeat ultrasonography performed the day before excisional biopsy confirmed the tumor reduction. On pathological examination, no tumor cells were observed in the mass. DISCUSSION: There was a discrepancy between FNA cytology and pathological diagnosis in our patient. The cytological findings indicated malignancy, but the pathological findings did not. When a tumor's pathological diagnosis is not malignant even though its FNA cytology diagnosis was malignant, sampling error, cytological over-diagnosis or some other error may have occurred. In this case, however, these were not detected. Because fibrosis was visible on pathological examination, we believe that these events corresponded to spontaneous remission. CONCLUSION: We report a rare case of spontaneous remission in which the cancer disappeared on pathological examination although the cytological diagnosis had been malignant.

Significance of fine needle aspiration cytology and vacuum-assisted core needle biopsy for small breast lesions.

BACKGROUND: In recent years, pathological diagnoses have been increasingly required, especially in small breast lesions, because malpractice lawsuits concerning erroneous cytological diagnoses have been commonly reported. Here, we retrospectively evaluated the significance of FNAC and VAB for small breast lesions using ultrasonography guidance. PATIENTS AND METHODS: A total of 1383 cases for which ultrasonography-guided VAB was performed between June 1996 and December 2012 were reviewed. Of these, 455 small breast lesions (239 nonpalpable and 216 nonmass lesions) were included in the study. RESULTS: Ultrasonography-guided FNAC was performed before VAB in 248 cases (54.5%). In 133 cases (53.6%), the results of FNAC were inconclusive. Pathological examinations using VAB revealed malignant and benign lesions in 199 and 256 cases, respectively. Of the 256 benign cases, we performed excisional biopsy in 17 cases (6.6%) and repeated VAB in 8 cases (3.1%). Excisional biopsy revealed malignant lesions in 2 cases. The reason for excisional biopsy was overdiagnosis using FNAC in 6 cases (35%). In all cases of repeated VAB, the pathological diagnosis was benign. The reason for repeated VAB was excision of the lesions in 5 cases (62.5%). The false positive and false negative rates of FNAC were 16.7% and 3.4%, respectively, whereas those of VAB were 0% and 1.0%, respectively. CONCLUSION: Cytology findings for small breast lesions should be considered only when imaging and cytology indicate benign lesions. Therefore, pathological examination without cytological examination should be the initial approach.

Diagnostic imaging strategy for MDCT- or MRI-detected breast lesions: use of targeted sonography.

BACKGROUND: Leading-edge technology such as magnetic resonance imaging (MRI) or computed tomography (CT) often reveals mammographically and ultrasonographically occult lesions. MRI is a well-documented, effective tool to evaluate these lesions; however, the detection rate of targeted sonography varies for MRI detected lesions, and its significance is not well established in diagnostic strategy of MRI detected lesions. We assessed the utility of targeted sonography for multidetector-row CT (MDCT)- or MRI-detected lesions in practice. METHODS: We retrospectively reviewed 695 patients with newly diagnosed breast cancer who were candidates for breast conserving surgery and underwent MDCT or MRI in our hospital between January 2004 and March 2011. Targeted sonography was performed in all MDCT- or MRI-detected lesions followed by imaging-guided biopsy. Patient background, histopathology features and the sizes of the lesions were compared among benign, malignant and follow-up groups. RESULTS: Of the 695 patients, 61 lesions in 56 patients were detected by MDCT or MRI. The MDCT- or MRI-detected lesions were identified by targeted sonography in 58 out of 61 lesions (95.1%). Patients with pathological diagnoses were significantly older and more likely to be postmenopausal than the follow-up patients. Pathological diagnosis proved to be benign in 20 cases and malignant in 25. The remaining 16 lesions have been followed up.Lesion size and shape were not significantly different among the benign, malignant and follow-up groups. CONCLUSIONS: Approximately 95% of MDCT- or MRI-detected lesions were identified by targeted sonography, and nearly half of these lesions were pathologically proven malignancies in this study. Targeted sonography is a useful modality for MDCT- or MRI-detected breast lesions.

Successful use of multi-detector row computed tomography for detecting contralateral breast cancer.

OBJECTIVE: We retrospectively evaluated whether multi-detector row computed tomography (MDCT) could contribute to the early detection of contralateral breast cancer in women with a diagnosis of breast cancer and no suspicious lesions on a mammogram or an ultrasonogram of the contralateral breast. METHODS: A total of 518 women with newly diagnosed unilateral breast cancer underwent MDCT. Multi-detector row CT was performed using a 16-detector row CT scanner set for 2-mm collimation, 120 kilovolt (peak), and 180 mA. Axial images of the contralateral breast were evaluated. RESULTS: Four hundred fifty-nine women were eligible for this study. There were suspicious malignant lesions only on MDCT in 21. Multi-detector row CT contributed to the diagnosis of contralateral occult breast cancer in 12 women (2.6%), including 1 in whom breast cancer was later diagnosed at another institution. CONCLUSIONS: Multi-detector row CT has a potential role in detecting contralateral breast cancer in women who are at high risk.

Evaluation and indications of ultrasound-guided vacuum-assisted core needle breast biopsy.

BACKGROUND: The Mammotome is a diagnostic tool used under stereotactic or with ultrasound guidance. A clear indication for Mammotome use under stereotactic guidance is when a non-palpable microcalcification is a target. However, the indications for the use of the Mammotome under ultrasound guidance vary among institutions, and it is difficult to find a place for the Mammotome among conventional biopsy techniques. The Mammotome biopsy has been available in our hospital since July 1999. We assessed the effectiveness and indications of ultrasound-guided Mammotome biopsy. METHODS: We performed Mammotome biopsies in 433 cases requiring histological diagnosis from July 1999 to September 2006, using an 11-gauge articulated arm-type Mammotome under ultrasound guidance. There were 377 mass lesions including 83 non-palpable cases and 56 hypoechoic lesions. RESULTS: The indications for Mammotome biopsy were 162 cases with inconsistent fine needle aspiration (FNA) and imaging findings, 114 cases indeterminate by FNA, 68 cases of an identified pathological type before neoadjuvant chemotherapy and confirmation of hormone receptor status, 36 inadequate cases by FNA, 20 cases of confirmation of fibroadenoma and other benign tumors, 8 removal cases of fibroadenoma, 8 microcalcification cases, and 17 others. The target lesion was obtained in 99.5% of the cases. CONCLUSIONS: Ultrasound-guided Mammotome biopsy is an accurate and useful diagnostic method that enables sufficient amounts of tissue to be obtained with minimal invasion and few complications. The Mammotome is the first choice for obtaining a definitive pathological diagnosis in breast lesions.