After lymphadenectomy for early breast cancer, seroma formation is a constant event requiring a suction drainage. This drainage is the strongest obstacle to reducing the hospital stay. Axillary padding without drainage appears to be a valuable option amid the various solutions for reducing the hospital stay.
We conducted a comparison between 114 patients with padding and 185 patients with drainage. Data were obtained from 2 successive prospective studies.
The mean hospital stay was 2.4 days (range 1–4) in the padding group and 4.2 days (range 2–9) in the drainage group (p < 0.05). There were fewer needle aspirations for seroma in the padding group (8.8 vs. 23%, p < 0.05). At 6 weeks, only 28% (32/114) of the patients in the padding group reported pain versus 51% (94/185) in the drainage group. The mean pain intensity at 6 weeks was 3 and 4.3 respectively (p < 0.0001).
Axillary padding without drainage was associated with a better post-operative course than suction drainage in this historical comparison, and the hospital stay was significantly shortened. There are only few series published on this new technique but they all indicate good feasibility and good tolerance. A large randomised multicentric evaluation is now warranted.
Breast cancer surgery; Axillary padding; Seroma; Drainage; Early discharge
Female breast tissue has a rich vascular supply and carries a high risk of excessive bleeding during large-core needle biopsy. It is crucial to shorten bleeding time and reduce hematoma size after the procedure. Currently, more efficient hemostatic dressings are becoming available.
Material and Methods
The bleeding time and hematoma size after breast biopsy with use of either Instant Clot Pad (ICP) dressings or cotton gauze were compared.
ICP could attract a vast number of red blood cells and formed blood clots in about 30 s (in vitro blood clotting test). In clinical breast biopsy examinations, the average bleeding time with ICP was significantly reduced to about 2.9 min as compared to 6.4 min with cotton gauze (p < 0.005). The average hematoma size was also reduced with the use of ICP (0.89 cm3) as compared to cotton gauze (1.28 cm3). In patients with benign breast disease, ICP significantly reduced hematoma size.
ICP used after breast biopsy could shorten the bleeding time in all patients, and significantly reduce the hematoma size in patients with benign compared to those with malignant breast disease.
Breast biopsy; Hemostasis; Bleeding time; Hematoma
Breast cancer during pregnancy (BCP) is an important subgroup within the young and very young breast cancer patients. It accounts for about 1% of all breast cancers. Due to an increased awareness, the attitude towards breast cancer during pregnancy has changed and, today, women with BCP are more likely to receive standard chemotherapy and have a term delivery instead of being advised to interrupt the pregnancy or undergo an early preterm delivery. This increased knowledge is based on small cohort studies and international collaborations such as the registry by the German Breast Group for BCP and the initiative of the European Society of Gynaecological Oncology (ESGO). Guidelines and recommendations such as the German guidelines by the AGO (Arbeitsgemeinschaft Gynäkologische Onkologie, www.ago-online.org) and the National Comprehensive Cancer Network (NCCN) guidelines include recommendations for BCP. In general, surgery and chemotherapy (beyond the 13th week of gestation) can be safely performed during pregnancy. Chemotherapy should follow the treatment recommendations for breast cancer in young women. Trastuzumab, endocrine treatment, and radiotherapy are not indicated during pregnancy. Preterm delivery should be avoided as far as possible because it bears a higher risk of infant morbidity and mortality. The treatment of BCP should be planned within a multidisciplinary team including perinatologists, obstetricians and neonatologists.
Breast cancer; Pregnancy; Chemotherapy; Guidelines
In the routine work-up of suspect breast lesions, ultrasound-controlled core needle biopsy (CNB) is the most common tool to acquire tissue for histopathologic analysis in a safe, quick and convenient way. Complications are generally rare. The most common complications are hematoma and infection, each with less than 1 in 1000 cases.
Here, we present a case of a 48-year-old patient who underwent CNB for several lesions that were assessed as Breast Imaging Report and Data System (BI-RADS) IV in breast ultrasound and mammography. In the past, she had had 2 bilateral breast reduction surgeries and 1 open biopsy of a fibroadenoma. Histology revealed a phyllodes tumor. Following this, mastitis occurred which was resistant to common conservative measurements such as intravenous antibiotics over months. Finally, mastectomy was performed, followed by adequate wound healing.
In the presented case, the prolonged course of breast infection after CNB was not as expected. If this occurs, conservative treatment with antibiotics can be initiated. Possible additional risk factors such as diabetes mellitus, steroid therapy, or immunosuppression should be identified. However, in case of missing recovery, wide surgical excision is recommended.
Core needle biopsy; Complication; Mastitis; Phyllodes tumor
Most young breast cancer survivors consider reproductive issues to be of great importance, but many questions remain undervalued and unanswered. Overall, available data support the safety and feasibility of pregnancy and breastfeeding after breast cancer. The accuracy of the evidence is however limited by: i) the retrospective and frequently incomplete population-based nature of the data, ii) data not representing the entire population, iii) patient-related effects, iv) underpowered sample size, and v) lack of control for biological factors and risk determinants. We review the available evidence in light of these limitations which outline the need for prospective data collection and focused priority research.
Breast cancer; Breastfeeding; Pregnancy
The aim of this study was to assess the efficiency of step-serial sectioning (SSS) combined with hematoxylin and eosin (H&E) and immunohistochemical (IHC) staining in detecting micrometastasis of internal mammary lymph nodes (IMLNs).
Patients and Methods
135 IMLNs from 88 breast cancer patients were re-examined by SSS, combined with either H&E or IHC staining of the biomarkers cytokeratin-19 and epithelial membrane antigen.
Of the 135 IMLNs, 6 nodes from 5 cases displayed 1 or more micrometastases. Histological grade and lymphovascular invasion status were significantly correlated with micrometastasis in the IMLNs (p = 0.018 and 0.001, respectively). Of the 6 nodes positive for micrometastasis, 1 node was detected by both H&E and IHC staining. The remaining 5 nodes from 4 cases showed evident tumor cells only by IHC staining. Finally 8 of the 83 patients (9.64%) without IMLN metastasis showed distant metastasis, while 2 of the 5 patients (40%) with IMLN metastasis showed distant metastasis within 28 months of operation.
SSS combined with H&E and IHC staining is more efficient in detecting micrometastasis than classic routine single-slice H&E only.
Breast cancer; Internal mammary nodes; Micrometastasis; Step-serial sectioning
Thanks to the recent advances in reproductive medicine, more and more young women with breast cancer may be offered the possibility of preserving their fertility. Fertility can be endangered by chemotherapy, by treatment duration and by patient's age at diagnosis. The currently available means to preserve a young woman's fertility are pharmacological protection with gonadotrophin-releasing hormone analogues during chemotherapy, and ovarian tissue or oocyte/embryo freezing before treatment. New future venues, including in vitro maturation, will improve the feasibility and efficacy of the fertility preservation methods in breast cancer patients.
Breast cancer; Chemotherapy; Ovarian failure; Oocytes; Fertility preservation; Cryopreservation
MRI has been demonstrated to be the most sensitive imaging method for detecting breast cancer in women at high risk, allowing depiction of cancers that are occult on mammography, ultrasound and clinical breast examination. This high sensitivity is tempered by imperfect specificity due to overlap in the features of benign and malignant lesions.
We present the case of a young BRCA2 mutation carrier whose breast cancer could have been diagnosed 2 years earlier; this is a rare case of a false-negative finding in MRI.
We discuss morphological, physiological and psychological reasons for underestimation of MRI sets, especially in young women.
We conclude that double reading in MR screening for breast cancer in high-risk women, as conducted for mammography screening, could be considered.
Breast imaging; Familiar breast cancer; Double reading
The 2013 St. Gallen Consensus Conference on early breast cancer provided mostly evidence-based, globally valid treatment recommendations for breast cancer care, with a broad spectrum of acceptable clinical practice. This report summarizes the results of the 2013 international panel voting procedures with regard to loco-regional and endocrine treatment, chemotherapy, targeted therapy as well as adjuvant bisphosphonate use. This report is not aimed to replace the official St. Gallen Consensus publication, some recommendations may even be altered in the final paper, but should serve a preliminary rapid report of this important meeting.
Early breast cancer; Bisphosphonates; Endocrine therapy; Chemotherapy; Surgery; Axillary dissection; Targeted therapy; Neoadjuvant therapy
Actinomycosis; Malignancy; Breast; Cytology
This article is concerned with the evaluation of an adolescent breast mass using imaging methods.
A 14-year-old girl presented with progressive asymmetric enlargement of the left breast. She had felt a breast lump about 4 months earlier, and over the last 2 months it had been growing progressively. Tumor markers, including AFP, CEA, CA15-3, and CA125, were all normal. Ultrasonography showed a hypoechoichyperechoic, solid mass. Magnetic resonance imaging of the breast revealed a well marginated mass with hypointensity on T1-weighted images and mild hyperintensity on T2-weighted images, which showed mild contrast uptake. Biopsy revealed an undifferentiated malignant mesenchymal sarcoma. The patient underwent mastectomy with axillary lymph node sampling. After the operation, she received 3 cycles of chemotherapy and radiotherapy.
Due to the rarity of breast sarcoma and inadequate imaging methods to establish an exact diagnosis, radiologists and clinicians may misdiagnose and merely follow these tumors. As in our case, the histology of the patient may be the leading factor in the management of these tumors. Even in very young patients, progressively growing breast masses should alert the clinician to check for malignancy verified by biopsy.
Breast lump; Sarcoma, undifferentiated; MRI; Adolescent breast cancer
Without a doubt, nipple-sparing mastectomy affords a better cosmetic result than modified radical mastectomy. However, the surgical safety, radicality, complications, indications, and psychological benefits associated with this method are controversially discussed.
Patients and Methods
We carried out a retrospective analysis of 35 patients (study group) who underwent nipple-sparing mastectomy between 2000 and 2008. Indications, incision selection, postoperative complications, recurrence, morbidity rate, and psychological status were recorded and assessed.
The survival outcome (5.7 vs. 6%; p = 0.35) and complication rate (5.7 vs. 19%; p = 0.062) of patients who underwent subcutaneous nipple-sparing mastectomy and immediate breast reconstruction with prosthesis were similar to those of patients who underwent modified radical mastectomy. Most patients in the study group were completely satisfied with the aesthetic results (immediately, p < 0.001; < 1 year, p < 0.001; > 1 year, p < 0.001), and no serious psychological disorders or stress were detected relative to patients with traditional mastectomy.
Subcutaneous nipple-sparing mastectomy was beneficial and safe in this cohort of breast cancer patients. The approach is suitable for patients with isolated lesions located ≥ 2 cm from the nipple, as well as for patients with multiple lesions who are anxious about a good cosmetic appearance.
Breast cancer; Immediate breast reconstruction; Mastectomy, nipple-sparing
The aim of this study was to investigate the prevalence of low bone mineral density (BMD) and associated factors in middle-aged breast cancer survivors (BCS).
Patients and Methods
A cross-sectional study was conducted with 70 BCS of 45–65 years of age undergoing complete oncology treatment. Logistic regression models were used to identify factors associated with low BMD (osteopenia and osteoporosis taken together as a single group).
The mean age of participants was 53.2 ± 5.9 years. BMD was low at the femoral neck in 28.6% of patients and at the lumbar spine in 45.7%. Body mass index ≤ 30 kg/m2 (adjusted odds ratio (OR) 3.43; 95% confidence interval (CI) 1.0–11.3) and postmenopausal status (OR adjusted 20.42; 95% CI 2.0–201.2) were associated with low BMD at the lumbar spine. Femoral neck measurements, age > 50 years (OR 3.41; 95% CI 1.0–11.6), and time since diagnosis > 50 months (OR adjusted 3.34; 95% CI 1.0–11.3) increased the likelihood of low BMD.
These findings show that low BMD is common in middle-aged BCS. Factors were identified that may affect BMD in BCS and should be considered when implementing strategies to minimize bone loss in middle-aged women with breast cancer.
Breast cancer; Menopause; Bone mass; Osteoporosis; Middle-aged women
Carcinosarcoma is an exceptionally rare and poorly differentiated kind of breast neoplasm with only few published reports in the literature.
We report a case of breast carcinosarcoma in a 26-year-old Chinese female patient, presenting as multiple lumps in a single breast. A nipple-sparing modified radical mastectomy was performed. The patient is now in her 7th postoperative month and disease-free.
Carcinosarcoma is challenging to diagnose preoperatively, even with core needle biopsy histopathology. Modified radical mastectomy is an efficient and practical operative treatment. Application of adjuvant therapy should be based on the proportion of carcinomatous component of the lesion in pathological test. Careful periodic follow-up after the initial treatment is strongly recommended.
Taxanes are regarded as the most effective single agents in the treatment of metastatic breast cancer (MBC). For conventional taxanes, crucial toxicities and impairments in clinical efficacy are related to solvents necessary because of the agents’ hydrophobicity. The mandatory premedication with corticosteroids causes additional side effects. Nab-paclitaxel is a solvent-free colloidal suspension of paclitaxel and human serum albumin that exploits the physiological transport properties of albumin. It is registered as monotherapy with a recommended dose of 260 mg/m2 every 3 weeks for the treatment of patients with MBC, who have failed a first-line treatment of metastatic disease and for whom a standard anthracycline treatment is not indicated. Clinical evidence is available for the registered 3-weekly administration and for alternative weekly schedules in first and further lines of therapy of patients with MBC. During an advisory board meeting, a group of 8 German breast cancer experts reviewed the clinical data of nab-paclitaxel in MBC and discussed how nab-paclitaxel could be used in clinical practice on the basis of the current data.
First-line therapy; Metastatic breast cancer; Chemotherapy; Weekly; nab-Paclitaxel; Paclitaxel; Docetaxel
Breast cancer patients with bone metastases often suffer from cancer pain. In general, cancer pain treatment is far from being optimal for many patients. To date, morphine remains the gold standard as first-line therapy, but other pure μ agonists such as hydromorphone, fentanyl, or oxycodone can be considered. Transdermal opioids are an important option if the oral route is impossible. Due to its complex pharmacology, methadone should be restricted to patients with difficult pain syndromes. The availability of a fixed combination of oxycodone and naloxone is a promising development for the reduction of opioid induced constipation. Especially bone metastases often result in breakthrough pain episodes. Thus, the provision of an on-demand opioid (e.g., immediate-release morphine or rapid-onset fentanyl) in addition to the baseline (regular) opioid therapy (e.g., sustained-release morphine tablets) is mandatory. Recently, rapid onset fentanyls (buccal or nasal) have been strongly recommended for breakthrough cancer pain due to their fast onset and their shorter duration of action. If available, metamizole is an alternative non-steroid-anti-inflammatory-drug. The indication for bisphosphonates should always be checked early in the disease. In advanced cancer stages, glucocorticoids are an important treatment option. If bone metastases lead to neuropathic pain, coanalgetics (e.g., pregabalin) should be initiated. In localized bone pain, radiotherapy is the gold standard for pain reduction in addition to pharmacologic pain management. In diffuse bone pain radionuclids (such as samarium) can be beneficial. Invasive measures (e.g., neuroaxial blockage) are rarely necessary but are an important option if patients with cancer pain syndromes are refractory to pharmacologic management and radiotherapy as described above. Clinical guidelines agree that cancer pain management in incurable cancer is best provided as part of a multiprofessional palliative care approach and all other domains of suffering (psychosocial, spiritual, and existential) need to be carefully addressed («total pain»).
Breast cancer; Palliative care; Palliative medicine; Bone metastases; Cancer pain; Opioids; Guidelines
The skeleton is a potential metastatic target of many malignant tumors. Up to 85% of prostate and breast cancer patients may develop bone metastases causing severe pain syndromes in many of them. In patients suffering from multilocular, mainly osteoblastic lesions and pain syndrome, radionuclide therapy is recommended for pain palliation. Low-energy beta-emitting radionuclides (153samarium-ethylenediaminetetrameth-ylenephosphonate (EDTMP) and 89strontium) deliver high radiation doses to bone metastases and micrometastases in the bone marrow, but only negligible doses to the hematopoietic marrow. The response rate regarding pain syndrome is about 75%; about 25% of the patients may even become pain free. The therapy is repeatable, depending on cell counts. Concomitant treatment with modern bisphosphonates does not interfere with the treatment effects. Clinical trials using a new, not yet approved nuclide (223Radium) and/or combinations of chemotherapy and radionuclides are aiming at a more curative approach.
Bone metastases; Pain palliation; Radionuclides; 153Sm-EDTMP; 89Sr; 223Ra
Bone metastases (BM) represent the most frequent indication for palliative radiotherapy in patients with breast cancer. BM increase the risk of skeletal-related events defined as pathological fractures, spinal cord compression, and, most frequently, bone pain. The therapeutic goals of palliative radiotherapy for BM are pain relief, recalcification, and stabilization, reducing spinal cord compression and minimizing the risk of paraplegia. In advanced tumor stages radiotherapy may also be used to alleviate symptoms of generalized bone metastasis. This requires an individual approach including factors, such as life expectancy and tumor progression at different sites. Side effects of radiation therapy of the middle and lower spine may include nausea and emesis requiring adequate antiemetic prophylaxis. Irradiation of large bone marrow areas may cause myelotoxicity making monitoring of blood cell counts mandatory. Radiotherapy is an effective tool in palliation treatment of BM and is part of an interdisciplinary approach. Preferred technique, targeting, and different dose schedules are described in the guidelines of the German Society for Radiooncology (DEGRO) which are also integrated in 2012 recommendations of the Working Group Gynecologic Oncology (AGO).
Bone metastasis; Radiotherapy; Breast cancer, metastatic
The purpose of this study was to investigate the relationship between blood supply detected by Doppler ultrasound and the Nottingham Prognostic Index (NPI) in breast cancer patients.
Patients and Methods
137 patients with breast carcinoma, who had undergone color Doppler flow imaging (CDFI) and surgery, were involved in this retrospective study. CDFI was divided into 4 levels: absent (grade 0), minimal (grade 1), moderate (grade 2), and marked (grade 3). NPI was calculated as: NPI = 0.2 × tumor size (cm) + grade (I-III) + lymph node score (1–3). All patients were followed until the final observation (July 2010), or until the time of death. The survival state of the patients was divided into 3 categories: healthy survival, metastasis, and death.
Blood signal grades were positively correlated with NPI (Spearman r = 0.55926, p < 0.0001) and survival state (χ2 = 9.0248, p < 0.01). Patients with abundant blood flow signal (grade 2–3) had a significantly shorter overall survival than did those with limited blood flow signal (grade 0–1) (χ2 = 5.0384, p = 0.0248).
Flow signal measured by Doppler ultrasound may be useful as a prognostic indicator for patients with breast carcinoma.
Ductal carcinoma; Ultrasonography, color Doppler; Breast neoplasm; Nottingham Prognostic Index
Reproductive tract sarcomas metastasizing to the breast are uncommon. To our knowledge, metastasis of vaginal leiomyosarcoma to the breast has not been previously reported in the literature.
We present the first report of a FIGO stage IV primary vaginal leiomyosarcoma with metastases to the lung and left breast. Treatment included neoadjuvant chemotherapy followed by surgery and postoperative chemotherapy. Lung metastasis disappeared but recurred 14 months later in conjunction with left breast metastasis which was resected.
Primary vaginal sarcoma with lung and breast metastases is very rare in female genital malignancies. We present this case to alert gynecologists to the need for early diagnosis and aggressive management.
Vaginal leiomyosarcoma; Breast metastasis; Lung metastasis; Neoadjuvant chemotherapy
A group of German breast cancer experts (medical oncologists and gynaecologists) reviewed and commented on the results of the first international ‘Advanced Breast Cancer First Consensus Conference’ (ABC1) for the diagnosis and treatment of advanced breast cancer. The ABC1 Conference is an initiative of the European School of Oncology (ESO) Metastatic Breast Cancer Task Force in cooperation with the EBCC (European Breast Cancer Conference), ESMO (European Society of Medical Oncology) and the American JNCI (Journal of the National Cancer Institute). The main focus of the ABC1 Conference was metastatic breast cancer (stage IV). The ABC1 consensus is based on the vote of 33 breast cancer experts from different countries and has been specified as a guideline for therapeutic practice by the German expert group. It is the objective of the ABC1 consensus as well as of the German comments to provide an internationally standardized and evidence-based foundation for qualified decision-making in the treatment of metastatic breast cancer.
ABC1-consensus; Metastatic breast cancer, diagnosis and staging, treatment; Tumor markers; Metastases, biopsy; Chemotherapy; Endocrine therapy; Anti-HER2-targeted therapy; Palliative care
The aim of this article was to evaluate the prognostic value of the MammaPrintTM signature in women $$ 60 years with invasive breast cancer.
Patients and Methods
60 female patients were included in this prospective study. Eligibility criteria included: pT1c-3, pN0–1a, grade 2/3, hormone receptor-positive and HER2-negative tumor. The clinical risk was determined by Adjuvant! Online (AOL).
38 patients (63%) where considered to be low-risk patients by the 70-gene signature, while 22 (37%) were considered to be high-risk patients. No statistically significant differences between low- and high-risk groups could be detected for conventional prognostic parameters, particularly not for Ki-67. By AOL, 33 patients (55%) were considered to be at high risk, of which 20 had a discordant MammaPrintTM result. The discordance rate between the profile and AOL was 48%, which is higher than in previous publications. When the 70-gene signature was used in combination with the clinical risk assessment, the recommendation for adjuvant systemic treatment differed in 11 patients (18%).
In the intermediate-risk subgroup, the 70-gene signature could be useful to decide in elderly patients whether they may benefit from adjuvant chemotherapy or not. Conventional clinicopathological factors were not suitable for a prediction of the 70-gene signature results in these patients.
Breast cancer; 70-Gene prognosis signature; Postmenopausal; Elderly; Prognostic factor