Radial Scar at Percutaneous Breast Biopsy That Does Not Require Surgery.

BACKGROUND: Surgical excision is currently recommended after pathologic radial scar is found on breast core needle biopsy because surgical upgrade to carcinoma is not uncommon. The goal of our study was to identify the true pathologic upgrade rate for a "pure" radial scar, those without associated proliferative lesion, based on indication for biopsy, biopsy type, and needle size. STUDY DESIGN: The pathology database of Continuum Health Partners was searched for the terms radial scar and radial sclerosing lesion, from January 2007 to December 2015. From review of 1,513 pathology reports, 292 cases of core biopsies without malignancy were identified. Age, indication for biopsy, type of biopsy, and excisional pathology were obtained. Data were then analyzed using SPSS. RESULTS: Two hundred nineteen (75%) of the 292 core biopsies showed pure radial scar without associated proliferative lesion, and 161 (74%) of these patients had surgical excision. Only 1 of these patients had disease that was upgraded to ductal carcinoma in situ-a 2-mm focus located 5 mm away from the radial scar biopsy cavity. This patient also had residual calcifications on mammography after the stereotactic biopsy. Six additional malignant upgrades were found in patients who had radial scar associated with atypical ductal hyperplasia (n = 5) or lobular neoplasia (n = 1) on needle biopsy. CONCLUSIONS: Surgical excision is unnecessary when radial scar is found at percutaneous needle biopsy without an associated proliferative lesion. Surgical excision is still indicated when radial scar is associated with atypical ductal hyperplasia or lobular neoplasia.

The consequence of undertreatment of patients treated with breast conserving therapy for ductal carcinoma in-situ.

BACKGROUND: The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial. METHODS: A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies. RESULTS: Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor-positive tumors did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis (P = .374). CONCLUSIONS: A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.

Incidence of occult carcinoma and high-risk lesions in mammaplasty specimens.

Objectives. To determine the incidence and type of premalignant or malignant changes in mammaplasty specimens and to determine the incidence of these changes according to age distribution. Methods. Retrospective database review of patients who underwent a reduction mammaplasty between 1999 and 2009 was performed from pathology records at a single institution. Results. 700 patients were identified. Of the 644 patients who had bilateral reductions, 25 (4%) had significant pathologic findings. The likelihood of finding premalignant changes or cancer increased with advancing patient age (0.8 percent for patients <40 years old and 10 percent for patients >60 years old). Of the 56 patients who underwent unilateral mammaplasty, 12 patients (21%) had significant pathologic findings. The incidence of finding premalignant changes or cancer in this population also increased with advancing patient age (0 for patients <40 years old to 25 percent for patients >60 years old). Conclusions. When a unilateral mammaplasty is performed to match a breast reconstructed after cancer surgery, the likelihood of identifying premalignant changes or cancer increases more than fourfold. Therefore, one should consider additional radiologic imaging in the preoperative workup of patients with a history of carcinoma prior to undergoing unilateral mammaplasty.

The significance of lobular carcinoma in situ and atypical lobular hyperplasia of the breast.

BACKGROUND: The significance of lobular neoplasia (LN), lobular carcinoma in situ (LCIS) and atypical lobular hyperplasia (ALH)) found at core needle biopsy (CNB) of the breast remains uncertain. There is a consistent risk of underestimating malignancy after the diagnosis of LN on CNB. The aim of this study was to determine if patients with a CNB result of LN need surgical excision. METHODS: Patients were identified by searching the institutions pathology database for the terms "lobular carcinoma in situ" and "atypical lobular hyperplasia" over 20 years. Excluded from this study were those with core needle biopsy (CNB) results of ductal carcinoma in situ, atypical ductal hyperplasia, radial scar, or papilloma. Upgrade was defined as final surgical pathology of invasive carcinoma and/or ductal carcinoma in situ that was directly correlated to the site of the initial biopsy containing LN. RESULTS: LN was found at CNB in 285 patients, and 71 % (n = 201) had subsequent surgical excisions. All patients with pleomorphic LCIS (pLCIS) underwent surgical excision. Following patients with pLCIS, patients with the diagnosis of LCIS were most likely to undergo surgical excision (80 %). Final pathology of the surgically excised specimens confirmed LN in 72 % (n = 144). Also, 13 % (n = 26) of the operated patients were upgraded to malignancy, including 8 % of ALH and 19 % of LCIS cases. CONCLUSION: This is the largest series of surgical excisional pathology following LN on CNB ever reported. The likelihood of finding malignancy at surgical excision after CNB showing LN was 13 %. Patients with the diagnosis of LN on CNB should be considered for surgical excision.

The value of mammography within 1 year of conservative surgery for breast cancer.

INTRODUCTION: Guidelines for screening mammography have been established by numerous medical societies. Guidelines have not been established for follow-up mammography for patients who have been treated with breast-conserving surgery. Many radiologists recommend mammography of the treated breast 6 months after completion of treatment. The purpose of this study was to determine the value of interval mammography. METHODS: Patients were identified by searching the breast cancer database for the diagnoses of ductal carcinoma in situ, infiltrating ductal carcinoma and infiltrating lobular carcinoma. Postoperative mammogram dates and results were obtained. Patients with mammography within 8 months of surgery were included in the study. RESULTS: Ductal carcinoma in situ, infiltrating ductal carcinoma, and infiltrating lobular carcinoma were found in 1,000 patients who underwent breast-conserving surgery, and 789 patients had complete mammographic follow-up data available. Postoperative interval mammography was performed in 169 patients (21 %), including 23 patients who had preradiation mammography. Ninety percent of the interval mammograms were BI-RADS 1 to 3 and 10 % were BI-RADS 4 or 5. Two cancers were found on interval mammography (1.2 % of 169) and 4 of 620 (0.6 %) patients who did not have interval mammography were found to have malignancy within 1 year of surgery (1.2 % vs. 0.6 %, P = 0.614). The use of interval mammography was not related to the mammographic findings at diagnosis. Interval mammography did not affect local and distant disease-free survival. CONCLUSIONS: The likelihood of obtaining a significant finding on short interval follow-up mammography after conservative surgery for breast cancer is 1.2 %.

Traumatic stress symptoms and breast cancer: the role of childhood abuse.

OBJECTIVE: The present study investigated relations between reported childhood abuse and recent traumatic stress symptoms in women newly diagnosed with breast cancer (n=330). METHODS: As part of a larger ongoing study, patients from eight public and private hospitals were referred by their physicians and completed the Childhood Trauma Questionnaire (CTQ), and the Impact of Events Scale-breast cancer (IES), which measured breast cancer-related intrusive and avoidant symptoms. RESULTS: Emotional abuse, physical abuse, and sexual abuse were correlated with intrusive symptoms. Cancer-related avoidant symptoms approached significance in their relation to emotional and sexual abuse. Multivariate analysis, controlling for age and time since diagnosis, revealed that childhood emotional abuse was an independent predictor of breast cancer-related intrusive symptoms, but that childhood physical abuse and sexual abuse were not significant predictors. CONCLUSIONS: Childhood emotional, physical, and sexual abuse were associated with breast cancer-related intrusive symptoms. Emotional abuse uniquely predicted intrusive symptoms after controlling for other predictors. Results suggest that a cancer diagnosis may trigger cognitive and emotional responses that relate to patients' prior trauma experiences. PRACTICE IMPLICATIONS: Physicians and psychologists treating women with breast cancer should be aware that a history of childhood abuse may exacerbate patients' cancer-related intrusive symptoms. Interventions for women affected by both childhood abuse and breast cancer may be most effective when they address both stressors and associated emotional responses. Findings highlight the importance of additional research to explore links between prior trauma and distress following a cancer diagnosis stress.

Does oncotype DX recurrence score affect the management of patients with early-stage breast cancer?

BACKGROUND: Oncotype DX is a 21-gene assay that calculates a risk of distant recurrence in women with estrogen-receptor-positive, lymph node-negative breast cancer. The purpose of this study was to determine whether the results of Oncotype DX influence the decision to administer chemotherapy. METHODS: A retrospective study was performed on 85 consecutive patients with estrogen-receptor-positive, lymph node-negative breast cancer who had an Oncotype DX recurrence score (RS) obtained. Tumor size, tumor grade, and treatment were then compared within each risk category. Statistical analysis was performed using STATA software. RESULTS: Tumors that were high grade and Her-2/neu positive more frequently had a high RS. Treatment was changed as a result of Oncotype DX in 44% of patients. CONCLUSIONS: Oncotype DX RS is significantly related to tumor grade and Her2/neu status. In this study, the treatment of 44% of patients was altered as a consequence of Oncotype DX RS.

Reoperative sentinel lymph node biopsy in patients with locally recurrent breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is considered a standard of care in the staging of breast cancer. The objective was to examine our experience with reoperative SLNB. METHODS: We identified 19 patients in our breast cancer database who had a SLNB in the reoperative setting. All 19 patients had undergone previous breast-conserving surgery with either an axillary lymph node dissection or an SLNB. The reoperative sentinel lymph node (SLN) was identified using blue dye, radioisotope, or both. RESULTS: The SLN was identified in 84% of the reoperative cases. Of these successful cases, both blue dye and radioisotope were used in five cases, and radioisotope alone was used in 11 cases. Radioisotope identified the SLN in the 100% of successful SLNB cases (P = .0003). There were 3 unsuccessful cases in which blue dye and radioisotope failed to identify the sentinel node. CONCLUSIONS: Reoperative SLNB after previous axillary surgery is technically feasible.

A single institution review of new breast malignancies identified solely by sonography.

BACKGROUND: The role of sonography as a sole identifier of breast malignancy remains undetermined. Currently, the American College of Radiology Imaging Network (ACRIN) trial, protocol 6666, is accruing high risk patients, with dense breast tissue on mammography, to evaluate the performance of screening sonography. STUDY DESIGN: We conducted a retrospective single institution review to identify the detection rate of nonpalpable, mammographically occult breast malignancies identified solely by sonography. RESULTS: A total of 34,694 breast sonograms were performed at our outpatient radiology affiliate between April 1998 and April 2006. This number includes unilateral and bilateral examinations, and, 6-month followup examinations. Computerized databases and individual charts were retrospectively reviewed. Sonographic and mammographic findings were compared to determine concordance of identified lesions. Four thousand ninety-one ultrasound guided biopsies, (fine needle aspiration biopsy [FNA] and core needle biopsy [CNB]) were performed over the 8-year period, and 452 malignancies were identified. Discarded fluid contents of pure cyst aspirations were not included in this number. Seven percent (32) of the biopsy-proved malignancies were mammographically occult, of which 59% (19) were palpable, and 31% (10) were not palpable. Of all cancers diagnosed, 2.2% were identified solely by sonography. The number of cancers identified solely by sonography relative to the total number of sonograms done was 0.03%. CONCLUSIONS: Given these results, we advocate the selective use of sonography in appropriate populations, namely, in those with palpable findings, mammographic abnormalities, and in women with dense tissue who have personal or family history of breast cancer.

Significance of papillary lesions at percutaneous breast biopsy.

BACKGROUND: The management of nonpalpable papillary lesions found in specimens obtained by percutaneous breast biopsy is controversial. We reviewed the treatment of patients found to have papillary lesions by stereotactic, sonographic, or fine-needle aspiration breast biopsy to identify indications for surgical excision. METHODS: Consecutive patients with intraductal papilloma, atypical papilloma/papilloma with atypical ductal hyperplasia, papillary neoplasm, and papillomatosis according to percutaneous breast biopsy were identified from radiology records. The charts were reviewed to identify patients who had subsequent surgical excision, and the pathologic findings were correlated with the biopsy method and indications for surgery. RESULTS: Papillary lesions were found in 120 biopsy samples from 109 patients. Malignancy was found at operation in 19 (24%) of 80 lesions that underwent surgical excision: 12 (63%) were ductal carcinoma-in-situ, 4 (21%) were infiltrating ductal carcinoma, 2 (11%) were infiltrating papillary carcinoma, and 1 (5%) was intracystic papillary carcinoma. Malignancy was found in 9 (30%) of 30 fine-needle biopsy papillary lesions, 6 (35%) of 17 core biopsy papillary lesions, and 4 (12%) of 33 stereotactic biopsy papillary lesions. Malignancy was missed significantly less frequently with stereotactic biopsy (P<.05). CONCLUSIONS: Malignancy is frequently found at surgical excision for papillary lesions found on percutaneous breast biopsy. Malignancy is missed significantly less frequently with stereotactic biopsy.

Immunohistochemical staining for cyclin D1 and Ki-67 aids in the stratification of atypical ductal hyperplasia diagnosed on breast core biopsy.

A diagnosis of atypical ductal hyperplasia (ADH) after breast core biopsy usually is followed by an excisional biopsy to exclude the presence of a more significant lesion. To determine whether the immunohistochemical expression of cyclin D1 (CyD1) and Ki-67 can aid in case stratification for the likelihood of finding ductal carcinoma in situ (DCIS) on subsequent excision, we immunohistochemically stained 21 consecutive ADH cases diagnosed by core biopsy, and proliferation indices (PIs) were calculated for each case. Fluorescence in situ hybridization to detect CCND1 amplification was performed in 10 cases. In 5 cases, DCIS (with or without invasive carcinoma) was identified in the subsequent excision. The mean PICyD1 and PIKi-67 for these cases were significantly higher than in the remainder (P = .03 and P = .05, respectively). The sensitivities of PICyD1 and PIKi-67 for the presence of DCIS on subsequent excision were 100%, and the specificities were 75% and 69%, respectively. The specificity of the 2 markers combined was 88%. The number of cells with CCND1 amplification was higher in cases with DCIS or ADH on subsequent excision. Immunostaining for CyD1 and Ki-67 might help stratify cases of ADH on core biopsy and identify patients unlikely to have DCIS found on excision.

Drains Prevent Seromas Following Lumpectomy with Axillary Dissection.

Lumpectomy with axillary dissection for breast cancer is usually followed by at least an overnight stay in the hospital for drain management. We eliminated drains and discharged patients following lumpectomy and axillary dissection. A retrospective study of 80 consecutive patients from July 1, 1994, to June 30, 1995, formed the basis for this study. Drains were omitted in 20 consecutive patients discharged to home after undergoing lumpectomy with axillary dissection. This group was compared to the 62 previous patients who had 7 mm closed suction drains until the drainage was less than 25 ml/shift. Seroma formation occurred in 40% of the undrained patients compared to 6% of patients kept overnight in the hospital with a closed-suction drain (p < 0.001). Tumors were smaller and the number of nodes examined by the pathologists was fewer in the patients managed without drains. Patients developing seromas were older, heavier, and shorter than those who did not develop seromas. The use of a drain was related significantly to seroma formation in multivariate analysis.