Factors associated with MRI detection of occult lesions in newly diagnosed breast cancers.

BACKGROUND: The use of preoperative magnetic resonance imaging (MRI) for newly diagnosed breast cancer remains controversial. We examined factors associated with detection of occult multicentric, multifocal, and contralateral malignant lesions only seen by MRI. METHODS: We performed a retrospective analysis of consecutive patients undergoing preoperative MRI for breast cancer. Clinicopathologic data were assessed regarding the findings of multifocality, multicentricity, and the presence of contralateral lesions. We analyzed the association of factors with these findings on MRI. RESULTS: Of 857 patients undergoing MRI, 770 patients met inclusion criteria. Mean age was 54.7 years. Biopsy-proven detection rates by MRI for multifocal, multicentric, and contralateral cancers were 6.2% (48 of 770), 1.9% (15 of 770) and 3.1% (24 of 770), respectively. African American race and heterogeneously or extremely dense mammographic density were associated with multifocal cancers on MRI. Larger lesion size and mammographic density were associated with multicentric cancers. Invasive lobular carcinoma (ILC) and progesterone receptor (PR)-positivity were associated with contralateral cancers. CONCLUSIONS: African American race, heterogeneously or extremely dense mammographic density, ILC, and PR-positivity were associated with additional biopsy-proven cancers based on MRI. These factors should be considered when assessing the clinical utility of preoperative breast MRI.

Clinical findings and outcomes of MRI staging of breast cancer in a diverse population.

BACKGROUND: The performance of magnetic resonance imaging (MRI), the effect of patient factors, and resulting surgical management in underserved and ethnically diverse breast cancer (BC) patient populations have been understudied. METHODS: We retrospectively analyzed the data of 1116 consecutive patients who were newly diagnosed with in situ or invasive BC with preoperative staging MRI. Non-index lesions (NILs) were defined as abnormal MRI findings with BI-RADS score of 4 or 5 in breast or axillary nodes not previously detected by conventional imaging. Occult cancers (OCs) were NILs found to be malignant by biopsy or surgery. Logistic regression was used to examine associations between probabilities of NILs or OCs and patient characteristics. RESULTS: Staging MRI detected NILs and OCs in 24% and 7.5% of patients, respectively. Of 1116 patients, 271 (24%) had 327 NILs, and 84 (7.5%) had 87 OCs. Follow-up information was available for 306 NILs. Ipsilateral breast NILs (n = 124) were seen in 115 patients (10.3%), with OCs (n = 51) seen in 48 patients (4.4%). Contralateral breast NILs (n = 134) were seen in 118 (10.6%) patients, with OCs (n = 20) seen in 20 patients (1.8%). Laterality (p < 0.001) and disease stage (p = 0.018) were associated with probability of OC. Patients without BRCA mutations had a significantly higher probability of having NILs (p = 0.003) but not OCs. CONCLUSIONS: Our study provides useful estimates of the rates of NILs and OCs anticipated in a younger, uninsured, ethnically diverse population. Prospective trials and larger pooled retrospective analyses are needed to define the long-term impacts of MRI staging after a BC diagnosis.

Inflammatory Breast Cancer Outcomes in a Contemporary Series.

BACKGROUND: Evidence on the management of inflammatory breast cancer (IBC) is limited. This study investigated factors influencing IBC treatment outcomes such as event-free survival (EFS) and overall survival (OS). MATERIALS AND METHODS: Data were collected from 173 patients with stage III non-IBC and 17 patients with IBC diagnosed at the Keck Medical Center and Los Angeles County and University of Southern California (LAC+USC) Medical Center. Cox proportional hazard regression evaluated associations between variables significant for EFS and OS. RESULTS: On multivariate analysis, negative estrogen receptor (ER)status [hazard ratio (HR)=1.88, 95% confidence interval (CI)=1.11-3.18, p<0.06) and lack of postoperative radiation treatment (HR=2.07, 95% CI=1.03-4.15, p<0.04) were significant for poorer EFS. High Scarff-Bloom-Richardson (SBR) score (HR=2.24, 95% CI=0.79-6.36, p<0.13) and lack of postoperative radiation treatment to the breast (HR=4.39, 95% CI=0.39-49.55, p<0.23) were associated with lower rates of OS. CONCLUSION: The diagnosis of IBC has a significantly worse prognosis. Receipt of post-mastectomy radiation therapy was a significant predictor of better EFS and OS.

Liver transplantation for metastatic neuroendocrine tumors: Outcomes and prognostic variables.

BACKGROUND: Patient selection for liver transplantation for metastatic neuroendocrine tumors remains a topic of debate. There is no established MELD exception, making it difficult to obtain donor organs. METHODS: A multicenter database was created assessing outcomes for liver and multivisceral transplantation for metastatic neuroendocrine tumors and identifying prognostic factors for survival. Demographic, transplant, primary tumor site and management, pathology, recurrent disease and survival data were collected and analyzed. Survival probabilities were calculated using the Kaplan-Meier method. RESULTS: Analysis included 85 patients who underwent liver transplantation November 1988-January 2012 at 28 centers. One, three, and five-year patient survival rates were 83%, 60%, and 52%, respectively; 40 of 85 patients died, with 20 of 40 deaths due to recurrent disease. In univariate analyses, the following were predictors of poor prognosis: large vessel invasion (P < 0.001), extent of extrahepatic resection at liver transplant (P = 0.007), and tumor differentiation (P = 0.003). In multivariable analysis, predictors of poor overall survival included large vessel invasion (P = 0.001), and extent of extrahepatic resection at liver transplant (P = 0.015). CONCLUSION: In the absence of poor prognostic factors, metastatic neuroendocrine tumor is an acceptable indication for liver transplantation. Identification of favorable prognostic factors should allow assignment of a MELD exception similar to hepatocellular carcinoma.

Lymph node status in inflammatory breast cancer.

Positive lymph node status in breast cancer is known to be an adverse prognostic factor, but the effect of lymph node (LN) status in inflammatory breast cancer (IBC) has not been evaluated. This study was designed to investigate the association between lymph node status and overall survival (OS) in individuals with IBC. Using the Surveillance, Epidemiology, and End Results (SEER) 18 registry, we collected data on 761 patients diagnosed with non-metastatic IBC from 2004 to 2008. Survival analysis was performed using the Kaplan-Meier method. Cox proportional hazard regression was performed to evaluate univariate and multivariate associations between estrogen and progesterone receptor (ER/PR) status, treatment, and OS. Positive nodal status was associated with a significant decrease in OS (p < 0.001). Five-year survival for LN-positive and LN-negative patients was 49 and 66 %, respectively. In node-positive patients, ER or PR positivity was associated with improved OS, (p = 0.025, p = 0.007). In node-positive patients, the combination of surgery and radiation therapy improved OS when compared with surgery alone (p = 0.002). Nearly 80 % of the patients in this study had nodal metastasis. Positive nodal status was found to be an adverse prognostic factor. ER/PR positivity and treatment with surgery and radiation in node-positive patients was found to improve outcomes. Further studies are required to characterize the biology of IBC and guide the optimal treatment of this disease.

Molecular markers for breast cancer diagnosis, prognosis and targeted therapy.

Precision medicine involves understanding the molecular drivers unique to an individual patient's cancer so that specific factors may be targeted with the goal of improved patient outcomes. The purpose of this article is to review standard of care and research grade (non-standard of care) biomarkers in breast cancer that may be useful for diagnosis, prognosis and targeted therapy.

Malignancy rates after surgical excision of discordant breast biopsies.

BACKGROUND: Vacuum-assisted core-needle biopsy (VAB) is increasingly used to perform breast biopsies instead of automated-gun core-needle biopsy (CNB). The significance of discordance between radiologic and pathologic findings has not been well established in the era of VAB predominance. This retrospective study was conducted to determine the rate of malignancy after surgical excisional biopsy (EXB) of these lesions at our two institutions. MATERIALS AND METHODS: We reviewed medical records from January 2008-June 2013 to identify female patients who underwent EXB for a Breast Imaging-Reporting and Data System (BI-RADS) 4 or 5 lesions found to be benign and discordant on CNB. Clinicopathologic data were gathered, and analysis was performed using descriptive statistics. RESULTS: A total of 8081 core biopsies were performed in the study timeframe. Six of 81 (7.4%) patients who had an EXB for a benign discordant breast lesion were found to have malignant pathology (two invasive, four in situ). Four of 63 (6.3%) lesions originally biopsied by VAB were upgraded, compared with 2 of 17 (11.8%) originally biopsied by CNB. There were no statistically significant differences in the rates of upgrade to malignancy when data were stratified by BI-RADS score or method of biopsy. CONCLUSIONS: The overall rate of malignancy after EXB of benign discordant lesions was 7.4%. Despite the widespread adoption of VAB, EXB is still warranted for clarification of discordant radiologic-pathologic findings.

Endoscopic sedation in the United States: results from a nationwide survey.

OBJECTIVES: The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to provide national and regional data on endoscopic sedation and monitoring practices within the United States. METHODS: A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide. RESULTS: A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001). CONCLUSIONS: During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.