Effect of Magnetic Resonance Imaging on Breast Conservation Therapy versus Mastectomy: A Review of the Literature

The utilization of MRI in the workup of breast cancer has played a controversial role in the surgical treatment of this disease. With the higher resolution of breast tissue afforded, additional lesions are being identified that often warrant additional procedures, subsequently affecting the decision to proceed with breast conservation therapy versus mastectomy. In this paper, a literature review is presented to help illuminate some of the benefits and pitfalls of employing MRI as a diagnostic tool in the care of breast cancer, while additionally providing insight into the management alterations this imaging modality can engender. Though further research is required in a randomized prospective form to fully answer this question, evidence for and against its use continues to mount, especially for select patient groups

Comparative evaluation of [(99m)tc]tilmanocept for sentinel lymph node mapping in breast cancer patients: results of two phase 3 trials.

BackgroundSentinel lymph node (SLN) surgery is used worldwide for staging breast cancer patients and helps limit axillary lymph node dissection. [(99m)Tc]Tilmanocept is a novel receptor-targeted radiopharmaceutical evaluated in 2 open-label, nonrandomized, within-patient, phase 3 trials designed to assess the lymphatic mapping performance.MethodsA total of 13 centers contributed 148 patients with breast cancer. Each patient received [(99m)Tc]tilmanocept and vital blue dye (VBD). Lymph nodes identified intraoperatively as radioactive and/or blue stained were excised and histologically examined. The primary endpoint, concordance (lower boundary set point at 90 %), was the proportion of nodes detected by VBD and [(99m)Tc]tilmanocept.ResultsA total of 13 centers contributed 148 patients who were injected with both agents. Intraoperatively, 207 of 209 nodes detected by VBD were also detected by [(99m)Tc]tilmanocept for a concordance rate of 99.04 % (p < 0.0001). [(99m)Tc]tilmanocept detected a total of 320 nodes, of which 207 (64.7 %) were detected by VBD. [(99m)Tc]Tilmanocept detected at least 1 SLN in more patients (146) than did VBD (131, p < 0.0001). In 129 of 131 patients with ≥1 blue node, all blue nodes were radioactive. Of 33 pathology-positive nodes (18.2 % patient pathology rate), [(99m)Tc]tilmanocept detected 31 of 33, whereas VBD detected only 25 of 33 (p = 0.0312). No pathology-positive SLNs were detected exclusively by VBD. No serious adverse events were attributed to [(99m)Tc]tilmanocept.Conclusion[(99m)Tc]Tilmanocept demonstrated success in detecting a SLN while meeting the primary endpoint. Interestingly, [(99m)Tc]tilmanocept was additionally noted to identify more SLNs in more patients. This localization represented a higher number of metastatic breast cancer lymph nodes than that of VBD

Factors associated with contralateral preventive mastectomy

INTRODUCTION: Contralateral prophylactic mastectomy (CPM) is an option for women who wish to reduce their risk of breast cancer or its local recurrence. There is limited data on demographic differences among patients who choose to undergo this procedure. METHODS: The population-based Florida cancer registry, Florida’s Agency for Health Care Administration data, and US census data were linked and queried for patients diagnosed with invasive breast cancer from 1996 to 2009. The main outcome variable was the rate of CPM. Primary predictors were race, ethnicity, socioeconomic status (SES), marital status and insurance status. RESULTS: Our population was 91.1% White and 7.5% Black; 89.1% non-Hispanic and 10.9% Hispanic. Out of 21,608 patients with a single unilateral invasive breast cancer lesion, 837 (3.9%) underwent CPM. Significantly more White than Black (3.9% vs 2.8%; P<0.001) and more Hispanic than non-Hispanic (4.5% vs 3.8%; P=0.0909) underwent CPM. Those in the highest SES category had higher rates of CPM compared to the lowest SES category (5.3% vs 2.9%; P<0.001). In multivariate analyses, Blacks compared to Whites (OR =0.59, 95% CI =0.42–0.83, P=0.002) and uninsured patients compared to privately insured (OR =0.60, 95% CI =0.36–0.98, P=0.043) had significantly less CPM. CONCLUSION: CPM rates were significantly different among patients of different race, socio-economic class, and insurance coverage. This observation is not accounted for by population distribution, incidence or disease stage. More in-depth study of the causes of these disparities in health care choice and delivery is critically needed

A tailored approach to regional nodal irradiation

Regional nodal irradiation for breast cancer has recently been shown to improve disease-free survival, distant disease-free survival, and breast-related mortality but is associated with morbidity. A tailored approach adding regional nodal irradiation only to patients with involvement of the internal mammary nodes is improving prognosis while minimizing morbidity

The Impact of Advanced Image-Guided Breast Surgery and Oncoplastic Techniques on Margin Positivity in Breast Conserving Surgery

Objective  Positive margins remain a significant psychological and economic burden after breast conserving surgery. The aim of this study was to test the hypothesis that advanced oncoplastic techniques as well as intraoperative integrative imaging with intraoperative ultrasound and mobile digital specimen radiography decreases positive margin rate in breast conserving surgery. Methods  A single-institution retrospective review of a prospectively collected database was performed. Patients with breast neoplasms who underwent lumpectomy with or without using intraoperative integrative imaging approaches and oncoplastic techniques were included. The primary outcome was positive margin rate for each technique. Results  A total of 392 patients were included in the study. The median age of the cohort was 59 years. Overall positive margin rate was 15%. Ductal carcinoma in situ (DCIS) histology and larger tumor size were associated with higher positive margin rate. Intraoperative integrative imaging significantly decreased positive margin rate (9% vs. 18%, p=0.018). Oncoplastic techniques also decreased positive margin rate from 16% to 12%, however this was not significant. Conclusion  Positive margin rate was significantly lower when intraoperative integrative imaging was used. Oncoplastic techniques also decreased positive margin rate in a selected group of patients with large tumor size. We suggest incorporating these techniques in all breast conserving surgery cases

Prognosis of metastatic internal mammary sentinel nodes (IMSN) in breast cancer.

103 Background: The presence of positive internal mammary nodes has historically been associated with a significant worse prognosis. Recent studies have also demonstrated a worse prognosis associated with drainage to the internal mammary nodes. Intense search for those nodes, biopsy, appropriate staging and modern treatment for positive IMSN might improve outcome. We sought to study the prognosis of pathologically positive IMSN at our institution. Methods: A retrospective analysis of a prospectively collected database including all breast cancer patients identified with an IMSN that was biopsied between 2005 and 2012 was performed. Demographics, histologic markers, patterns of recurrence as well as survival data were collected. Univariate and multivariate analysis were performed. Results: Thirteen of 82 patients with a biopsied IMSN were metastatic (16%). In 8 of those (62%), the biopsy resulted in a change in staging. In all cases of positive IMSN additional radiation to the internal mammary chain was added. Eighteen percent (18%) of positive nodes did not show drainage to the internal mammary basin during Lymphoscintigraphy. There was no statistical difference in regional and distant recurrences between the patients with positive IMSN and those with negative IMSN. Furthermore there was no difference in disease specific survival. Conclusions: Intense search for IMSN presence and biopsy of those nodes is associated with changes in staging and treatment for metastatic IMSN. In our study, pathologically positive IMSN were associated with a non- inferior prognosis than negative IMSN