Screening for distant metastases in patients with ipsilateral breast tumor recurrence: the impact of different imaging modalities on distant recurrence-free interval

Purpose In patients with ipsilateral breast tumor recurrence (IBTR), the detection of distant disease determines whether the intention of the treatment is curative or palliative. Therefore, adequate preoperative staging is imperative for optimal treatment planning. The aim of this study is to evaluate the impact of conventional imaging techniques, including chest X-ray and/or CT thorax-(abdomen), liver ultrasonography(US), and skeletal scintigraphy, on the distant recurrence-free interval (DRFI) in patients with IBTR, and to compare conventional imaging with 18F-FDG PET-CT or no imaging at all. Methods This study was exclusively based on the information available at time of diagnoses of IBTR. To adjust for differences in baseline characteristics between the three imaging groups, a propensity score (PS) weighted method was used. Results Of the 495 patients included in the study, 229 (46.3%) were staged with conventional imaging, 89 patients (19.8%) were staged with 18F-FDG PET-CT, and in 168 of the patients (33.9%) no imaging was used (N=168). After a follow-up of approximately 5 years, 14.5% of all patients developed a distant recurrence as frst event after IBTR. After adjusting for the PS weights, the Cox regression analyses showed that the diferent staging methods had no signifcant impact on the DRFI. Conclusions This study showed a wide variation in the use of imaging modalities for staging IBTR patients in the Netherlands. After using PS weighting, no statistically signifcant impact of the diferent imaging modalities on DRFI was shown. Based on these results, it is not possible to recommend staging for distant metastases using 18F-FDG PET-CT over conventional imaging technique

[Secondary breast operations are often necessary and are no indication of poor oncological quality]

Contains fulltext : 69254.pdf (publisher's version ) (Closed access)The most important factor for tumour recurrence after breast-saving surgery is the margin status. In the Netherlands a 1-mm free margin has been formulated as sufficient, and totally free margins are not necessary in all cases. The current Dutch Health Inspectorate performance indicator, i.e. 10% reexcisions allowed to achieve free margins, is a performance indicator of questionable validity. As long as there is worldwide discussion about the ideal margin in breast-saving surgery a specific norm cannot not be dictated. The aim of the discussion should be how to prevent local recurrence. This percentage is the real performance indicator

Magnetic resonance imaging of ductal carcinoma in situ: what is its clinical application? A review.

Contains fulltext : 79912.pdf (publisher's version ) (Closed access)BACKGROUND: After breast-conserving surgery of ductal carcinoma in situ (DCIS) of the breast or invasive breast carcinoma with an extensive intraductal component, tumor-positive surgical margins are frequently found. Therefore, the extent of the intraductal disease needs to be accurately determined preoperatively. METHODS: Data for this review were identified by search of PubMed. Reference lists of selected articles were cross-searched for additional literature. RESULTS: DCIS is accurately detected with magnetic resonance imaging (MRI), but the typical malignant features are inconsistently seen and most often in high-grade DCIS or in DCIS with a small invasive component. The histopathologic extent of DCIS is more accurately demonstrated with MRI. However, overestimation due to benign proliferative lesions does frequently occur. An improved depiction of DCIS could lead to improved preoperative staging. Conversely, the identification of more extensive disease on MRI could give rise to unnecessary interventions. Therefore, MRI should be used carefully and preferable in specialized and experienced centers. CONCLUSSION: To date, there is no evidence that the use of MRI improves outcomes (ie, decreases recurrence rates) in patients with DCIS

Performance characteristics of specimen radiography for margin assessment for ductal carcinoma in situ: a systematic review

Item does not contain fulltextBACKGROUND: Reducing positive margin rate (PMR) and reoperation rate in breast-conserving operations remains a challenge, mainly regarding ductal carcinoma in situ (DCIS). Intra-operative margin assessment tools have emerged to reduce PMR over the last decades, including specimen radiography (SR). No consensus has been reached on the reliability and efficacy of SR in DCIS. OBJECTIVE: We performed a systematic literature review to assess the performance characteristics of SR for margin assessment of breast lesions with pure DCIS and invasive cancers with DCIS components. METHODS: A literature search was conducted for diagnostic studies up to April 2017 concerning SR for intra-operative margin assessment of breast lesions with pure DCIS or with DCIS components. Studies reporting sensitivity and specificity calculated using final pathology report as reference test were included. Due to improved imaging technology, studies published more than 15 years ago were excluded. Methodological quality was assessed using quality assessment of diagnostic accuracy studies-2 checklist. Due to clinical and methodological diversity, meta-analysis was considered not useful. RESULTS: Of 235 citations identified, 9 met predefined inclusion criteria and documented diagnostic efficacy data. Sensitivity ranged from 22 to 77% and specificity ranged from 51 to 100%. Positive predictive value and negative predictive value ranged from 53 to 100% and 32 to 95%, respectively. High or unclear risk of bias was found in reference standard in 5 of 9 studies. High concerns regarding applicability of index test were found in 6 of 9 studies. CONCLUSIONS: The present results do not support the routine use of intra-operative specimen radiography to reduce the rate of positive margins in patients undergoing breast-conserving surgery for pure DCIS or the DCIS component in invasive cancer. Future studies need to differentiate between initial and final specimen margin involvement. This could provide surgeons with a number needed to treat for a more applicable outcome

The value of mammography in women with focal breast complaints in addition to initial targeted ultrasound

PURPOSE: To determine the added value of mammography in women with focal breast complaints and the utility of initial targeted ultrasound in this setting. METHODS: Women with symptomatic breast disease who were evaluated by breast imaging (mammography/digital breast tomosynthesis and ultrasound) between January 2016 and December 2016 in the Radboud University Medical Centre were included. We retrospectively collected the following data: date of birth, indication of imaging, visibility on mammography/ultrasound, whether biopsy was taken, additional findings, BI-RADS-classification, pathology and follow-up results. RESULTS: A total of 494 women were included (mean age 46.5, range 30 to 93). In 49 women (9.9%), symptomatic breast cancer was diagnosed, all visible during targeted ultrasound. The negative predictive value of targeted ultrasound was very high (99.8%). Additional findings on mammography were significantly more often malignant when the symptomatic lesion was also malignant (3.8% vs 70%, P < 0.05). In only one patient with symptoms caused by a benign finding, an incidental malignancy was detected on mammography outside the area of complaint (detection rate 2.2/1000 examinations). CONCLUSIONS: The contribution of mammography for cancer detection in women with focal breast complaints is very low when targeted ultrasound is performed. Additional findings are most common in patients with symptomatic breast cancer. Our results suggest that initial targeted ultrasound is a more appropriate initial tool for the evaluation of focal breast complaints. Mammography could be performed on indication only

Group medical consultations in the follow-up of breast cancer: a randomized feasibility study

Contains fulltext : 155381.pdf (publisher's version ) (Closed access)PURPOSE: Group medical consultations (GMCs) provide individual medical visits conducted within a group of four to eight peer patients. This study evaluated the feasibility and efficacy of GMCs in the follow-up of breast cancer. METHODS: In this randomized controlled trial, 38 patients participated in a single GMC (intervention group), while the control group (n = 31) received individual outpatient visits. Feasibility is measured in terms of acceptability, demand, practicability and costs, integration and implementation, and efficacy. Between-group differences on the efficacy outcomes distress (SCL-90) and empowerment (CEQ), 1 week and 3 months after the visit, were analyzed using ANCOVAs. RESULTS: GMCs scored high on most areas of feasibility. Patients in GMCs and individual visits were equally satisfied. Patients and professionals reported more discussed themes in GMCs, despite no between-group differences on information needs prior to the visit. Sixty-nine percent of GMC patients experienced peer support. Costs for GMCs were higher compared to individual visits. However, involving a clinical nurse specialist (CNS) instead of a medical specialist reduced costs to the level of individual CNS care. Efficacy outcomes (distress and empowerment) were equal in both groups. CONCLUSION: GMCs in this study were feasible. Further optimization of GMCs in future (cost-)effectiveness trials is possible by increasing the frequency of GMCs, stating criteria for the type of professionals, number of patients involved, and time limits. IMPLICATIONS FOR CANCER SURVIVORS: BCS may benefit from GMCs by receiving more information and additional peer support. GMCs cover all aspects of follow-up and may be a good alternative for individual follow-up.12 p

Risk of Regional Recurrence After Negative Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence

Contains fulltext : 194597.pdf (publisher's version ) (Open Access)BACKGROUND: Repeat sentinel lymph node biopsy (rSLNB) has increasingly been used in patients with ipsilateral breast tumor recurrence (IBTR). The safety in terms of regional disease control after this procedure remains unclear. This study evaluates occurrence of regional recurrence as first event in patients with IBTR and negative rSLNB, treated without additional lymph node dissection. PATIENTS AND METHODS: Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 201 patients, tumor-negative rSLNB was obtained without performing additional lymph node dissections. RESULTS: With median follow-up of 4.7 (range 0.9-12.7) years, regional recurrence occurred after median time of 3.0 (range 0.4-6.7) years in 4.5% (N = 9) of patients as first event after IBTR and rSLNB. In four of these nine patients, the site of recurrence was in concordance with the anatomical location of rSLNB. Two of the nine recurrences were reported in the ipsilateral axilla, resulting in an ipsilateral axillary regional recurrence rate of 1.0%. In the other seven patients, regional recurrence occurred in aberrant basins. Univariable analysis showed that triple-negative IBTR and lower amount of radioactive-labeled tracer ((99m)technetium) used during rSLNB were associated with developing regional recurrence as first event after negative rSLNB (P < 0.05). CONCLUSIONS: The risk of developing regional recurrence after negative rSLNB is low. The low relapse rate supports the safety of rSLNB as primary nodal staging tool in IBTR. The time has come for clinical guidelines to adopt rSLNB as axillary staging tool in patients with IBTR

Laparoscopic cholecystectomy using abdominal wall retraction: hemodynamics and gas exchange, a comparison with conventional pneumoperitoneum

BACKGROUND: Disadvantages related to CO2 pneumoperitoneum have led to development of the abdominal wall retractor (AWR), a device designed to facilitate laparoscopic surgery without conventional pneumoperitoneum (15 mmHg CO2). We investigated the effects of the AWR on hemodynamics and gas exchange in humans. We also investigated whether the use of an AWR imposed extra technical difficulties for the surgeon. A pilot study revealed that cholecystectomy without low-pressure pneumoperitoneum was technically impossible. METHODS: A prospective randomized controlled trial: Twenty patients undergoing laparoscopic cholecystectomy were randomly allocated into group 1: AWR with low-pressure pneumoperitoneum (5 mmHg), or group 2: conventional pneumoperitoneum (15 mmHg). RESULTS: Surgery using the AWR lasted longer, 72 +/- 16 min (mean +/- SD) vs 50 +/- 18 min compared with standard laparoscopic cholecystectomy. There were no differences between the groups with respect to hemodynamic parameters, although a small reduction of the cardiac output was observed using conventional pneumoperitoneum (from 3.9 +/- 0.7 to 3. 2 +/- 1.1 l/min) and an increase during AWR (from 4.2 +/- 0.9 to 5.2 +/- 1.5 l/min). Peak inspiratory pressures were significantly higher during conventional pneumoperitoneum compared to AWR. A slight decrease in pH accompanied by an increase in CO2 developed during pneumoperitoneum and during the use of the AWR. In both groups arterial PO2 decreased. CONCLUSIONS: The results indicate that the view was impaired during use of the AWR and therefore its use was difficult and time-consuming. Possible advantages of this devices' effects on hemodynamics and ventilatory parameters could not be confirmed in this stud