Diagnosis and treatment of advanced HER2-positive breast cancer in young pregnant female: A case report.

RATIONALE: The incidence of pregnancy-associated breast cancer (PABC) is increasing nowadays, and its diagnosis and treatment remain complicated due to the consideration of the fetus. The available data on PABC are primarily derived from case reports since there are ethical restrictions on conducting randomized clinical trials. In the present work, we reported a case of the human epidermal growth factor receptor 2 (HER2)-positive PABC and described the diagnosis and treatment for such type of breast cancer. PATIENT CONCERNS: A 27-year-old patient was admitted to our hospital with the complaints of right breast mass for 3 days, and she was a first-time pregnant woman with a single live intrauterine fetus at 26 + 3 weeks of gestation. Physical examination of the right breast revealed a palpable and hard mass with obscure boundaries (5.0 cm × 4.0 cm) in the upper outer quadrant. Significant axillary lymph nodes (2.0 cm) were also present. DIAGNOSIS: PABC. INTERVENTION: To protect the fetus, breast ultrasonography was used to test her breast mass, a core needle biopsy was adopted to confirm the diagnosis, and abdominal ultrasound and chest X-ray were used to evaluate the metastasis. The patient was scheduled for neoadjuvant therapy using bi-weekly pirarubicin in combination with cyclophosphamide (AC) without anti-HER2 therapy for consideration of the fetus's safety. After 4 cycles of AC, the patient delivered a healthy male infant. After the delivery, all the treatments were carried out according to the standard recommendation for HER2 + breast cancer as non-pregnant patients. OUTCOMES: After the surgery, the disease-free survival for the patient was 12 months until brain metastasis was diagnosed. She was still undergoing second-line anti-HER2 therapy and currently in a stable situation. Besides, the child was also healthy so far. LESSONS: The methods for the diagnosis and treatment of PABC that result in teratogenesis should be avoided to protect the fetus. Mammogram and chest X-ray were safe approaches for the fetus. Moreover, chemotherapy-based on pirarubicin in combination with cyclophosphamide had no risk to the fetus.

[Study of diagnostic features, health care quality and surgical treatment among women living in the LHAs of Novara and Verbano Cusio Ossola hospitalized for breast cancer]. / Studio delle caratteristiche diagnostiche, della qualità dell'assistenza sanitaria e degli interventi chirurgici, nelle donne residenti nelle ASL di Novara e Verbano Cusio-Ossola ricoverate per carcinoma della mammella.

This study included 304 women, 128 Screen Detected (SD) e 176 non Screen Detected (NSD), aged 50-69, living in the ex-local health authorities (LHAs) 13 and 14, hospitalized for breast cancer or related chemotherapy or radiation treatments in 2003-2004. Some variables were detected from medical records in order to evaluate the local screening program. The results confirm that a prevention activity allows a rapid identification of cancer and less invasive surgery procedures.

Sarcomas de mama posradiación / Radiation-induced sarcomas of the breast

El cáncer de mama es la neoplasia más frecuente en la mujer. El tratamiento conservador implica el tratamiento adyuvante con radioterapia. Alrededor del 60% de los pacientes con cáncer reciben radioterapia durante el curso de su enfermedad. Los sarcomas son tumores raros y corresponden al 0,03-0,8% de toda la patología tumoral. Su origen es controvertido siendo asociado a traumatismos, exposición a agentes químicos, linfedema crónico y radioterapia. El porcentaje de sarcomas radioinducidos supone el 0,1-0,4% de los mismos. Ya en 1904 Perthes y posteriormente Cahan describieron la asociación de radioterapia como desencadenante en la patogénesis de los sarcomas. El mejor conocimiento actual de la biología aporta nuevos indicios sobre su origen. La distancia temporal entre la exposición a la radiación y la aparición del sarcoma es el criterio principal que ha sido modificado por la mayor parte de los investigadores, y está entre 3-10 años. El tratamiento de elección, sigue siendo la cirugía con amplios márgenes de seguridad. Respecto al tratamiento adyuvante, la radioterapia y quimioterapia tienen un efecto limitado. El pronóstico es desfavorable, con una supervivencia global a los 5 años, que oscila del 17-58%, significativamente menor que la de los sarcomas de partes blandas de novo. Debido al escaso número de casos recogidos en la literatura, es difícil definir el protocolo de actuación más correcto, por lo que pretendemos ofrecer una revisión de las manifestaciones clínicas, técnicas de imagen, tratamiento y pronóstico de los sarcomas radioinducidos, aportando a la vez 2 nuevos casos de sarcomas radioinducidos tras neoplasia mamaria (AU)

Breast cancer is the most common neoplasm in women. Conservative treatment involves adjuvant therapy with radiotherapy. About 60% of cancer patients receive radiotherapy during the course of their disease. Sarcomas are rare tumors and account for 0,03-0,8% of all tumoral disease. Their origin is controversial and has been associated with trauma, exposure to chemicals, radiation and chronic lymphedema. The percentage of radiation-induced sarcomas represents the 0.1-0.4% of these tumors. As early as 1904, Perthes, and later Cahan, described the association of radiotherapy as a trigger in the pathogenesis of sarcomas. Greater current knowledge of biology provides new clues to the origin of sarcomas. The time interval between radiation exposure and the appearance of a sarcoma is the main criterion that has been modified by most researchers and is between 3 and 10 years. The treatment of choice is still surgery with wide safety margins. Regarding adjuvant treatment, radiotherapy and chemotherapy have limited effect. Prognosis is poor, with an overall 5-year survival ranging from 17% to 58%, significantly lower than that of de novo soft tissue sarcomas. Due to the small number of cases reported in the literature, it is difficult to define the most appropriate protocol. Consequently, our aim is to provide a review of the clinical manifestations, imaging techniques, treatment and prognosis of radiation-induced sarcomas and to report two new cases of radiation-induced sarcomas after breast cancer (AU)

Mammary neuroendocrine carcinoma with mucinous differentiation: a clinicopathological study of 15 cases.

BACKGROUND: Mammary neuroendocrine carcinoma (NEC) displays morphological features including mucinous type. OBJECTIVE: To describe clinicopathological of NEC with mucinous differentiation. METHODS: A total of 15 cases of mammary NEC with mucinous differentiation were reviewed. RESULTS: All patients in this study were women aged from 37 to 78 year olds (median 68.1 years). The tumors ranged in size from 1.2 cm to 16 cm (mean 3.74 cm). The amount of extracellular mucin varied from 10% to 90%. Histological grade was I in 7 cases and II in 8 cases. Immunohistochemically, estrogen receptor (ER) and progesteron receptor (PR) were expressed in 12 and 14 cases, respectively. All tumors were negative for Her-2. Ki-67 proliferative index was lesser than 1% in all cases and no cases had demonstrated p53 overexpression. Three patients died of disease with a follow-up of 3 to 6 months. One patient was alive with metastasis at 96 months. Ten patients were disease free (follow-up range from 15 to 125 months). CONCLUSIONS: Mammary NEC with mucinous differentiation affects mostly older women. All tumors were low grade and immunoreactive for ER/PR and negative for Her-2. Mammary NEC with mucinous differentiation seems associated with well survival parameters.

La asistencia de la enfermera en la visión de mujeres mastectomizadas / Nursing care to mastectomized women

El trabajo relata la experiencia de mujeres que tuvieron cáncer de mama y fueron sometidas a mastectomía, recibiendo la asistencia de las enfermeras y de sus auxiliares. Los objetivos fueron: identificar las expectativas de las mujeres que se sometieron a la mastectomía en relación al cuidado de la enfermera y cómo estas mujeres percibían la asistencia que les fue prestada. Consiste en una investigación descriptiva, del modelo de estudio de caso, cualitativa, utilizando encuesta directa con nueve mujeres de un grupo de apoyo a mujeres mastectomizadas, en Niterói - RJ - Brasil. Fueron identificadas las expectativas relativas a la enfermera: que deberá tener capacidad y conocimiento técnico, además de comprender el momento vivido por ellas. En cuanto a la actuación de las enfermeras, ellas relataron que éstas aclararon sus dudas y fueron esenciales en el posoperatorio, realizaron procedimientos técnicos y dieron apoyo emocional. Se evidenció que la asistencia de enfermería, tanto relativa a la enfermera como a sus auxiliares, presentó una manera distinta con respecto a la institución. En la especializada, enfermera con función clara y definida; en la general, con función no definida (AU)

This goal of this research is to talk about the daily life of women who had developed breast cancer and underwent mastectomy and the treatment, and were assisted by a nurse and a nurse group. The objectives were to identify the expectations of women who underwent mastectomy with respect to the care of the nurse and describe how these women perceived the assistance extended to them. It is a descriptive case study with a qualitative approach, using open interview and engaging with nine women from a support group of mastectomized women in Niterói - RJ - Brazil. It was observed that the expectation related to the nurse, who must be professional technically competentc and understnad the moment the patients are going through. In terms of the nurse’s action: women related that some of their doubts were qualmed, which was essential during the post-surgery,by technical procedures and giving emotional support. The research showed that the assistance from the nurse and the others in the group were different, according to the Institution’s policy. I, in the specialized institution, nurses performed a clear and defined job; however, in the generalized institution, the function was not so clear (AU)

[Modern breast surgery]. / Modern emlosebészet.

Today, as a result of the complex and coordinated medical treatment of breast malignancies the long-term survival rate reaches 80%. Modern breast surgery plays a prominent role in the multidisciplinary treatment of breast tumors. Breast surgery in the 21st century simultaneously performs medical and aesthetic procedures on the same organ. Modern day breast surgery is founded on a complex view of breast malignancies, multidisciplinary cooperation, oncoplastic practice, and selecting the optimal surgery techniques, based on state of the art tools and a detailed treatment plan. Authors present the evolution of modern breast surgery; discuss the procedures such as mastectomy, breast conservation surgery, axillary lymph node removal, prophylactic mastectomy, as well as possible versions of immediate or delayed breast reconstruction.

A prospective trial on initiation factor 4E (eIF4E) overexpression and cancer recurrence in node-negative breast cancer.

BACKGROUND: Eukaryotic Initiation Factor 4E (eIF4E) plays a crucial role in translation control. High eIF4E increase in tumor specimens independently predicted recurrence by multivariate analysis. This prospective trial of node-negative only breast cancer patients was initiated to test the hypothesis that high eIF4E increase predicts cancer recurrence and death, independent of nodal status. METHODS: The trial was powered to detect a 2.4-fold increase in relative risk for cancer recurrence in 240 node-negative patients on the basis of high versus low eIF4E increase in tumor specimens (type I error = .05, statistical power = .08). eIF4E level was quantified by using Western blot test. Treatment and surveillance regimens were standardized. Primary endpoints were cancer recurrence and cancer-related death. RESULTS: Of the 242 patients accrued, 112 were in the low eIF4E group (<7.5-fold), 82 were in the intermediate eIF4E group (7.5- to 15-fold), and 48 were in the high eIF4E group (>15-fold). Patients in the high eIF4E group had a statistically significant higher rate of cancer recurrence and cancer-related death (P = .0001 and P < or = .0001, log rank test). The relative risk for cancer recurrence was 2.2-fold higher in the high eIF4E group (P = .001, Cox model), and 3.7-fold higher for cancer-related death (P = .0009). CONCLUSIONS: In node-negative breast cancer, high eIF4E increase predicted a higher rate of cancer recurrence and death. High eIF4E patients had a >2-fold increase in relative risk for cancer recurrence and nearly a 4-fold increase in relative risk for death. This supports our hypothesis that high eIF4E is an independent predictor for breast cancer outcome independent of nodal status.

Internal mammary nodes in breast cancer: diagnosis and implications for patient management -- a systematic review.

The management of internal mammary nodes (IMNs) in breast cancer is controversial. Surgical series from the 1950s showed that one third of breast cancer patients had IMN involvement, with a higher risk in patients with medial tumors and/or positive axillary nodes. IMN metastasis has similar prognostic importance as axillary nodal involvement. However, after three randomized trials showed no survival benefit from extended mastectomy compared with radical or modified radical mastectomy, IMN dissection was largely abandoned. Recently, lymphoscintigraphy studies have renewed interest in IMN evaluation. Approximately one fifth of internal mammary sentinel nodes are pathologic, although most centers do not perform IMN biopsies because of concerns about morbidity and lack of established survival benefit. In addition, results from randomized trials testing the value of postmastectomy irradiation and a meta-analysis of 78 randomized trials have provided high levels of evidence that local-regional tumor control is associated with long-term survival improvements. This benefit was limited to trials that used systemic therapy, which was not routinely administered in the earlier surgical studies, although the contribution from IMN treatment is unclear. IMN irradiation has also been shown to cause increased cardiac morbidity. Before mature results from current randomized trials assessing the benefit of IMN irradiation become available, lymphoscintigraphy may be used to help guide decisions regarding systemic and local-regional treatment. However, even in patients with visualized primary IMN drainage, the potential benefit of treatment should be balanced against the risk of added morbidity.

Extended radical mastectomy versus simple mastectomy followed by radiotherapy in primary breast cancer. A fifty-year follow-up to the Copenhagen Breast Cancer randomised study.

From November 1951 to December 1957, 666 consecutive patients with untreated primary breast cancer admitted to the Radium Center in Copenhagen were randomised before their operability was evaluated into two groups, simple mastectomy with postoperative radiotherapy or extended radical mastectomy. Following physical examination 241 of the patients were excluded, primarily due to tumours deemed inoperable due to clinical criteria (n =107) and due to poor general condition (n =69). Twenty-five years results of disease-free free survival and fifty years results of survival are presented, showing no difference between the two groups. Patients with clinical stage I did significantly better than patients with stage II-III tumours. Patients with grade I tumours had a better survival than patients with grade II-III. The breast cancer associated mortality was lower in premenopausal patients compared to postmenopausal patients. An excess mortality due to breast cancer was evident up to 20-25 years following the primary diagnosis.

Inflammatory breast cancer in Tunisia in the era of multimodality therapy.

BACKGROUND: This study aimed to identify prognostic factors for outcome in Tunisian patients with nonmetastatic inflammatory breast cancer (IBC) receiving multimodality therapy. PATIENTS AND METHODS: From 1994 to 2000, 100 patients with nonmetastatic IBC were reviewed. Patients underwent neo-adjuvant chemotherapy including anthracyclines (99%), then mastectomy (93%) when feasible, radiotherapy (83%) and adjuvant chemotherapy (84%). Sixty patients (60%) had hormone therapy. RESULTS: Median age at diagnosis was 44 years (range 23-71). Seventy patients had premenopausal status (70%). Ten cases occurred during pregnancy (10%). Body mass index indicated overweight or obesity in 76 patients (76%). After neo-adjuvant chemotherapy, pathologic complete response (pCR) rate was 20%. Median time of follow-up for surviving patients was 44 months. Median progression-free survival (PFS) was 19 months and overall survival (OS) 30 months. Factors associated with improved survival were no pregnancy (P = 0.0095), estrogen receptor positivity (P = 0.028), tumor size <5 cm (P = 0.021), clinical complete response (cCR) (P = 0.022), pCR (P = 0.011), negative nodes (P = 0.053) and hormone therapy (P < 0.001). In multivariate analysis, cCR, negative nodes and hormone therapy were independently associated with better OS and PFS. Factors predictive to pCR were age >45 years, negative nodes and cCR. CONCLUSIONS: Tunisian patients with IBC have particular epidemiologic characteristics, with earlier disease and context of overweight and obesity, but prognostic factors are similar to those reported in the literature. Hormone therapy seems to improve patient outcome.

Breast cancer subpopulation with high risk of internal mammary lymph nodes metastasis: analysis of 2,269 Chinese breast cancer patients treated with extended radical mastectomy.

PURPOSE: The selective treatment of internal mammary lymph nodes (IMNs) in breast cancer is controversial. The purpose of this research was to determine the subpopulation patients with high risk of internal mammary lymph nodes metastasis who received extended radical mastectomy without any preoperative treatment from 1956 to 2003 in China. PATIENTS AND METHODS: 1,679 Chinese patients were underwent extended radical mastectomy (ERM) between 1956 and 2003. Four individual variables were selected (tumor site, tumor size, the number of ALNs involvement, patient age),then classified by following standards: tumor site(lateral, central, medial),tumor size(T1:5 cm), ALNs(0,1-3,4-6, >or=7), age(50 y). Chi-square and binary logistic regression were used to analysis relationship of these variable and IMMs. RESULTS: The four individual variables were significantly associated with IMNs metastasis using univariate analysis. However, three individual variables except for tumor size independently impact the IMNs metastasis using multivariate analysis. The incidence of IMNs metastasis in patients with 4-6 and >or=7 positive ALNs was 28.1%, 41.5%. Within subgroup patients with medial tumor and positive ALNs, the incidence of IMNs metastasis was 23.6% for patients with 1-3 positive ALNs, and 47.5% for 4-6 positive ALNs, 38.7% for patients with >or=7 positive ALNs. The incidence of IMNs metastasis was 25.4% for patients with T3 tumor and younger than 35 y. CONCLUSION: Patients with following conditions had high risk of IMNS metastasis: (1) patients with 4 or more positive ALNs. (2) patients with medial tumor and positive ALNs.(3) patients with T3 tumor and younger than 35 y. (4) patients with T2 tumor and positive ALNs.(5) patients with T2 tumor and medial tumor .The incidences of IMNS metastasis for those patients were more than 20%.

Cystosarcoma phyllodes of the breast: a rare diagnosis: case studies and review of literature.

Cystosarcoma phyllodes (CP), otherwise known as phyllodes tumour (PT) of the breast, is a very rare but locally aggressive fibroepithelial tumour in its malignant form, and accounts for 0.3-1% of all breast neoplasias. Using 4 cases reports with different histological classifications as examples (benign-borderline-malignant), we describe the (differential) diagnosis and treatment options of this tumour entity and give an additional review of the available literature.

Role of breast surgeons in evolution of the surgical management of breast cancer.

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.

A prospective trial on initiation factor 4E (eIF4E) overexpression and cancer recurrence in node-positive breast cancer.

OBJECTIVE: A previous study of patients with stage I to III breast cancer showed that those patients whose tumors were in the highest tertile of eIF4E overexpression experienced a higher risk for recurrence. This study was designed to determine whether high eIF4E overexpression predicts cancer recurrence independent of nodal status by specifically targeting patients with node-positive disease. METHODS: The prospective trial was designed to accrue 168 patients with node-positive breast cancer to detect a 2.5-fold increase in risk for recurrence. eIF4E level was quantified by Western blots as x-fold elevated compared with breast tissues from noncancer patients. End points measured were disease recurrence and cancer-related death. Statistical analyses performed include survival analysis by the Kaplan-Meier method, log-rank test, and Cox proportional hazard model. RESULTS: One hundred seventy-four patients with node-positive breast cancer were accrued. All patients fulfilled study inclusion and exclusion criteria, treatment protocol, and surveillance requirements, with a compliance rate >95%. The mean eIF4E elevation was 11.0 +/- 7.0-fold (range, 1.4-34.3-fold). Based on previously published data, tertile distribution was as follow: 1) lowest tertile (<7.5-fold) = 67 patients, 2) intermediate tertile (7.5-14-fold) = 54 patients, and 3) highest tertile (>14-fold) = 53 patients. At a median follow up of 32 months, patients with the highest tertile had a statistically significant higher cancer recurrence rate (log-rank test, P = 0.002) and cancer-related death rate (P = 0.036) than the lowest group. Relative risk calculations demonstrated that high eIF4E patients had a 2.4-fold increase in relative risk increase for cancer recurrence (95% confidence interval, 1.2-4.1; P = 0.01). CONCLUSIONS: In this prospective study designed to specifically address risk for recurrence in patients with node-positive breast cancer, the patients whose tumors were in the highest tertile of eIF4E overexpression had a 2.4-fold increase in relative risk for cancer recurrence. Therefore, eIF4E overexpression appears to be an independent predictor of a worse outcome in patients with breast cancer independent of nodal status.