Axillary nodal burden in primary breast cancer patients with positive pre-operative ultrasound guided fine needle aspiration cytology: management in the era of ACOSOG Z011.

INTRODUCTION: Recent years have seen a dramatic shift to more conservative management of the axilla in patients with a positive sentinel lymph node biopsy (SLNB). Identification of nodal disease with positive pre-operative ultrasound guided axillary fine needle aspiration cytology (AUS/FNAC) may represent a higher axillary disease burden mandating an axillary clearance and thus an upfront SLNB may be avoided. The aims of this study were to quantify nodal burden in patients with positive pre-operative AUS/FNAC and identify patients who may have been able to avoid an axillary clearance (ALND) based on ACOSOG Z011 criteria. METHODS: A retrospective review of a prospectively maintained database identified patients with positive pre-operative AUS/FNAC between 2007 and 2012. Core biopsies were excluded. Demographic and tumour characteristics were analysed. Eligibility for ACOSOG Z011 criteria was assessed and patients who may have avoided ALND were identified. RESULTS: 432 patients were identified with positive AUS/FNAC. 85 patients were excluded leaving 347 for analysis. Median age was 56 years (22-87), median tumour size was 25 mm (1.5 mm-150 mm) and median tumour pathology was grade 3 (50%) and invasive ductal carcinoma (82%). Median number of nodes removed at ALND was 23 (1-55) with a median number of positive nodes being 4 (1-47). 134 (39%) patients had ≤2 positive nodes identified on ALND making them eligible for the ACOSOG Z011 study. When other ACOSOG Z011 exclusion factors were applied only 27 (7.8%) patients may have avoided ALND. CONCLUSIONS: Nodal positivity on AUS/FNAC is associated with higher axillary disease burden. Few patients would satisfy ACOSOG/Z011 criteria and avoid ALND making an upfront SLNB unnecessary.

[Nipple-sparing mastectomy (subcutaneal mastectomy with preserving of the areolomammilar complex) like alternative of the modify radical mastectomy in selected cases].

INTRODUCTION: In the last ten years breast's surgery changed significantly. The different types mastectomy which conserve the skin and the halo and nipple are more and more popular. From oncology's point of view this kind of operations show similar results compared with the classical modified radical mastectomy, but they have significantly advantage to imrove the final aesthetic result and to reduce the psychological stress of surgery intervention for the patient. Our main goal is to make survey of medical data and to prove oncological radicality and reconstructive efficiency of nipple-sparing mastectomy (NSM) with one-moment reconstruction. MATERIALS AND METHODS: In period 2006-2009 in our clinic to 52 patients with breast cancer or with high risk of occurrence is done NSM and one-moment reconstruction with prothesis or expander. Of this number five patients are operated bilateral. We selected patients with small to medium size breasts and tumor to 3 sm, distant at least 2 sm from NSM. On a stable preparation in two cases (3.8% of all cases) is established invasion of retro-mamilarian tissue with tumor cells which indicated excision of NSM on second stage. This cases are not included in our study. The adjuvant therapy is conducted in indications according with approved standards. RESULTS: After 2-36 months period monitoring non of the patients showed local relapse. One of them (1.75%) receive distant metastases and died. Necrosis of NSM is observed in 13 patients (22.9%) and in all ot these cases it was partial and it was contained with conservative methods. In one case only (1.75%) the patient reported significant change in sensitivity of NSM. The final aesthetic result was evaluated subjectively of the patients and their doctors as very good or excellent in majority of cases. CONCLUSION: Our results are similar with established from other collegues and support the thesis that conserve NSM with one-moment reconstruction is oncologycally justified operation which conserve the patients in good psychological condition, improving the quality of life and it's reasonable alternative of MRM in similar cases.

Distant metastasis after radical treatment of breast cancer: risk factors and their prognostic relevance in 378 consecutive patients.

PURPOSE: To evaluate the prognostic significance of 16 clinical, pathomorphological and immunohistochemical features for predicting distant metastasis (DM) and 5-year overall survival (OS) in breast cancer (BC) patients. PATIENTS AND METHODS: A retrospective study of 378 patients with invasive BC (T1-3N0-3M0), who were operated between 2000 and 2003 at our Institution, was carried out. Almost 80% had undergone modified radical mastectomy (MRM). Tumor size (T), axillary lymph nodes status (N), age, menstrual status, histological type, grade (G), lymphovascular invasion (LVI), in situ component, estrogen receptor (ER), progesterone receptor (PgR) content, HER-2, Ki-67, p53, bcl-2, cathepsin D and E-cadherin were evaluated. Mean follow- up time was 56 months (range 1-88). RESULTS: During the follow-up period 66 (17.4%) patients developed DM and 76 (20.1%) patients died. Univariate analysis showed that T (p=0.0001), N (p=0.0001), presence of comedo type in situ component (p=0.0001), LVI (p=0.016), Ki-67 (+) (p=0.007) and cathepsin D (+) (p=0.013) were independent prognostic indicators for increased risk for DM. After multivariate analysis only N (+) status (odds ratio/OR 8.8; 95% confidence interval/ CI 3.5- 21.77; p=0.0001) and presence of comedo type in situ component (OR 2.4; 95% CI 1.19-4.74; p=0.015) retained their significant association with DM development. The same 2 factors also influenced 5-year OS: N(+), OR 3.8; 95% CI: 1.36-10.56; p=0.011; and comedo type in situ component, OR 3.3; 95% CI: 1.61-6.56; p=0.001. CONCLUSION: N (+) status and presence of comedo type in situ component are the most reliable predictors of unfavorable events in BC patients. Our study is among the first ones to find a relationship between the presence of in situ component and risk for DM in patients after MRM. The results also show that comedo type intraductal component, no matter how extensive it is, bears high risk for DM equal to N1 axillary status and patients with presence of such intraductal component should be treated as N(+). The evaluation of optimal number of risk markers is substantial for making an individualized decision regarding adjuvant therapy, especially in N0 group.

Subdermal laterocranial mapping of sentinel lymph nodes in breast cancer as an alternative to the peritumoral mapping.

PURPOSE: Peritumoral injection of blue dye is standard method of sentinel lymph nodes (SLN) biopsy in breast cancer. Applying the marker to different locations will be of great benefit in cases in which the peritumoral mapping is difficult to implement. The aim of this study was to demonstrate that the subdermal laterocranial (SLC) mapping with a dye has similar diagnostic reliability to the peritumoral mapping and is applicable for clinical use. PATIENTS AND METHODS: 254 patients with operable breast cancer (cT

Intraductal aspiration cytology and galactography for nipple discharge.

The objective of this study was to assess the diagnostic value of preoperative cytology and galactography in women with nipple discharge using a simple intraductal aspiration method. From May 1997 to February 2002, 172 patients with unilateral, spontaneous nipple discharge without palpable masses underwent intraductal aspiration cytology followed by galactography. Major duct excision was performed in 133 of 155 successful cases. Pathological findings showed solitary papilloma in 65 cases, breast cancer in 16 cases, fibrocystic disease in 17 cases, papillomatosis in 12 cases, ductal hyperplasia in 11 cases, and finally, duct ectasia in 12 cases. Our results showed sensitivity of 75.0% and 68.8%, specificity of 86.3% and 62.4%, and overall accuracy of 85.1% and 63.2%, respectively, for cytological analysis and galactography. This suggests that the intraductal aspiration method for preoperative cytology and galactography is a minimally invasive and well-tolerated procedure that seems to be useful in differentiating between benign and malignant lesions in patients with unilateral, spontaneous nipple discharge.

[Breast cysts--diagnostic and therapeutic management and risk for subsequent development of breast carcinoma]. / Kisti na mlechnata zhleza--diagnostichno-lechebna taktika i riskove ot posledvashto razvitie na kartsinom na gurdata.

Cystic breast disease is a relatively widespread pathological condition in the female sex, it has an incidence of around 7% and predominantly affects women aged between 35 and 50 year old. The diagnosis is based on the standardised protocol including breast examination, mammography, fine-needle aspiration cytology and pneumocystography. While the majority of cysts can be managed by simple aspiration, a small percentage (0.3-1.4%) are malignant. The clinical and pathological features of 7 cases of intracystic carcinoma of the breast which are 0.73% of all cases of cystic breast disease between 1996-2001, are considered in the present article.

[Guanfacine in the treatment of arterial hypertension in diabetics]. / Guanfatsin pri lechenie na arterialnata khipertoniia u diabetno bolni.

30 patients with hypertension and diabetes mellitus type II were treated with guanfacine (Estulic--"Sandoz" Switzerland) 1 mg tablets in the course of 6 months. The trial began with a placebo period at the end of which the patients were classified into groups: I groups--mild hypertension--14 patients, II group--moderate hypertension--8 patients and III group--severe hypertension - 8 patients. The treatment began in all patients with 0.5 mg Estulic once a day in the evening. According to the effect the dose was increased in one week intervals to 1, 2 and 3 mg daily. A very good effect was achieved in 24 patients (80%), good effect--in 3 patients (10%). There was no effect in 3 patients (10%) with diastolic pressure at the end of the placebo period of 15.3 kP (115 mm Hg). The drug Estulic did not deteriorate the glucose tolerance and in 22 patients (73.3%) a decrease of the blood sugar levels with mean 3.47-1.98 mmol/l was found.

[Immunoenzyme methods for determining thyroid hormones]. / Imunoenzimni metodi za opredeliane na tireoidni khormoni.

The analytical reliability of the immunoenzyme methods for determination of the thyroid hormones thyroxin, triiodothyronine, thyroid-binding globulin, thyrotropic hormone and the thyroid-binding capacity was examined by the peroxidase activity of the marker enzyme of "Specol-11" 28 healthy controls, 28 patients with subcompensated insulin-dependent diabetes with mean duration of 8.4 years and 11 patients with hypogonadism were examined. In the diabetic patients were found changes in their thyroid state characteristic for hypothyroidism--increased thyroxin and a decrease of the thyroid-stimulating hormone with a lowered level of the binding proteins. The patients with hypogonadism showed changes mainly in the binding proteins level, a decrease of the thyroid-binding capacity with 70%. The results reveal interrelations between the thyroid gland hormonal state and other hormonal disorders.

[Our experience in treating diabetes mellitus with the preparation Minidiab]. / Nashiiat opit pri lechenie na zakharniia diabet s preparata Minidiab.

55 patients with non-insulin-dependent diabetes mellitus were treated with the new oral drug Minidiab. In 58.2% of the patients the carbohydrate metabolism was influenced. No relation between the immunoreactive insulin increase and the effect of the treatment was found. An extrapancreatic action of the drug is suggested as its hypoglycemic activity.