Sentinel node biopsy: an in depth appraisal.

Sentinel node biopsy (SNB) in primary breast cancer has been taken-up widely to avoid the morbidity attributable to axillary node clearance (ANC). Currently many issues surrounding SNB are undecided. This review summarises why some form of axillary surgery is required and presents data on all aspects of SNB including methodology, clinical results and problems that may delay the introduction of SNB as best practice for all patients with primary breast cancer. There is no long or medium term data relating to the consequences of replacing ANC with SNB, but the mechanisms and probable magnitude of both beneficial and detrimental effects are estimated. A low level of false negative results are inherent to the technique but it is demonstrated that SNB is likely to have an only marginal (0.6%) effect on survival that would be undetectable by clinical trials. Patient sub-groups particularly likely to benefit from SNB are identified.

MR navigated breast surgery: method and initial clinical experience.

3D dynamic contrast enhanced magnetic resonance (MR) images may help to reduce the high re-excision rate associated with breast conserving surgery. However these images are acquired prone, whilst surgery is performed supine which results in a large deformation that limits their usefulness. We describe here a registration technique based on a biomechanical model to account for soft tissue deformation between prone MR imaging and surgery. The accuracies of the individual registration steps are assessed off-line. We then report our first clinical experience with an image-guided surgery system which incorporates these algorithms. The system's accuracy is assessed against tracked ultrasound images, and is determined to be around 5mm for this case.

Breast carcinoma in women age 25 years or less.

BACKGROUND: Although several studies have examined breast carcinoma in young women aged < or = 35 years at diagnosis, there are only occasional cases reported in very young women aged < or = 25 years, and, to the authors' knowledge, no series are available. The presentation, tumor biology, behavior, and outcome of breast carcinoma in very young women are not known, and the rarity of breast malignancy within this age group could lead to diagnostic delays. METHODS: The tumor characteristics and survival of 15 women aged < or = 25 years at the time of diagnosis, have been reviewed and compared with women aged 26-35 years under the care of Guy's Hospital's Breast Unit during the same period of time. Where appropriate, the two groups were individually matched for tumor size (clinical measurement) and histologic grade. RESULTS: Fifteen cases were examined, with a median follow-up of 108 months and a median age of 24 years. The median duration of symptoms was 4 weeks, and the median tumor size was 20 mm. Two patients had ductal carcinoma in situ (DCIS) only, while the other 13 patients had invasive carcinomas, none of which were Grade I. A mastectomy was performed on 8 out of 15 patients (53%). Axillary nodal metastases were present in 4 out of 12 patients (33%). Of the 13 cases of invasive disease, 9 out of 13 patients (69%) experienced recurrence and died of breast carcinoma. Median disease free survival for patients with invasive disease was 86 months. There was no difference in overall survival between the patients aged < or = 25 years and those aged 26-35, but taken together young women < or = 35 had a worse prognosis than women between 36 and 65, due to a higher incidence of high grade and estrogen receptor negative tumors. CONCLUSIONS: The current study suggests that among young women with breast carcinoma there is no difference in prognosis between the very young and the young. Despite two thirds of patients being node negative, the high mortality rate indicates a need for an optimal selection of adjuvant therapy among these cases.

Paget disease of the nipple: a multifocal manifestation of higher-risk disease.

BACKGROUND: The treatment of Paget disease by mastectomy has been challenged recently in favor of breast-conserving techniques. A large series of patients treated with mastectomy has been reviewed to assess the feasibility of less radical surgery. METHODS: The cases of 70 women with a clinical diagnosis of Paget disease were reviewed. The type, grade, receptor and node status, and the mammographic and pathologic extent of the underlying breast malignancy were determined. The survival of patients with invasive disease was compared with matched controls without Paget disease. RESULTS: The underlying malignancy was invasive in 58% of cases. Despite the fact that only one third of women presented with a palpable mass, the malignancy was frequently extensive, being confined to the retroareolar region in only 25% of cases. The true extent of the disease was underestimated by mammography in 43% of cases. Of the patients with ductal in situ carcinoma, 96.5% had high-grade carcinomas and 100% had invasive carcinomas of high cytonuclear grade. Overexpression of the c-erb-B2 oncogene was detectable in 83% of cases. Patients with Paget disease had a significantly worse survival than matched controls, but this difference was eliminated if they were also matched for c-erb-B2 status. CONCLUSIONS: Paget disease is often associated with extensive underlying malignancy, which is difficult to assess accurately either clinically or mammographically. As a consequence, cone excision of the nipple would have resulted in incomplete excision in 75% of cases. The underlying disease is of high grade and is frequently c-erb-B2 positive with a resulting poor prognosis. Aggressive local and systemic treatment would seem to be merited.