Excision of breast fibroepithelial lesions: when is it still necessary?-A 10-year review of a regional centre.

PURPOSE: Fibroepithelial lesions (FEL) range from benign fibroadenoma (FA) to malignant phyllodes tumor (PT), but can be difficult to diagnose on core needle biopsy (CNB). This study assesses risk factors for phyllodes tumor (PT) and recurrence and whether a policy to excise FELs over 3 cm in size is justified. METHODS: Patients having surgery for FELs from 2009 to 2018 were identified. The association of clinical, radiology and pathological features with PT and recurrence were evaluated. Trend analysis was used to assess risk of PT based on imaging size. RESULTS: Of the 616 patients with FELs, 400 were identified as having FA on CNB and 216 were identified as having FEL with a comment of concern for phyllodes tumor (query PT, QPT). PT was identified in 107 cases; 28 had CNB of FA (7.0%), while 79 had QPT (36.6%). Follow-up was available for 86 with a mean of 56 months; six patients had recurrence of PT, all of whom had QPT on CNB. The finding of PT was associated with CNB of QPT, increasing age and size on multivariate logistic regression. All patients diagnosed with PT following CNB of FA had enlarging lesions with a mean size of 38.3 mm. CONCLUSIONS: Our data does not support routine excision of FELs based on size alone. All patients with QPT on CNB, regardless of size should consider excision due to high risk of PT and recurrence, and the decision to excise FAs to rule out PT should also consider whether the lesion is enlarging.

Measurements using mammography and ultrasonography underestimate the size of high-volume ductal carcinoma in situ.

BACKGROUND: Surgical decisions for ductal carcinoma in situ (DCIS) are based on lesion sizes. This study aims to determine the accuracy of pre-operative imaging in estimating the size of DCIS. METHODS: This was a retrospective review of clinicopathologic data of patients treated for DCIS with breast conserving surgery (BCS) between 2012 and 2018. Mammographic and sonographic lesion sizes were compared with final pathology sizes. RESULTS: For the 152 lesions visible on mammography, mean size on imaging was significantly smaller when compared to final pathology (2.3 vs. 3.6 cm, p < 0.001). The mean difference of 1.3 cm was a significant underestimation with a correlation coefficient of 0.367 (p < 0.001). For 48 sonographically visible lesions, the radiologic size was significantly smaller than pathologic size (1.7 vs. 4.1 cm, p < 0.001), but the degree of underestimation was not significantly correlated (p = 0.379). CONCLUSION: DCIS size was significantly underestimated by imaging. This must be taken into consideration during surgical planning.

Development and Prospective Validation of a Risk Calculator That Predicts a Low Risk Cohort for Atypical Ductal Hyperplasia Upstaging to Malignancy: Evidence for a Watch and Wait Strategy of a High-Risk Lesion.

BACKGROUND: Guidelines recommend surgical excision of atypical ductal hyperplasia (ADH) due to the concern of undersampling a potential malignancy on core needle biopsy (CNB). The purpose of this study was to determine clinical, radiological and pathological variables associated with ADH upstaging to cancer and to develop a predictive risk calculator capable of identifying women who have a low oncological risk of upstaging. METHODS: A prospectively collected database from a tertiary breast referral center was analyzed for women diagnosed with ADH on CNB between January 2013 to December 2017 who underwent surgical excision. CNB and surgical pathology reports were examined to determine rate of upstaging. The association between clinical, radiological and pathological variables were evaluated using regression analysis to determine predictors of ADH upstaging to cancer. Significant variables (p ≤ 0.05) identified on univariate analysis were assigned a score of "1" and were included in the ADH upstaging risk calculator. RESULTS: A total of 1986 patients underwent surgery for a high-risk lesion. We identified 318 (16.0%) patients who had ADH identified on their CNB who underwent surgery-of which 290 were included in our study. The upstage rate was 24.8%. Five variables were associated with upstaging and included in our calculator: (1) lesion > 5 mm on ultrasound; (2) lesion > 5 mm on mammogram; (3) one or more "high-risk" lesion(s) on CNB; (4) pathological suspicion for cancer and; (5) incomplete removal of calcifications on CNB. Patients with a score of 0 had a 2% risk of being upstaged to cancer and were deemed low risk with 17.2% of patients falling within this category. CONCLUSIONS: Patients with ADH on CNB can be stratified into a low oncological cohort who have a 2% risk of being upstaged to carcinoma. In the future, these select patients may be counselled and potentially offered observation as an alternative to surgery.

Pure flat epithelial atypia identified on core needle biopsy does not require excision.

BACKGROUND: Routine excision of flat epithelial atypia (FEA) of the breast found on core needle biopsy (CNB) is being questioned and a policy of selective excision of FEA was adopted in our area. The purpose of this study was to evaluate the upstage rate to malignancy across multiple diagnostic centers in our area following the policy of selective excision and to identify factors predictive of malignancy. METHODS: Patients having excision of CNB FEA at our regional Hospital between 2013 and 2017 were identified. The primary endpoint was upstage to malignancy after excision. We also assessed for clinical, radiological, and pathological features associated with malignancy. RESULTS: We identified 187 patients. Eighty-nine had pure FEA, 71 had concurrent ADH, and 18 had other pathological lesions. Following surgical excision, 9 patients were upstaged to malignancy (4. 8%) with 8 having concurrent ADH (2 invasive ductal carcinoma, 6 DCIS) and 1 with concurrent Complex Sclerosing Lesion (DCIS). None of the pure FEA cases upstaged. The presence of ADH or CSL in the CNB were the only factors found to be predictive of upstaging (p = 0.001, p = 0.0001 respectively). CONCLUSIONS: The upstage rate to malignancy after excision of pure FEA at out center is 0%. Therefore, we recommend that pure FEA with radiology and pathology concordance does not require surgical excision and can instead be followed with serial imaging. However, patients with FEA in association with other high-risk lesions should be managed as per indicated for the other high-risk lesion and FEA with ADH should be excised.

Is microductectomy still necessary to diagnose breast cancer: a 10-year study on the effectiveness of duct excision and galactography.

PURPOSE: Patients with spontaneous nipple discharge (SND) who have neither clinically palpable masses nor evidence of disease on imaging with mammogram and/or ultrasound are traditionally investigated with galactogram and duct excision. As breast imaging improves, it has raised the question whether galactography and microductectomy are necessary to diagnose breast cancer. The purpose of this study was to determine the incidence of malignancy in patients presenting with SND who underwent microductectomy and to evaluate the utility of duct excision and galactography in patients whose initial clinical and radiological evaluation were negative. METHODS: A 10-year retrospective study was conducted in British Columbia's largest tertiary breast referral center examining the clinical, radiological and pathological results for all patients who underwent a microductectomy procedure for SND between 2008 and 2017. RESULTS: A total of 231 microductectomies were performed and the overall incidence of malignancy was 13% (n = 32). Following initial work up, 155 patients (67%) had only discharge on exam and no radiologically suspicious findings of malignant disease. Of these patients, 14% (n = 21) were diagnosed with cancer by duct excision. Galactography yielded a sensitivity and specificity of 63% and 36%, respectively (PPV 15% and NPV 85%). Lastly, we found that 3% of patients (n = 8) initially diagnosed with benign disease later developed breast cancer. CONCLUSIONS: Patients with SND should continue to be evaluated with microductectomy to prevent missing a breast cancer. Moreover, we do not recommend performing galactography for diagnosing breast cancer due to poor sensitivity and specificity though it may assist in preoperative planning.

Prospective surveillance and targeted physiotherapy for arm morbidity after breast cancer surgery: a pilot randomized controlled trial.

OBJECTIVE: To evaluate prospective surveillance and targeted physiotherapy (PSTP) compared to education (EDU) on the prevalence of arm morbidity and describe the associated program cost. DESIGN: Pilot randomized single-blinded controlled trial. SETTING: Urban with assessments and treatment delivered in hospitals. PARTICIPANTS: Women scheduled for breast cancer surgery. INTERVENTIONS: Participants were randomly assigned (1:1) to PSTP ( n = 21) or EDU ( n = 20) and assessed presurgery and 12 months postsurgery. All participants received usual care, namely, preoperative education and provision of an education booklet with postsurgical exercises. The PSTP group was monitored for arm morbidity every three months and referred for physiotherapy if arm morbidity was identified. The EDU group received three education sessions on nutrition, stress and fatigue management. MAIN OUTCOME MEASURES: Arm morbidity was based on changes in the surgical arm(s) from presurgery in four domains: (1) shoulder range of motion, (2) strength, (3) volume, and (4) upper body function. Complex arm morbidity indicated ≥2 domains impaired. Second, the cost of the PSTP program was described. RESULTS: At 12 months, 18 (49%) participants (10 PSTP and 8 EDU) had arm morbidity, with EDU participants presenting more complex arm morbidity compared to PSTP participants. PSTP participants attended 4.4 of 5 assessments with 90% retention. The PSTP program cost was $150 covered by the Health Care Provider and the Patient Out-of-Pocket Travel cost was CAN$40. CONCLUSION: Our results suggest that PSTP is feasible among women with breast cancer for early identification of arm morbidity. A larger study is needed to determine the cost and effectiveness benefits.

Routine shave margins are not necessary in early stage breast cancer treated with Breast Conserving Surgery.

INTRODUCTION: Breast Conserving Surgery (BCS) is considered standard of care for women with early stage breast cancer. Between 20 and 50% of women treated with BCS will require re-operation for positive or close margins and it has been suggested that routine cavity shave margins may reduce the frequency of positive margins. METHODS: Retrospective chart review of a prospectively maintained surgical database of patients undergoing BCS for early stage breast cancer, at a single institution, between January 2012 and December 2015. Cohort was followed until June 2016 to capture re-operations. RESULTS: Among 2096 patients with stage 0-III breast cancers, 872 (42%) underwent primary mastectomies and 1224 (58%) underwent primary BCS. Margins were positive in 128 (11%) and close in 442 (36%). Re-operation rate for patients after BCS was 19%. CONCLUSION: A lower than predicted positive margin rate suggests that routine shave margins are not warranted at our institution.

Reduced Time to Breast Cancer Diagnosis with Coordination of Radiological and Clinical Care.

Introduction Diagnostic delays for breast problems is a current concern in British Columbia and diagnostic pathways for breast cancer are currently under review. Breast centres have been introduced in Europe and reported to facilitate diagnosis and treatment. Guidelines for breast centers are outlined by the European Society for Mastology (EUSOMA). A Rapid Access Breast Clinic (RABC) was developed at our hospital applying the concept of triple evaluation for all patients and navigation between clinicians and radiologists. We hypothesize that the Rapid Access Breast Clinic will decrease wait times to diagnosis and minimize duplication of services compared to usual care. Methods A retrospective review was undertaken looking at diagnostic wait times and the number of diagnostic centres involved for consecutive patients seen by breast surgeons with diagnostic workups performed either in the traditional system (TS) or the RABC. Only patients presenting with a new breast problem were included in the study. Results Patients seen at the RABC had a decreased time to surgical consultation (33 vs 86 days, p<0.0001) for both malignant (36 vs 59 days, p=0.0007) and benign diagnoses (31 vs 95 days, p<0.0001). Furthermore, 13% of the patients referred to the surgeon in the TS without a diagnosis were eventually diagnosed with a malignancy and waited a mean of 84 days for initial surgical assessment. Of the patients seen at the RABC, 5% required investigation at more than one institution compared to 39% patients seen in the TS (p<0.0001). Cancer patients had a shorter time from presentation to surgery in the RABC (64 vs 92 days, p=0.009). Conclusion The establishment of the RABC has significantly reduced the time to surgical consultation, time to breast cancer surgery, and duplication of investigations for patients with benign and malignant breast complaints. It is feasible to introduce a EUSOMA-based breast clinic in the Canadian Health Care System and improvements in diagnostic wait times are seen. We recommend the expansion of coordinated care to other sites.

Axillary reverse mapping in breast cancer: a Canadian experience.

BACKGROUND: The aim of this study was to evaluate the axillary reverse lymphatic mapping (ARM) procedure for reducing the risk of arm lymphedema after breast cancer surgery. METHODS: The ARM procedure was carried out with a subareolar injection of technetium-99 sulfur colloid the morning of surgery, and a patent blue dye injection into the upper inner arm after anesthesia. RESULTS: Fifty-two women made up our study population. Thirty-seven patients underwent sentinel lymph node biopsy (SLNB) and 15 patients underwent an axillary lymph node dissection (ALND) for known nodal metastasis. The sentinel lymph node was identified in 36 of the 37 cases who underwent SLNB alone and in 12 of 15 patients who underwent on ALND. In 13 patients, both blue and radioactive lymph nodes or lymphatics were clearly identified (25%) and 5 patients had a clear crossover with nodes being both blue and hot. Only a single patient with crossover lymphatics had metastases present in their sentinel node. CONCLUSION: The ARM technique did not prevent identification of the SLN and we identified much greater crossover than reported. We had a single patient, who underwent a sentinel node biopsy, with mild arm lymphedema (1.9%) after 2 years of follow up.

Utility of screening for blunt vascular neck injuries with computed tomographic angiography.

PURPOSE: To prospectively study the impact of implementing a computed tomographic angiography (CTA)-based screening protocol on the detected incidence and associated morbidity and mortality of blunt vascular neck injury (BVNI). METHODS: Consecutive blunt trauma patients admitted to a single tertiary trauma center and identified as at risk for BVNI underwent admission CTA using an eight-slice multi-detector computed tomography scanner. The detected incidence, morbidity, and mortality rates of BVNI were compared with those measured before CTA screening. A logistic regression model was also applied to further evaluate potential risk factors for BVNI. RESULTS: A total of 1,313 blunt trauma patients were evaluated. One hundred seventy screening CTAs were performed, of which 33 disclosed abnormalities. Twenty-three were evaluated angiographically, of which 15 were considered to have significant BVNIs, as were 4 of the 10 patients with abnormal CTAs and no angiogram. The incidence of angiographically proven BVNIs in our series was 1.1%. If four patients who were treated for BVNIs based on CTA alone are included, the incidence rises to 1.4%. This is significantly higher than the 0.17% incidence before screening (p < 0.001). In addition, the delayed stroke rate and injury-specific mortality fell significantly from 67% to 0% (p < 0.001) and 38% to 0% (p = 0.002), respectively. Overall mortality also fell significantly, from 38% to 10.5% (p = 0.049). Univariate logistic regression identified the presence of cervical spine injury as a significant predictor of BVNI (p < 0.001). CONCLUSION: CTA screening increases the detected incidence of BVNI 8-fold, with rates similar to angiographically based screening protocols. CTA screening significantly decreases BVNI-related morbidity and mortality in an efficient manner, underlying its utility in the early diagnosis of this injury.

Geriatric trauma: resource use and patient outcomes.

INTRODUCTION: Elderly patients who suffer trauma have a higher mortality and use disproportionately more trauma resources than younger patients. To compare these 2 groups and determine the outcomes and characteristics of elderly patients, we reviewed patients in these 2 groups admitted and treated in our tertiary care provincial trauma centre. METHODS: From the provincial trauma registry we selected a cohort of 40 geriatric patients (group 1) (> or = 65 yr of age) with an ISS of 16 or more who were admitted to and spent time in our trauma service for more than 48 hours and compared them with a similar randomly selected cohort of 44 patients (group 2) aged 20-30 years. Family physicians were contacted for follow-up of these patients 2 years after discharge. We considered length of hospital stay, complications, disposition of the patients and use of consultation services. RESULTS: Patients in group 1 had a mean age of 72.1 years (range from 65-98 yr) and a mean ISS of 27.3 (range from 17-50). Patients in group 2 had a mean age of 26.3 years (range from 22-29 yr) and a mean ISS of 26.3 (range from 17-54). Hospital stay was significantly longer in the group 1: 34.5 days (95% confidence interval [CI]: 24-44 d) versus 21.6 days (95% CI: 15-28 d). More elderly patients experienced complications (35 v. 13, p < 0.001) and required medical consultations (35 v. 26, p < 0.001). In-hospital death rates were 8% (3 of 40) and 4% (2 of 44) respectively (p = 0.3). Fewer geriatric patients could be discharged home (35% [14 of 40] v. 27% [22 of 44], p = 0.056) or to rehabilitation facilities (28% [11 of 40] v. 34% [15 of 44], p = 0.3). Five geriatric patients were discharged to nursing homes (p = 0.007). Of the geriatric patients discharged to rehabilitation facilities or home, 75% were independent 2 years after discharge. CONCLUSIONS: Aggressive care for geriatric trauma patients is warranted, and resources should be directed toward rehabilitation. Based on our findings, we expect that creating a directed care pathway for these patients, targetting complications and earlier discharge, will further improve their outcomes.

Blunt vascular neck injuries: diagnosis and outcomes of extracranial vessel injury.

BACKGROUND: Blunt vascular neck injuries (BVNIs) are rare, often occult, and potentially devastating injuries. The purpose of this study was to identify a high-risk group, which would benefit from screening. METHODS: Patients with BVNIs were identified from our trauma registry and charts were reviewed. Potential risk factors for BVNI were evaluated by univariate and multivariate logistic regression. RESULTS: Thirty-one BVNIs were identified in 22 patients. The stroke rate was 60% and the mortality rate was 25%. Univariate analysis showed Glasgow Coma Scale score < or = 8, head injury (Abbreviated Injury Scale [AIS] score > or = 3), basal skull fracture, facial injury, other neck injury, thorax injury (AIS score > or = 3), abdominal injury, and cervical spine injury to be significant (p < 0.05). The multivariate predictive model had two predictors remaining significant: thorax injury (AIS [thorax] score > or = 3) and Glasgow Coma Scale score < or = 8. CONCLUSION: Screening should be undertaken for patients at increased risk for BVNI: those with risk factors identified in our regression analysis and factors previously reported.

Identifying patients at risk for intracranial and extracranial blunt carotid injuries.

BACKGROUND: Blunt carotid injuries are rare, often occult, and potentially devastating. Angiographic screening programs have detected this injury in up to 1% of blunt trauma patients. Implementing a liberal angiographic screening program at our hospital is impractical and we want to identify a high-risk group to target for screening. We hypothesize that intracranial and extracranial carotid injuries have different risks, presentations, and outcomes. METHODS: Patients with intracranial and extracranial carotid injuries were identified from the British Columbia trauma registry. Presentation and outcome were reviewed. To facilitate statistical modeling the analysis was done by matching cases to 5 randomly selected controls. Risk factors for injury were evaluated by univariate and multiple logistic regression. RESULTS: A total of 35 carotid injuries were identified. Thirteen intracranial injuries were identified in 10 patients. Twenty-two extracranial injuries were identified in 18 patients. Sixty-seven percent of patients with intracranial injuries and 31% of those with extracranial injuries died (P = 0.11). Eleven percent of intracranial injuries and 56% of extracranial injuries were occult (P = 0.04). Glasgow outcome scores were 2.04 intracranial and 3.12 extracranial (P = 0.18). For intracranial injuries the multiple variable predictive model had two predictors: Glasgow Coma Score or =3). CONCLUSIONS: Intracranial injuries were frequently detected on initial investigations and have very poor outcomes. Extracranial injuries were more frequently occult and stand to benefit from early detection by screening programs. As independent risk factors for these two injuries differ, limited screening resources should focus on risk factors for occult extracranial injury: namely, low GCS and significant thoracic injury.