Numerical and physical modeling of breast cancer based on image fusion and artificial intelligence.

PURPOSE: The key problem raised in the paper is the change in the position of the breast tumor due to magnetic resonance imaging examinations in the abdominal position relative to the supine position during the surgical procedure. Changing the position of the patient leads to significant deformation of the breast, which leads to the inability to indicate the location of the neoplastic lesion correctly. METHODS: This study outlines a methodological process for treating cancer patients. Pre-qualification assessments are conducted for magnetic resonance imaging (MRI), and 3D scans are taken in three positions: supine with arms raised, supine surgical position (SS), and standing. MRI and standard ultrasonography (USG) imaging are performed, and breast and cancer tissue are segmented from the MRI images. Finite element analysis is used to simulate tissue behavior in different positions, and an artificial neural network is trained to predict tumor dislocation. Based on the model, a 3D-printed breast with a highlighted tumor is manufactured. This computer-aided analysis is used to create a detailed surgical plan, and lumpectomy surgery is performed in the SS. In addition, the geometry of the tumor is presented to the medical staff as a 3D-printed element. RESULTS: By utilizing a comprehensive range of techniques, including pre-qualification assessment, 3D scanning, MRI and USG imaging, segmentation of breast and cancer tissue, model analysis, image fusion, finite element analysis, artificial neural network training, and additive manufacturing, a detailed surgical plan can be created for performing lumpectomy surgery in the supine surgical position. CONCLUSION: The new approach developed for the pre-operative assessment and surgical planning of breast cancer patients has demonstrated significant potential for improving the accuracy and efficacy of surgical procedures. This procedure may also help the pathomorphological justification. Moreover, transparent 3D-printed breast models can benefit breast cancer operation assistance. The physical and computational models can help surgeons visualize the breast and the tumor more accurately and detailedly, allowing them to plan the surgery with greater precision and accuracy.

Detection of BRCA1/2 pathogenic variants in patients with breast and/or ovarian cancer and their families. Analysis of 3,458 cases from Lower Silesia (Poland) according to the diagnostic algorithm of the National Cancer Control Programme.

Breast and ovarian cancers are among the most common malignancies in the female population, with approximately 5-10% of cases being hereditary. BRCA1 and BRCA2 with other homologous recombination genes are the most tested genes in hereditary breast and ovarian cancer (HBOC) patients. As next-generation sequencing (NGS) has become a standard and popular technique, such as for HBOC, it has greatly simplified and accelerated molecular diagnosis of cancer. The study group included 3,458 HBOC patients or their relatives from Lower Silesia (Poland) (a voivodeship located in south-west Poland inhabited by 2.9 million people). All patients were tested according to the recommendations from the National Cancer Control Programme of the Ministry of Health for the years 2018-21. We tested 3,400 patients for recurrent pathogenic variants for the Polish population: five BRCA1 founder variants (c.5266dup, c.181T>G, c.4035del, c.3700_3704del, and c.68_69del), two PALB2 variants (c.509_510del, c.172_175del) and three CHEK2 variants [c.1100del, c.444+1G>A, g.27417113-27422508del (del5395)]. Next 260 patients from the study group were chosen for the BRCA1/2 NGS panel, and additionally selected marker pathogenic variants were tested using Sanger sequencing and MLPA methods in 45 and 13 individuals, respectively. The analysis of BRCA1/2 in the 3,458 patients with HBOC or their relatives revealed 144 carriers of 37 different pathogenic variants (22 in BRCA1 and 15 in BRCA2). Among all detected variants, 71.53% constituted founder pathogenic BRCA1 variants. Our study has revealed that for the Lower Silesian population, the first-line BRCA1/2 molecular test may be limited to only three variants in BRCA1-c.5266dup, c.181T>G, and c.4035del-but the aim should be to provide a full screening test of HBOC critical genes. The key and still growing role of molecular diagnostics of neoplasms, which includes HBOC, is undeniable. Therefore, it is necessary to provide complete and optimal therapeutic and prophylactic algorithms in line with current medical knowledge.

Multimodality imaging in lobular breast cancer: Differences in mammography, ultrasound, and MRI in the assessment of local tumor extent and correlation with molecular characteristics.

Introduction: Invasive lobular breast cancer (ILC) is a diagnostic challenge due to the diversity of morphological features. The objective of the study was to investigate the presentation and local extent of ILC using various imaging techniques and to assess the correlation between imaging and molecular profile. Materials and methods: We reviewed 162 consecutive patients with ILC found on vacuum-assisted biopsy, who underwent evaluation of the lesion morphology and extent using ultrasound (US), mammography (MMG), and magnetic resonance imaging (MRI). Radiographic features were compared with ILC intrinsic subtype based on the expression of Ki-67 and estrogen, progesterone, and HER2 receptors. Results: A total of 113 mass lesions and 49 non-mass enhancements (NMEs) were found in MRI. Masses were typically irregular and spiculated, showing heterogeneous contrast enhancement, diffusion restriction, and type III enhancement curve. NMEs presented mainly as the area of focal or multiregional distribution with heterogeneous or clumped contrast enhancement, diffusion restriction, and type III enhancement curve. Lesion extent significantly varied between MRI and MMG/ultrasonography (USG) (P < 0.001) but did not differ between MGF and ultrasonography (USG). The larger the ILC, the higher the disproportion when lesion extent in MRI was compared with MMG (P < 0.001) and ultrasonography (USG) (P < 0.001). In the study group, there were 97 cases of luminal A subtype (59.9%), 54 cases of luminal B HER2- (33.3%), nine cases of luminal B HER2+ (5.5%), and two cases of triple negative (1.2%). The HER2 type was not found in the study group. We did not observe any significant correlation between molecular profile and imaging. Conclusion: MRI is the most effective technique for the assessment of ILC local extent, which is important for optimal treatment planning. Further studies are needed to investigate if the intrinsic subtype of ILC can be predicted by imaging features on MRI.

Identification of a localization wire tip in an occult breast lesion using a handheld magnetometer.

BACKGROUND: The Sentimag hand-held probe detects the magnetic response from iron oxide particles trapped in a sentinel node. OBJECTIVES: To investigate if an electromagnetic probe can be helpful in the identification of a hook wire tip located in an occult breast lesion. MATERIAL AND METHODS: Forty-two patients undergoing lumpectomy without axillary procedure were enrolled. In all cases, suspicious non-palpable microcalcifications without mass were found, and a vacuum-assisted stereotactic biopsy was performed. On the day of surgery, a traditional localization wire (LW) was placed under imaging guidance. The Sentimag magnetometer was used to precisely detect the wire tip through the skin. Then, the skin incision was made and Sentimag was used again to guide the surgeon to the lumpectomy bed. The accuracy of excision was assessed with intra-operative specimen 3D tomosynthesis. RESULTS: Median lesion size was 16 mm (range: 4-38 mm) and median depth was 33 mm (range: 14-78 mm). In all cases, the wire tip was successfully identified. Neither wire displacement nor transection occurred. Intraoperative radiography demonstrated doubtful margin requiring selective cavity shaving in 6 patients (14%). The need for cavity shaving was significantly influenced by the lesion size and histology: median size 30 mm (range: 24-38 mm) compared to 15 mm (range: 4-28 mm) and histology of ductal carcinoma in situ (DCIS) compared to atypical ductal hyperplasia (ADH) and lobular neoplasia (LN). Tumors requiring cavity shaving tended to be deeper - they had a median depth of 43 mm (range: 17-78 mm) compared to 32 mm (range: 14-76 mm) in patients who did not need cavity shaving, but this parameter was statistically significant. CONCLUSIONS: Intraoperative identification of the wire tip using Sentimag is a simple technique facilitating targeted excision without excessive removal of breast tissue. Since it is not associated with additional costs, it may be worth considering, particularly in developing countries.

The use of ultrasonic scalpel lowers the risk of post-mastectomy seroma formation in obese women.

Introduction: Seroma formation (SF) is the most common postoperative complication after mastectomy and axillary surgery. The aim of this study was to assess its incidence and risk factors following a modified radical mastectomy in breast cancer patients. Materials and methods: 271 patients who underwent a modified radical mastectomy (250 with traditional electrocautery and 21 with an ultrasonic scalpel) were studied. The SF rate was calculated and its association with patient-related factors, surgical features and postoperative variables was assessed and statistically analyzed with P<0.05 as a significance threshold. Results: SF was observed in 18% of patients. Patient's age, operating time and number of removed axillary lymph nodes did not significantly differ between SF and non-SF patients. Patients BMI, total drainage amount, number of days with drain were higher and postoperative hospital stay was significantly longer in SF patients (P<0.001 each). The dissection instrument was also an important risk factor: SF developed in 20% of patients operated with electrocautery and in none with an ultrasonic scalpel (P<0.05). The association between surgical instrument and the number of removed lymph nodes, patient's age and BMI was not significant. Dissection with an ultrasonic scalpel resulted in a statistically significant lower total drainage amount. However, it was also related to a significantly longer operating time (P<0.001 each). Conclusions: Risk of SF after a modified radical mastectomy is significantly higher in patients with obesity. Despite longer operating time, using an ultrasonic scalpel is a valuable option in those cases because it lowers the total drainage amount and seems to be an important protective factor against SF.

Ultralow anterior resection with implantation of gentamicin-collagen sponge and no defunctioning stoma: anastomotic leakage and local cancer relapse.

Background Anterior resection with total mesorectal excision (TME) of ultralow rectal cancer may result in the increased risk of the anastomotic leakage (AL). The aim of this study was to evaluate the usefulness of the gentamicin-collagen sponge (GCS) for the protection against symptomatic AL and investigate association between AL and local relapse (LR). Patients and methods A series of 158 patients with ultralow rectal cancer was studied. All the patients underwent R0 sphincter-saving TME with anastomosis wrapping using GCS. In none of the cases a temporary protective stoma was constructed. Results AL rate was 3.2% (5/158) while median time to AL diagnosis was 5 days following surgery (range 3-15). There was no postoperative and leakage-related mortality. Patient age > 75 years and smoking were independent risk factors related to significantly increased AL rate: 12.5% vs. 0.8% (P = 0.0004) and 5.7% vs. 0% P = 0.043), respectively. LR was observed in 12% of cases. It was highly significantly more common and developed earlier in patients who have had AL when compared with non-AL group: 80% vs. 9% (P = 0.00001) and 8.5 vs. 17 months (P = 0.014), respectively. Conclusions Anastomosis wrapping with GCS after anterior resection with TME is a safe procedure resulting in the low incidence of anastomotic leakage which may be also associated with decreased risk of local relapse.

Biological Aggressiveness of Subclinical No-Mass Ductal Carcinoma In Situ (DCIS) Can Be Reflected by the Expression Profiles of Epithelial-Mesenchymal Transition Triggers.

Epithelial-mesenchymal transitions (EMTs) have been recently implicated in the process of cancer progression. The aim of this study was to assess how the preoperative expression patterns of EMT biomarkers correlate with the risk of postoperative invasion in ductal carcinoma in situ (DCIS) found on stereotactic breast biopsies. N-cadherin, Snail1, and secreted protein acidic and rich in cysteine (SPARC) immunoreactivity was observed in 8%, 62%, and 38% of tumors, respectively. Snail1 and SPARC expressions were significantly related to N-cadherin expression and to each other. The postoperative upgrading rate was associated with a positive preoperative expression of all biomarkers. Significance of Snail1 and SPARC persisted in multivariate analysis, but the impact of SPARC on invasion was more significant. When these two EMT triggers were considered together, the risk of invasion did not significantly differ between the subtypes of DCIS with single positive expression (SPARC-/Snail1+ vs. SPARC+/Snail1-). However, it was significantly lower in single-positive DCIS when compared to lesions of a double-positive profile (SPARC+/Snail1+). Moreover, there were no cases in the double-negative DCIS (SPARC-/Snail1-), with foci of infiltrating cancer found postoperatively in residual postbiopsy lesions. In contrast, DCIS with a combined high SPARC and Snail1 expression (intermediate or strong) had an invasive component in 66⁻100% of tumors.

Molecular characterization and heterogeneity of circulating tumor cells in breast cancer.

INTRODUCTION: This study analyzes peripheral blood samples from breast cancer (BC) patients. CTCs from peripheral blood were enriched by size-based separation and were then cultivated in vitro. The primary aim of this study was to demonstrate the antigen independent CTC separation method with high CTC recovery. Subsequently, CTCs enriched several times during the treatment were characterized molecularly. METHODS: Patients with different stages of BC (N = 167) were included into the study. All patients were candidates for surgery, surgical diagnostics, or were undergoing chemotherapy. In parallel, 20 patients were monitored regularly and in addition to CTC presence, also CTC character was examined by qPCR, with special focus on HER2 and ESR status. RESULTS: CTC positivity in the cohort was 76%. There was no significant difference between the tested groups, but the highest CTC occurrence was identified in the group undergoing surgery and similarly in the group before the start of neoadjuvant treatment. On the other hand, the lowest CTC frequencies were observed in the menopausal patient group (56%), ESR+ patient group (60%), and DCIS group (44.4%). It is worth noting that after completion of neoadjuvant therapy (NACT) CTCs were present in 77.7% of cases. On the other hand, patients under hormonal treatment were CTC positive only in 52% of cases. DISCUSSIONS: Interestingly, HER2 and ESR status of CTCs differs from the status of primary tumor. In 50% of patients HER2 status on CTCs changed not only from HER2+ to HER2-, but also from HER2- to HER2+ (33%). ESR status in CTCs changed only in one direction from ESR+ to ESR-. CONCLUSIONS: Data obtained from the present study suggest that BC is a heterogeneous disease but CTCs may be detected independently of the disease characteristics in 76% of patients at any time point during the course of the disease. This relatively high CTC occurrence in BC should be considered when planning the long-term patient monitoring.

Ductal carcinomas in situ and invasive cancers detected on screening mammography: Cost-effectiveness of initial and subsequent rounds of population-based program 2007-2014.

BACKGROUND: Potential benefits of screening need to be carefully balanced against the financial burden for the national health care system. OBJECTIVES: To assess the cost-effectiveness of population-based mammographic screening in the 3-million region of Lower Silesia (Poland) after initial and 3 subsequent rounds. MATERIAL AND METHODS: Data was collected in a prospective manner using the databases of the official computer system for the monitoring of prophylaxis programs (SIMP), National Health Fund (Lower Silesia Regional Branch) and the Lower Silesia Cancer Registry. The expenses from each analyzed year were obtained from the Regional Coordinating Center for Screening Programs. The number of screen-detected and pathologically proven invasive and ductal in situ cancers was calculated. Costs of cancer detection were measured, converted into US dollars (USD), and expressed in 2015 USD using the comparison of purchasing power of money calculated with the Consumer Price Index. RESULTS: The total expense for the screening program in the initial round (2007-2008), first (2009-2010), second (2011-2012) and third (2013-2014) subsequent rounds was 4 732 383, 6 043 509, 6 484 834, and 5 900 793 USD whereas the number of cancer detected was 1049, 987, 1312, and 1070. The costeffectiveness ratio obtained in the program for each year was 4511, 6123, 4943, and 5515 USD per cancer found. The average cost of breast cancer detection in screening program in the region of Lower Silesia in years 2007-2014 was 5243 USD. CONCLUSIONS: The low cost of breast cancer detection in mammographic screening program makes it applicable for the health care systems in emerging economies.

Epithelial-mesenchymal transition inducer Snail1 and invasive potential of intraductal breast cancer.

BACKGROUND AND OBJECTIVES: Transcription factor Snail1 is a key inducer of epithelial-mesenchymal transition (EMT), a biological process implicated in the cancer progression and metastasis. The aim of the study was to investigate Snail1 expression in DCIS found on breast biopsy and assess its predictive value for the final invasion. METHODS: A total of 209 patients with histologically diagnosed pure DCIS entered the study. Snail1 reactivity was evaluated with immunohistochemistry in tumor tissue from stereotactic vacuum-assisted biopsy of suspicious microcalcifications. RESULTS: Snail1 staining was observed in 62% of tumors: weak, intermediate, and strong in 27%, 21%, and 14% of lesions, respectively. Positive Snail1 expression was significantly rarer in DCIS presenting as powdery microcalcifications, when compared with crushed stone-like and casting-type and was more common in DCIS with comedonecrosis. Correlation with other features was not significant. None of standard parameters significantly influenced the upgrading rate. In contrast, in uni- and multivariate analysis the risk of postoperative invasion was significantly associated with positive Snail1 immunoreactivity. Moreover, there was a significant stepwise increase of upgrading rate according to Snail1 expression in DCIS cells: weak 9%, intermediate 26%, and strong 55%, respectively. CONCLUSIONS: Snail1 can reflect the invasive potential of DCIS and help identify its more aggressive subtypes.

Lobular carcinoma in situ of the breast - correlation between minimally invasive biopsy and final pathology.

INTRODUCTION: Lobular carcinoma in situ (LCIS) is regarded as a non-obligate precursor of invasive breast cancer (IBC). Hence, the optimal management of LCIS found on minimally invasive breast biopsy remains a subject of debate. The aim of this study was to evaluate the correlation of biopsy findings with postoperative histology and to identify risk factors for upstaging to IBC. MATERIAL AND METHODS: Twenty-seven patients with pure LCIS diagnosed on image-guided biopsy (vacuum-assisted or core-needle) underwent subsequent surgery. Clinical, radiological and histological features were compared to the final pathology after surgical excision. RESULTS: Median age of patients was 56 years while median size of LCIS was 15 mm. Final examination demonstrated IBC foci in 29.6% of lesions. Upstaged patients were younger and had larger lesions but without statistical significance (p = 0.07 and p = 0.09, respectively). Palpable tumours (p = 0.0004), BIRADS 5 lesions (p = 0.0001), masses (p = 0.016) and pleomorphic LCIS (p = 0.0001) had a significantly increased rate of upstaging. Guidance of the procedure (ultrasound vs. stereotactic) was significantly associated with the upstaging risk (p = 0.016), while the importance of the biopsy technique (core-needle vs. vacuum-assisted) was not confirmed (p = 0.37). After excluding pleomorphic LCIS and mass-forming classic LCIS, there was no risk of upstaging for lesions with BIRADS 4 mammographic abnormalities. CONCLUSIONS: Pleomorphic histology, mass formation and BIRADS 5 category reflect more aggressive behaviour of LCIS and identify patients who need subsequent surgery. For other patients, close follow-up could be a safe alternative.

Ductal carcinoma in situ on stereotactic biopsy of suspicious breast microcalcifications: Expression of SPARC (Secreted Protein, Acidic and Rich in Cysteine) can predict postoperative invasion.

BACKGROUND AND OBJECTIVES: Secreted protein, acidic and rich in cysteine (SPARC) is able to play an important role in cancer invasion due to de-adhesive properties and impact on stromal remodeling. The aim of study was to investigate SPARC expression in preoperatively diagnosed breast DCIS and to assess its predictive value for the final invasion. METHODS: A total of 209 patients with DCIS found on stereotactic vacuum-assisted biopsy of suspicious microcalcifications were studied prospectively. RESULTS: SPARC staining was positive in luminal epithelial cells, stromal fibroblasts, and myoepithelial cells in 38%, 62%, and 61% of tumors, respectively. Neither patient age nor pattern of microcalcifications were related to SPARC expression. High nuclear grade and comedonecrosis were associated with strong immunoreactivity of SPARC in stromal fibroblasts and myoepithelial cells while not in luminal epithelial cells. Rate of postoperative invasion was significantly increased in DCIS with strong SPARC staining with regard to all investigated cells. None of standard parameters significantly influenced the upgrading risk. In multivariate analysis most significant and independent predictive factors were strong SPARC expression in luminal epithelial cells, and stromal fibroblasts. CONCLUSIONS: SPARC can be a new biomarker helpful to identify more aggressive DCIS and for prediction of invasive disease on final pathology. J. Surg. Oncol. 2016;114:548-556. © 2016 Wiley Periodicals, Inc.

Screen-detected ductal carcinoma in situ found on stereotactic vacuum-assisted biopsy of suspicious microcalcifications without mass: radiological-histological correlation.

BACKGROUND: Commonly identified on screening mammography breast microcalcifications are the predominant manifestation of ductal carcinoma in situ (DCIS). The aim of this study was to investigate the association between clinico-radiological features and histological findings in patients with screen-detected DCIS. PATIENTS AND METHODS: Consecutive 127 patients with pure DCIS found on stereotactic vacuum-assisted biopsy of screen-detected suspicious microcalcifications without mass entered the study. Patient age, type and distribution of microcalcifications, DCIS nuclear grade (NG) and the presence of comedonecrosis were investigated. Association between parameters was statistically analysed with P < 0.05 as a significance level. Results. Powdery microcalcifications were most often clustered while regional were most common of casting-type (P < 0.001). High, intermediate and low NG of DCIS was significantly related to casting-type, crushed stone-like and powdery microcalcifications, respectively (P < 0.01). Low and intermediate NG DCIS were the most common in clustered and grouped microcalcifications while high NG DCIS was the most often when regional distribution was observed (P < 0.05). Comedonecrosis was significantly more common in high NG DCIS (P < 0.01). The association between comedonecrosis and type of microcalcifications was not significant, but with their distribution was close to the significance level (P = 0.07). Patient age was not significantly related to imaging or histological findings. CONCLUSIONS: The association between pattern of mammographic microcalcifications and histological findings related to more aggressive disease can be helpful in optimal surgery planning in patients with screen-detected DCIS, regarding the extent of breast intervention and consideration of synchronous sentinel node biopsy.

Breast segmentectomy with rotation mammoplasty as an oncoplastic approach to extensive ductal carcinoma in situ.

BACKGROUND: The aim of this study was to assess the usefulness of the breast segmentectomy with rotation mammoplasty (BSRMP) in conserving therapy for an extensive ductal carcinoma in situ (DCIS) with or without an invasive component. METHODS: Thirty-six women with DCIS visible as large area of microcalcifications distributed out of the retroareolar area regardless of the quadrant were studied prospectively. All the patients underwent BSRMP and axillary procedure (31 sentinel node biopsy, 5 axillary dissection) followed by radiotherapy. In each case, follow-up was carried out carefully and special effort was made to identify postoperative complications. Cosmetic result was judged 6 months after radiotherapy by the patient herself and two surgeons being rated as poor, mediocre, medium, good or excellent. RESULTS: Operation was completed without any difficulties in all the cases. Appropriate BSRMP was easily done after the skin marking. Regardless of the type of axillary approach, it was conveniently performed. Wound was healed by primary adhesion; skin or breast tissue necrosis did not develop. Neither haematoma nor surgical site infection was observed. In none of the patient, centralisation of the nipple-areola complex (NAC) was needed. Three patients (8.3%) with close margins (1 mm or less) successfully underwent subsequent re-excision. The scar did not result in any impairment of arm movement. Cosmetic outcome was evaluated by the women as excellent and good in 55 (87%) and 8 (13%) cases, respectively, while by the surgeons as excellent, good and medium in 52 (82%), 8 (13%), and 3 cases (5%), respectively. CONCLUSIONS: BSRMP is a simple and safe technique achieving good cosmetic results without NAC centralisation and giving the wide and easy access to axilla for both sentinel node biopsy and lymphadenectomy. It can be helpful in cases of extensive, radially spreading tumours (in particular DCIS or invasive cancers with intraductal component), eccentric lesions, or superficially located cancers when the neighbouring skin is excised. However, due to its limitations (long incision, difficult subsequent mastectomy, possibility of scar placement in the visible area of decollete), a careful patients' selection should be done. Further studies are needed to assess long-term cosmetic outcomes including delayed post-radiotherapy effects.

Preoperatively diagnosed ductal cancers in situ of the breast presenting as even small masses are of high risk for the invasive cancer foci in postoperative specimen.

BACKGROUND: In ductal carcinoma in situ of the breast (DCIS), histologic diagnosis obtained before the definitive treatment is related to the risk of underestimation if the presence of invasive cancer is found postoperatively. These patients need a second operation to assess the nodal status. We evaluated the upstaging rate in patients with mass-forming DCIS. METHODS: Sixty-three women with pure DCIS presenting as sonographic mass lesion underwent vacuum-assisted or core-needle biopsy and subsequent surgery. Rates of postoperative upstaging to invasive cancer were calculated and compared with clinical character and size of DCIS. RESULTS: Median age of patients (range) was 63 years (27-88) while median diameter of DCIS was 11 mm (6-60). Fifty-six percent of DCIS were upstaged. Patient age did not differ significantly between groups with and without final invasion (median, mean, SD): 63, 61.4, 12.5 vs 62, 61.2, 10.6 years, respectively (P=0.659). The difference of DCIS size between these groups was statistically important (median, mean, SD): 13, 17.3, 11.4 vs 9.5, 9.8, 3.2 mm, respectively (P=0.0003). Mass size and palpability were significant risk factors (P<0.001 and P<0.01, respectively). Rate of underestimation for mass with diameter≤10 mm, 10-20 mm and >20 mm was 37, 64 and 91%, respectively. CONCLUSIONS: DCIS diagnosed on minimal-invasive biopsy of even small sonographic mass is of high risk for the upstaging to invasive cancer after final surgical excision. In these patients, subsequent intervention is needed for nodal status assessment. They are good candidates for the sentinel node biopsy during the breast operation to avoid multi-step surgery.

Multidisciplinary management in Merkel cell carcinoma.

Herein, the authors describe the experience with the treatment of Merkel cell carcinoma (MCC) and review the literature regarding MCC treatment regimens. Nine patients underwent treatment due to stage I, II, or III MCC. The median follow up was 39 months. In five cases, tumors were excised with skin margins of >2 cm, and skin margins were <2 cm in four patients. Local adjuvant radiotherapy (RT) was given to four patients, while three patients underwent local lymphadenectomy (LAD). Local recurrence occurred in four patients who did not undergo RT (among them three patients had excision margins <2 cm) after a mean time of 9 months. Despite retreatment, two of those patients developed metastases. Recurrence-free survival after primary therapy was achieved: (a) in three patients with stage I and II MCC treated surgically with excision margins <2 cm combined with RT or wide excision >2 cm alone and (b) in two patients with stage III MCC treated with wide excision and LAD combined with local and regional RT. A review of the literature supports the following recommendations: (a) excision with adequate margins combined with RT; (b) LAD with regional RT in cases of lymph node involvement; and (c) sentinel lymph node biopsy in patients without clinically suspicious lymph nodes.

Batwing mastopexy as oncoplastic surgical approach to periareolar tumors in upper quadrants.

AIMS AND BACKGROUND: Batwing mastopexy (BWM) is an oncoplastic technique most commonly used in the treatment of 12 o'clock periareolar tumors. The aim of this study was to assess the early cosmetic results of BWM performed for periareolar lesions located in the upper quadrants, i.e. from 10 to 2 o'clock position. METHODS AND STUDY DESIGN: A prospective analysis of a preliminary group of 35 women with periareolar intraductal or invasive breast cancer in the upper quadrants was done. All patients underwent wide lumpectomy with clear margins followed by BWM in order to obtain favorable cosmesis. For invasive cancers axillary biopsy or dissection was performed by separate incision. Cosmetic outcome was assessed 4 weeks after surgery by the patient with reference to breast shape, nipple-areola complex (NAC) position and scar arrangement. The result was rated as poor, medium or good for each parameter. RESULTS: There were no poor ratings of cosmetic outcome. The result was rated as medium by 5 women (14%) regarding breast shape and by 3 regarding NAC position (9%). The remaining women evaluated these parameters as good (86% and 91%, respectively). In contrast, scar arrangement was assessed as good by 26 patients (74%), medium by 8 (23%), and poor by 1 (3%). All women rating scar arrangement as other than good had a lesion located in the upper lateral quadrant. Considering the reasons for the relatively low scar acceptance by these women, the only important cause of disappointment was the placement of one of the radial parts of the scar in the area of decolletage in the upper medial quadrant. CONCLUSIONS: BWM allows to achieve favorable breast shape and NAC position for lesions located in the upper quadrants regardless of the medial or lateral side. However, when performed in the lateral quadrant it produces a scar that can be hard to accept for some women.

[The role of TGF-ß-related signal transduction pathways in pathogenesis of epithelial-mesenchymal transition as a key element in cancer development and progression]. / Rola szlaków sygnalizacyjnych zwiazanych z TGF-ß w patogenezie przejscia nablonkowo-mezenchymalnego (EMT) jako glównego elementu warunkujacego progresje choroby nowotworowej.

Epithelial-mesenchymal transition (EMT) is a biological process that drives polarized, immotile epithelial cells to undergo multiple biochemical changes to acquire a mesenchymal cell phenotype. The characteristic features of EMT are cell apolarity, loss of cellular adhesion, reduced expression of E-cadherin and increased migratory capacity, as well as invasiveness. EMT is a physiological process that is essential for normal embryonic development. Additionally, abnormal activation of EMT contributes to some human pathologies such as tissue fibrosis, cancer cell invasion and metastasis. In both situations, the basic molecular mechanisms are similar, but lead to different effects depending on cell type and biological conditions of the environment. TGF-ß is a multifunctional cytokine that controls proliferation, differentiation and other functions in many cell types. It has been found that neoplastic development converts TGF-ß into an oncogenic cytokine. It activates various molecular processes, which are engaged in EMT initiation. All that makes TGF-ß a key regulator of EMT.  

Urinary complications in rectal cancer patients are related to the dissection tool.

BACKGROUND/AIMS: To assess the incidence and risk of urinary complications after anterior rectal cancer resection with regard to the surgical device used for total mesorectal excision (TME). METHODOLOGY: During the years 2004-2009 we operated 374 rectal cancer patients with TME and the intent of autonomic nerves sparing intent. Seventeen patients underwent mesorectal dissection with ultrasound scalpel (US). They were compared to the control series of 35 cases selected from the patients for whom electrocautery was used. Selection was done in the manner to eliminate any other significant differences between groups. RESULTS: Intraoperative complications, postoperative mortality, anastomotic leakage and infectious complications did not occur. Urinary bladder disturbances developed in US group in 1 patient (6%) while in 12 patients (34%) in EC group (p<0.05). In US group the character of complication was transient stress incontinence with symptoms being significantly reduced during six postoperative months. In EC group two patients had dysuria, two nycturia, one had both. Stress incontinence occurred in six patients, complete incontinence requiring catheterization in one. CONCLUSIONS: When compared to EC, TME with US is related to lower risk of urinary complications and facilitates autonomic nerve preservation due to minimized thermal lateral tissue damage.

Lobular neoplasia found on breast biopsy: marker of increased risk of malignancy or direct pre-cancerous lesion?

The aim of this study was to compare the imaging symptoms and microscopic findings in females with lobular neoplasia (LN) found on biopsy. 1,478 women who underwent primary open biopsy or surgical excision after percutaneous biopsy were reviewed. In 24 of them (1.6%), LN was found. In four patients, excisional biopsy with hook-wire localization was done primarily due to the radial scar. In 20 females, surgical excision of BIRADS 4 lesion was performed because of the presence of LN in specimens from the vacuum-assisted or core-needle percutaneous biopsy. Postoperative pathologic findings were compared to the radiological symptoms. In 13 women, LN did not produce any radiological symptoms and was an additional histologic finding existing near the other lesion: fibroadenoma and radial scar. In none of these lesions was an invasive cancer noticed. In one single patient, ductal carcinoma in situ was observed in the other segment of the breast. Invasive ductal cancer developed in the contralateral breast in one patient. In 11 patients, LN was diagnosed due to radiological symptoms produced by itself. In this group, the invasive lobular cancer was found in seven lesions (64%). Our finding suggests that LN producing suspicious radiological symptoms can be a different biologic type of this lesion when compared asymptomatic LN diagnosed which is usually found on biopsy as additional microscopic pathology. Symptomatic LN is probably associated with a higher potential of malignant transformation.