Contralateral Axillary Lymph Node Metastases from Breast Carcinoma: Is it Time to Review TNM Cancer Staging?

BACKGROUND: Contralateral axillary lymph node metastasis (CAM) is an infrequent clinical condition currently considered an M1, stage IV, disease. Due to the absence of shared data on CAM significance and on its therapeutic approach, be it curative or simply palliative, its management is still uncertain and undoubtedly represents a clinical challenge. PATIENTS AND METHODS: Patients with pathologically confirmed metachronous CAM were retrospectively evaluated. All patients had been managed at the European Institute of Oncology, Milan, Italy, from 1997. Patients with distant metastases at the time of CAM were excluded. Possible treatments included surgery, systemic therapy and RT (radiotherapy). Outcomes were evaluated as rates of disease-free survival (DFS) and of overall survival (OS). RESULTS: Forty-seven patients with CAM were included in the study. Metachronous CAM occurred 73 months (range 5-500 months) after diagnosis of the primary tumor. The median follow-up time was 5.4 years (interquartile range 2.9-7.0 years). The estimated OS was 72% at 5 years (95% CI 54-83), and 61% at 8 years (95% CI 43-75). The estimated DFS was 61% at 5 years (95% CI 44-74), and 42% at 8 years (95% CI 25-59). CONCLUSION: These findings, together with those from previous studies, show that CAM outcome, particularly if measured as OS, appear better than at other sites of distant dissemination, when CAM is subjected to surgical and systemic treatments with a curative intent. Therefore, a new clinical scenario is suggested where, in the TNM system, CAM is no longer classified as a stage IV, but as an N3 disease.

Use of bilateral prophylactic nipple-sparing mastectomy in patients with high risk of breast cancer.

BACKGROUND: Nipple-sparing mastectomy (NSM) is being performed increasingly for risk reduction in high-risk groups. There are limited data regarding complications and oncological outcomes in women undergoing bilateral prophylactic NSM. This study reviewed institutional experience with prophylactic NSM, and examined the indications, rates of postoperative complications, incidence of occult malignant disease and subsequent breast cancer diagnosis. METHODS: Women who had bilateral prophylactic NSM between 2000 and 2016 were identified from a prospectively maintained database. Rates of postoperative complications, incidental breast cancer, recurrence and overall survival were evaluated. RESULTS: A total of 192 women underwent 384 prophylactic NSMs. Indications included BRCA1 or BRCA2 mutations in 117 patients (60·9 per cent), family history of breast cancer in 35 (18·2 per cent), lobular carcinoma in situ in 29 (15·1 per cent) and other reasons in 11 (5·7 per cent). Immediate breast reconstruction was performed in 191 patients. Of 384 NSMs, 116 breasts (30·2 per cent) had some evidence of skin necrosis at follow-up, which resolved spontaneously in most; only 24 breasts (6·3 per cent) required debridement. Overall, there was at least one complication in 129 breasts (33·6 per cent); 3·6 and 1·6 per cent had incidental findings of ductal carcinoma in situ and invasive breast cancer respectively. The nipple-areola complex was preserved entirely in 378 mastectomies. After a median follow-up of 36·8 months, there had been no deaths and no new breast cancer diagnoses. CONCLUSION: These findings support the use of prophylactic NSM in high-risk patients. The nipples could be preserved in the majority of patients, postoperative complication rates were low, and, with limited follow-up, there were no new breast cancers.

ANTECEDENTES: La mastectomía con preservación del pezón (nipple-sparing mastectomy, NSM) se realiza cada vez más para reducir riesgos en los grupos de pacientes de alto riesgo. Se dispone de pocos datos sobre complicaciones y resultados oncológicos en mujeres sometidas a NSM bilateral profiláctica. Este estudio revisó la experiencia institucional de la NSM profiláctica, y analizó las indicaciones, tasas de complicaciones postoperatorias, incidencia de enfermedad maligna oculta y diagnóstico de subsiguiente cáncer de mama. MÉTODOS: Se identificaron mujeres sometidas a NSM bilateral profiláctica durante el periodo 2000-2016 a partir de una base de datos prospectiva. Se evaluaron tasas de complicaciones postoperatorias, cáncer de mama incidental, recidiva y supervivencia global. RESULTADOS: Un total de 192 mujeres fueron sometidas a 384 NSMs profilácticas. Las indicaciones incluyeron mutaciones BRCA1 o BRCA2 en 117 (61%) pacientes, historia familiar de cáncer de mama en 35 (18%), carcinoma lobulillar in situ en 29 (15%) y otros motivos en 11 (5,7%). La reconstrucción mamaria inmediata se realizó en 191 pacientes. De las 384 NSMs, 116 (30%) presentaron alguna evidencia de necrosis de la piel durante el seguimiento y la mayoría se resolvieron de forma espontánea, con solo 24 (6,2%) mamas que requirieron desbridamiento. Globalmente hubo al menos una complicación en 129 (34%) mamas; 3,6% y 1,6% tuvieron hallazgos incidentales de carcinoma ductal in situ o cáncer de mama invasivo, respectivamente. El complejo areola-pezón se preservó completamente en 378 mastectomías. Tras una mediana de seguimiento de 36,8 meses, no hubo fallecimientos ni ningún diagnóstico nuevo de cáncer de mama. CONCLUSIÓN: Estos hallazgos apoyan la utilización de la NSM profiláctica en pacientes de alto riesgo. En la mayoría pacientes fue posible la preservación del pezón, las tasas de complicaciones postoperatorias fueron bajas y, con un seguimiento limitado, no hubo nuevos casos de cáncer de mama.

Sentinel lymph node biopsy in microinvasive ductal carcinoma in situ.

BACKGROUND: Microinvasive breast cancer is an uncommon pathological entity. Owing to the rarity of this condition, its surgical axillary management and overall prognosis remain controversial. METHODS: A database was analysed to identify patients with microinvasive ductal carcinoma in situ (DCIS) who had surgery for invasive breast cancer at the European Institute of Oncology, Milan, between 1998 and 2010. Women who had undergone axillary staging by sentinel lymph node biopsy were included in the study. RESULTS: Of 257 women with microinvasive breast cancer who underwent sentinel lymph node biopsy (SLNB), 226 (87·9 per cent) had negative sentinel lymph nodes (SLNs) and 31 had metastatic SLNs. Twelve patients had isolated tumour cells (ITCs), 14 had micrometastases and five had macrometastases in sentinel nodes. Axillary lymph node dissection was performed in 16 of the 31 patients with positive SLNs. After a median follow-up of 11 years, only one regional first event was observed in the 15 patients with positive SLNs who did not undergo axillary lymph node dissection. There were no regional first events in the 16 patients with positive SLNs who had axillary dissection. CONCLUSION: Good disease-free and overall survival were found in women with positive SLNs and microinvasive DCIS. This study is in line with studies showing that SLNB in microinvasive DCIS may not be useful, and supports the evidence that less surgery can provide the same level of overall survival with better quality of life.

Nipple-sparing mastectomy in patients with BRCA1/2 mutations and variants of uncertain significance.

BACKGROUND: Nipple-sparing mastectomy (NSM) is associated with improved cosmesis and is being performed increasingly. Its role in BRCA mutation carriers has not been well described. This was a study of the indications for, and outcomes of, NSM in BRCA mutation carriers. METHODS: BRCA mutation carriers who underwent NSM were identified. Details of patient demographics, surgical procedures, complications, and relevant disease stage and follow-up were recorded. RESULTS: A total of 177 NSMs were performed in 89 BRCA mutation carriers between September 2005 and December 2013. Twenty-six patients of median age 41 years had NSM for early-stage breast cancer and a contralateral prophylactic mastectomy. Mean tumour size was 1·4 (range 0·1-3·5) cm. Sixty-three patients of median age 39 years had prophylactic NSM, eight of whom had an incidental diagnosis of ductal carcinoma in situ. There were no local or regional recurrences in the 26 patients with breast cancer at a median follow-up of 28 (i.q.r. 15-43) months. There were no newly diagnosed breast cancers in the 63 patients undergoing prophylactic NSM at a median follow-up of 26 (11-42) months. All patients had immediate breast reconstruction. Five patients (6 per cent) required subsequent excision of the nipple-areola complex for oncological or other reasons. Skin desquamation occurred in 68 (38·4 per cent) of the 177 breasts, and most resolved without intervention. Debridement was required in 13 (7·3 per cent) of the 177 breasts, and tissue-expander or implant removal was necessary in six instances (3·4 per cent). CONCLUSION: NSM is an acceptable choice for patients with BRCA mutations, with no evidence of compromise to oncological safety at short-term follow-up. Complication rates were acceptable, and subsequent excision of the nipple-areola complex was rarely required.

Local approaches to hereditary breast cancer.

The diagnostic and local treatment modalities of hereditary breast cancer (HBC) are evolving based on emerging evidence from new imaging, radiotherapy and surgical studies. The optimal selection of diagnostic and therapeutic strategies for the individual HBC patient remains an area of active research in this relatively new patient population. In this context, some rational pathways of intervention are currently available to both reduce cancer risk in mutation carriers without a cancer diagnosis, as well as to reduce the risk of recurrence or new cancers among the carriers already diagnosed with a malignancy. It is encouraging to notice to what degree certain interventions have successfully reduced both the risk of malignancy and the anxiety associated with this genetic diagnosis. This updated report aims at summarizing the most recent findings, while it identifies the areas of uncertainty that remain, and continue to present difficult challenges, particularly among younger HBC patients.

New innovative techniques in radiotherapy for breast cancer.

Breast-conserving surgery (BCS) followed by adjuvant whole breast radiotherapy (WBRT) is an established treatment for early-stage breast cancer. Long-term follow-up has demonstrated equivalent survival to mastectomy. However, standard WBRT to the conserved breast requires daily radiation treatment, 5 days per week, for 5-7 weeks. This schedule imposes a considerable burden on breast cancer patients and healthcare systems alike. For the last decade, there has been considerable interest in lessening the volume of breast treated with radiotherapy and reducing the number of fractions of radiation treatment. Accelerated partial breast irradiation (APBI), including intraoperative radiotherapy (IORT), delivers high-dose radiation immediately surrounding the lumpectomy cavity, with relative sparing of the majority of the ipsilateral breast. Hypofractionated WBRT delivers radiation to the entire ipsilateral breast; however, this is achieved using a smaller number of fractions and total dose of radiotherapy. The attraction of less invasive or demanding radiotherapy schedules has led to the widespread introduction of APBI before its long-term results have been established. In the past 5 years, data from prospective trials of hypofractionated WBRT and IORT compared to standard WBRT have become available. Additionally, a large, prospective randomized study of APBI versus WBRT is nearing accrual. In this review article, we will discuss these new innovative techniques in radiotherapy for breast cancer. We will also discuss the recently completed and ongoing prospective studies that will provide a robust evaluation of the safety and efficacy of these techniques.

Study of quadrant high-dose intraoperative radiation therapy for early-stage breast cancer.

BACKGROUND: Partial breast irradiation has been tested in limited pilot studies and shown to provide acceptable cosmesis, minimal toxicity and adequate local control. The aim of this study was to determine the feasibility of using quadrant high-dose intraoperative radiation therapy (IORT) for the treatment of early-stage breast cancer. METHODS: Fifty-two women with early-stage breast cancer were treated with breast-conserving therapy and IORT between October 2002 and January 2006. The first 18 women received a radiation dose of 20 Gy. The protocol was then amended and the remaining 34 women were treated with 18 Gy. Each patient was evaluated after surgery, and at 3, 6 and 12 months; complications, toxicity and cosmetic outcomes were recorded by the breast surgeon. RESULTS: Women treated with 18 Gy appeared to have a more favourable cosmetic outcome compared with the earlier treatment group. At last follow-up, none of the women treated on the protocol had a breast recurrence. CONCLUSION: Experience suggests that this IORT technique is feasible, although further follow-up is necessary to assess its therapeutic value.

Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series.

BACKGROUND: Axillary lymph node dissection is an established component of the surgical treatment of breast cancer, and is an important procedure in cancer staging; however, it is associated with unpleasant side effects. We have investigated a radioactive tracer-guided procedure that facilitates identification, removal, and pathologic examination of the sentinel lymph node (i.e., the lymph node first receiving lymphatic fluid from the area of the breast containing the tumor) to predict the status of the axilla and to assess the safety of foregoing axillary dissection if the sentinel lymph node shows no involvement. METHODS: We injected 5-10 MBq of 99mTc-labeled colloidal particles of human albumin peritumorally in 376 consecutive patients with breast cancer who were enrolled at the European Institute of Oncology during the period from March 1996 through March 1998. The sentinel lymph node in each case was visualized by lymphoscintigraphy, and its general location was marked on the overlying skin. During breast surgery, the sentinel lymph node was identified for removal by monitoring the acoustic signal from a hand-held gamma ray-detecting probe. Total axillary dissection was then carried out. The pathologic status of the sentinel lymph node was compared with that of the whole axilla. RESULTS: The sentinel lymph node was identified in 371 (98.7%) of the 376 patients and accurately predicted the state of the axilla in 359 (95.5%) of the patients, with 12 false-negative findings (6.7%; 95% confidence interval = 3.5%-11.4%) among a total of 180 patients with positive axillary lymph nodes. CONCLUSIONS: Sentinel lymph node biopsy using a gamma ray-detecting probe allows staging of the axilla with high accuracy in patients with primary breast cancer. A randomized trial is necessary to determine whether axillary dissection may be avoided in those patients with an uninvolved sentinel lymph node.

Effect of tamoxifen on measurements of hemostasis in healthy women.

BACKGROUND: Tamoxifen citrate is being evaluated for primary prevention of breast cancer, but this drug with estrogen-like properties may cause changes in the hemostatic system that would increase the risk of thrombosis. METHODS: Women who had undergone hysterectomy were consecutively enrolled in the placebo-controlled, randomized, double-blind Breast Carcinoma Chemoprevention Tamoxifen Study, which was designed to evaluate the efficacy of oral tamoxifen citrate (20 mg/d). Our substudy of hemostasis and lipid measurements included the first 68 consecutive women assigned to tamoxifen (n = 31) or placebo (n = 37). Blood specimens were obtained before treatment and after 1,2,4, and 6 months of treatment. Measurements included blood cell counts, lipid levels, coagulation activation markers, clotting factors, and anticoagulant and fibrinolysis proteins. RESULTS: Hematocrit and hemoglobin and platelet levels fell slightly but significantly in women treated with tamoxifen. No between-treatment differences were observed in any of the clotting factors. Naturally occurring anticoagulant proteins such as antithrombin and protein C fell slightly in women treated with tamoxifen. However, no significant changes were observed in any of the markers of activated coagulation or fibrinolysis (fibrinopeptide A, prothrombin fragment 1 + 2, thrombin-antithrombin complex, D-dimer). Total and low-density lipoprotein cholesterol levels fell significantly in women treated with tamoxifen. CONCLUSIONS: Tamoxifen induced a modest decrease in anticoagulant proteins, but without biochemical signs of activation of coagulation and fibrinolysis. Tamoxifen improved the lipid profile and induced changes in blood cell counts, which should determine an improvement in blood rheologic factors. These preliminary findings seem to justify continuation of the double-blind study in healthy women, but only direct comparison of thromboembolic complications in the 2 treatment groups will establish whether tamoxifen carries a risk of thrombosis.

Quantitative and qualitative cosmetic evaluation after conservative treatment for breast cancer.

148 consecutive patients treated by two different types of conservative surgery were objectively and subjectively evaluated for cosmetic outcome. In 73 patients, tumorectomy, axillary dissection, external radiotherapy (45 Gy) plus iridium implant (15 Gy) were performed, while in the other group of 73 patients a more extensive surgical approach was carried out: quadrantectomy, axillary dissection plus external radiotherapy (50 + 10 Gy). The appearance of the patients' breasts was analysed for symmetry by computer, and differences in symmetry were correlated with tumour location and breast size. A subjective assessment was given by a 3-member panel and the results were correlated with objective measurements. In addition, patients were asked to fill out a self-assessment questionnaire on the aesthetic result of the operated breast. Better results were generally noted in the group of patients treated by more conservative surgery. Substantial differences in the aesthetic outcome were noted between the patient's own evaluation, the computer's measurement of symmetry and the assessment of the panel of observers.

Prediction of response to primary chemotherapy for operable breast cancer.

The use of primary systemic cytotoxics leads to a high remission rate in patients with breast cancer. Response was identified as an important variable associated with survival. Thus, features which predict response, are potentially relevant for planning treatments and improving survival. Retrospectively, we investigated several histopathological features (expression of oestrogen and progesterone receptors, Mib1, bcl-2, c-erbB-2, and p53) prior to two programmes of either sequential preoperative chemotherapy (doxorubicin plus cyclophosphamide) and radiotherapy (Group A), or preoperative chemotherapy (5-fluorouracil, folinic acid and vinorelbine) alone (Group B) in patients with operable breast cancer. After three courses, patients with a partial or complete response were given a further three courses, which was followed for patients in Group A by radiotherapy 50 Gy plus a boost of 10 Gy. All patients were submitted to surgery after completion of preoperative treatment and pathology material from 73 patients (median age, 49 years, range, 30-70; performance status, 0-1; 68 T2, 5 T3) was obtained. The overall response rate according to radiological and clinical evaluation was 59% (68% for Group A and 49% for Group B). 12 of 14 patients with p53-positive tumours and 31 of 59 with p53-negative tumours responded (P = 0.04). 6 of 7 patients with elevated c-erbB-2 had a response compared with 37 of 66 patients in the group with c-erbB-2 negative tumours (P = 0.03). Mib1 expression decreased substantially (> or = 50%) in 25 patients during treatment, of whom 20 responded compared with 21 of 48 patients with a lower decrease (P = 0.04). Response was observed in 28 of 37 patients with high baseline Mib1 (> 20%) and in 15 of 36 patients in the low Mib1 group (P = 0.05). Finally, 32 of 44 tumours with low expression of progesterone receptors responded compared with 11 of 29 tumours with high receptors expression (P = 0.05). These markers might be useful for tailoring primary and postsurgical systemic treatments.

The influence of radiotherapy on cosmetic outcome after breast conservative surgery.

PURPOSE: The influence of radiotherapy in the cosmetic outcome after conservative surgery for breast cancer was evaluated using an objective method of calculating the asymmetry between the two breasts. METHODS AND MATERIALS: One hundred and one patients treated with the same conservative surgery were evaluated for cosmetic outcome. Sixty-one of them received external radiotherapy (50 + 10 Gy) to the residual breast; the remaining 40 underwent surgery only. The aspect of the patients' breasts was objectively assessed for symmetry by means of a computerized technique. A subjective assessment of the cosmetic outcome was performed both by physician and patient. These objective and subjective assessments were compared in the two groups treated with or without radiotherapy. RESULTS: The results obtained did not show significant differences in terms of cosmetic outcome in the two groups. Skin telangectasia was noted in two radiotherapy patients, while hypertrophic breast scars were only noted in six nonirradiated patients. CONCLUSIONS: We found that standard radiotherapy does not seem to influence the symmetry and the cosmetic results in breast conservative treatment when compared to a similar group of patients with the same quadrantectomy procedure and no radiotherapy.

Percutaneous transthoracic needle aspiration biopsy: a case report of implantation metastasis.

Dissemination of tumor cells along the needle tract after needle aspiration biopsy has been reported in the literature, but it is an extremely uncommon event, especially when 'fine needles' (above 21 Gauge) are used. In the work presented, a patient with a mammary nodule of doubtful nature is reported. After histological evaluation the node proved to be an intra-mammary dissemination of poorly differentiated adenocarcinoma of the lung via the needle track after aspiration biopsy. The needle used was a 20 Gauge, which is not included in the fine needle category recommended by most authors. The possibility of tumor cells dissemination after needle biopsies is discussed.

Resectable breast cancer: axillary dissection sparing pectoralis muscles and nerves.

In breast cancer surgery, axillary dissection is currently considered an essential step. Nevertheless, procedures commonly used include the resection of the pectoralis minor muscle and/or pectoralis nerves. Since 1984 we have performed axillary dissection by sparing both the pectoralis muscles and their nerves. In this paper we present the surgical technique. The comparison of the two groups with clinical N0 N1a assessment, the former of 103 patients submitted to this kind of surgical procedure, the latter (108 women) treated by resection of the pectoralis minor muscle, showed that the mean number of dissected lymph nodes in both procedures was superimposable.

Extent of metastatic axillary involvement in 1446 cases of breast cancer.

One thousand, four hundred and forty-six patients with carcinoma of the breast treated with Halsted mastectomy (167), Patey mastectomy (732), and conservative surgery with axillary dissection, either at the same time (340), or separately (207), were evaluated with regard to the number and distribution of axillary lymph nodes. A total of 29,378 were removed and examined, on average 20.3 per patient. The average number of nodes was 13.5 at the first level, 4.5 at the second and 2.3 at the third. The same number of nodes were removed in patients treated with extensive surgery, such as Halsted mastectomy and limited surgery such as lumpectomy and in independent axillary dissection. In 839 cases metastases were found in the axilla. The average number of involved nodes was 6.4. Out of 839 patients, the first level was the site of metastases in 828, the second level in 364 and the third in 187. When a single lymph node was involved, it was nearly always at the first level. In only 11 cases, were the second and/or third levels invaded without metastases at the first level. Therefore, the percentage of cases with skipping metastases was very low (1.3%). It appears from the present data that the spread of breast cancer to the axilla follows a regular pattern; the first level is invaded first, whilst in most cases, the second and third levels are involved only when the first is substantially affected.

Preoperative localization and surgical approach in 344 cases of non-palpable breast lesions.

From June 1985 to August 1989, 344 cases of mammographic non-palpable breast lesions were operated on at the National Cancer Institute in Milan. The mammographic findings consisted of clusters of microcalcifications in 162 cases (42.1%), suspicious opacities with irregular borders in 116 cases (37.7%) and opacities containing microcalcifications in 66 cases (19.2%). The mean age of the patients was 51 years (range 31-77 years). In all patients localization was performed 1 day before the operation, introducing a self-retaining anchor wire into the mammary parenchyma. The histological findings showed benign breast disease in 184 cases (53.4%); proliferative dysplasia without atypia in 150 cases (81.5%); proliferative dysplasia with atypia in 22 cases (12%); fibroadenoma in nine and papilloma in three cases. Of 160 patients with carcinoma, 37 had non-infiltrating carcinoma: 28 of these cases (17.5%) had non-infiltrating ductal carcinoma and nine cases (5.6%) had lobular carcinoma in situ. In the 123 cases with infiltrating breast cancer the histological types were ductal infiltrating carcinoma (32.5%), lobular infiltrating carcinoma (9.8%), and 34.1% of the cases an associated or prevalent intraductal carcinoma was found. In 138 cases (85.6%) a conservative surgical procedure (quadrantectomy or more limited excision) was done, and in 22 (14.4%) cases a total mastectomy was necessary because of the extent of the disease. Axillary dissection was performed in 116 of the 123 patients with histological invasive carcinoma. Nodal metastases were found in 24 cases (20.7%), and only one node was involved in nine of the cases (37.5%), two to three nodes in nine cases (37.5%) and four to ten nodes in six cases (25%).

Evaluation of resection margins after breast conservative surgery with monoclonal antibodies.

An immunocytochemical method for the detection of cancer cells, in the cell suspension obtained by scraping the surface of the surgical resection margins is described and its sensitivity compared to the conventional histology performed on random biopsies from the same margins. The reactivity of the cells with a pool of monoclonal antibodies (Mab) directed against epithelial markers indicated that in 80% of the 42 cases tested, the scraping method was adequate for the gathering of cells from the margins. The analysis of the samples using B72.3 Mab specific for tumor cells revealed that, among B72.3-positive tumor cases, 31% of breast margins contained tumor cells, whereas only 12% were histologically positive. Our results indicate that the immunocytological methodology is therefore more sensitive and should be used alongside histological examination to detect the tumor contamination in the surgical resection margins.

Contralateral breast cancer after limited surgery plus radiotherapy of early mammary tumors.

Conservative treatment of early breast cancer with limited surgery requires a mandatory irradiation of the affected breast, which implies a low but measurable irradiation of contralateral breast too. As ionizing radiations can produce an oncogenic effect on mammary tissues, the series of 701 patients of the Milano clinical trial on T1 No breast cancer (1973-1980) was investigated to compare the incidence of contralateral breast cancer in the Halsted group (not irradiated) and in the QU.A.RT. group (irradiated on the operated breast with a total dose of 50 Gy plus a limited boost of 10 Gy). In March 1986, a contralateral breast cancer was diagnosed in 17/349 patients (4.9%) of the Halsted group and in 18/352 patients (5.1%) of the QU.A.RT. group after a median follow-up of 108 months. The sites of contralateral cancer were superimposable in the two groups of patients, with a constant prevalence of external quadrants, despite the great difference of dose distribution in the irradiated patients. Our data on the incidence of contralateral breast cancer failed to demonstrate an oncogenic effect of irradiation to date, but the follow-up is still in progress and any future event will be registered and discussed.

A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer.

Internal mammary lymph-node (IMN) metastases in breast carcinomas have a major influence on survival, comparable with the influence of axillary lymph-node metastases (ALNM). Prospective, randomized trials have demonstrated that complete IMN dissection as part of extended radical mastectomy does not improve overall or disease-free survival. In the subset of patients with tumours 1cm or less in size and no ALNM, information on IMN status would provide important information. In these cases, the presence of IMN metastases would change the staging from stage I to stage IIIB, according to the current tumour, node and metastasis classification. More importantly, it would influence these patients' adjuvant treatment. Lymphatic mapping for sentinel lymph-node (SLN) biopsy has demonstrated extra-axillary drainage in up to 35% of patients. Recent reports have demonstrated the feasibility of internal mammary sentinel lymph-node (IM-SLN) biopsy. Here we review the general prognostic and clinical significance of tumor location and lymph-node metastases in breast cancer and discuss the specific factors associated with IMN identification, metastases and treatment in the pre-SLN and SLN eras. Based on our review, we propose an algorithm for a selective approach to IM-SLN in breast cancer.

Electropotential evaluation as a new technique for diagnosing breast lesions.

A new approach, termed the Biofield test, may have the potential to augment the process of diagnosing breast cancer. This technique is based on the analysis of skin surface electrical potentials measured by an array of specially designed sensors which are placed on the breasts. Measurements are recorded noninvasively and then analyzed using pattern recognition algorithms to produce an immediate and objective assessment of breast tissue in vivo. Initial clinical trials suggests that the test can achieve a sensitivity of approximately 90% and a specificity of 40-50%, which indicates that the test might be useful for excluding cancer when it is, in fact, absent. Although research to date has focused on the differential diagnosis of suspicious breast lesions, future applications could include breast cancer screening, close surveillance and diagnosis of recurrent cancers in breasts previously treated with conservative therapy, and monitoring the effectiveness of breast cancer therapies. Improvements and new applications are expected to occur as additional research and validation in actual clinical settings is performed.