The reimbursement for breast cancer-specific operative interventions in Germany is regulated by the diagnosis-related group (DRG) system. The essential elements of the German DRG system, which was developed as a per-case lump-sum payment system, are presented, including the participating institutions. The actual treatment situation in breast cancer surgery is now aptly reflected in the introduction of the OPS (operation and treatment procedure classification) 2012. This is oriented on the classification model of Hoffmann and Wallwiener, with its complexity-based differentiation that reflects the basic idea of different resource usage. Despite the actual potential of the appropriately differentiated encryption of surgical procedures, which illustrates their differences in resource costs and consumption, appropriate reimbursement has still not been achieved. Hopefully, in the future the calculation of the DRGs in the field of breast cancer surgery will be based on data feedback from the hospitals and treatment institutions, and will be more suited to the main purpose of the DRG system, i.e. that reimbursement reflects resource expenditure. A necessary basic tool for differentiated, complexity-oriented encryption has been achieved with the OPS 2012, which mirrors our classification model for oncological, oncoplastic and reconstructive breast surgery.
German diagnosis-related groups (G-DRG); Classification system for oncological, reconstructive and oncoplastic breast surgery; Breast surgery; OPS (operation and treatment procedure classification) 2012; Reimbursement
Breast cancer (BC) is the most frequent cancer in European women with nearly 30% of the patients eventually developing metastases. Neuroendocrine differentiation is a rare event, but overexpression of somatostatin receptors in BC has been reported in many studies.
A patient with liver metastases from BC was treated with peptide receptor radionuclide therapy (PRRT). Computed tomography scan and biochemical examinations showed a clear response to radionuclide therapy.
PRRT may be useful in metastatic BC patients.
Radionuclide therapy; Peptide receptors
Axillary lymph node dissection plays an important role in breast cancer management in terms of staging, prediction of prognosis, determination of adjuvant therapy, and local control of the primary tumor. The objective of this study was to evaluate the axillary lymph node involvement in multicentric breast tumors and breast tumors with nipple involvement in comparison with unifocal tumors.
Patients and Methods
We reviewed the records of 267 patients with stage I or IIA disease. The rates of axillary lymph node metastasis (ALNM) in patients with unifocal tumors, multicentric tumors, or nipple involvement were compared.
209 (78%) patients had unifocal tumors, 24 (8%) had multicentric tumors, and 34 (12%) had nipple involvement. The incidence of ALNM was 9.76% in patients with unifocal tumors, 24.84% in patients with multicentric tumors, and 36.71% in patients with nipple involvement. Hence, the incidence of ALNM was significantly higher in patients with nipple involvement or multicentric tumors than in patients with unifocal tumors.
Our data suggest that compared to unifocal tumors, breast tumors with nipple involvement or multiple foci show a significantly higher incidence of ALNM which is a predictor of a poor prognosis.
Breast cancer: multicentric, nipple involvement; Axillary lymph nodes
Surgery is still a main therapeutic option in breast cancer treatment. Nowadays, methods of resection and reconstruction vary according to different tumors and patients. This review presents and discusses standards of care and arising questions on how radical primary breast cancer surgery should be according to different clinical situations. In most early breast cancer patients, breast conservation is the method of choice. The discussion on resection margins is still controversial as different studies show conflicting results. Modified radical mastectomy is the standard in locally advanced breast cancer patients, although there are different promising approaches to spare skin or even the nipple-areola complex. A sentinel node biopsy is the standard of care in clinically node-negative invasive breast cancer patients, whereas the significance of axillary lymphonodectomy seems to be questioned through a number of different findings. Although there are interesting findings to modify surgical approaches in very young or elderly breast cancer patients, it will always be an individualized approach if we do not adhere to current guidelines. Up to date, there are no special surgical procedures in BRCA mutation carriers or patients of high-risk families.
Breast cancer surgery; Resection margins; Sentinel lymph node biopsy; Axillary lymphonodectomy
For patients with anthracycline-resistant metastatic angiosarcoma, there is currently no available standard for second-line therapy, and a need exists for novel effective regimens to improve response rates.
We report here on a case of a primary angiosarcoma of both breasts in a 34-year-old woman presenting with lung metastases. Upon completion of 3 cycles of the MAID regimen (mesna, adriamycin, ifosfamide, dacarbazine), computed tomography showed disease progression. Subsequently, a second-line chemotherapy was started using the GVP regimen (gemcitabine, vincristine, cisplatin). Complete response of the lung metastases was achieved after 6 cycles of treatment.
In the absence of an effective therapy among patients with anthracycline-resistant metastatic breast angiosarcoma, a GVP chemotherapy regimen can be performed as a selective option.
Breast neoplasm; Angiosarcoma; Lung metastases; Gemcitabine; Vincristine; Cisplatin; Chemotherapy
Since breast-conserving surgery has become the gold standard for early breast cancer, the development of less radical or less burdensome technologies has been pressed for in order to preserve the patient from unnecessary harm through the operative procedure. Different technical approaches are under evaluation, and some of them are already being used in the clinical setting. The aim of this article is to present a perspective on future breast cancer surgery by shedding light on the current innovative and new techniques.
Breast cancer; Intraoperative surgical margin assessment; Radiofrequency spectroscopy; Sentinel node detection; Acellular dermal matrix
Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement.
Patients and Methods
Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement.
The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64–0.8), 0.665 (95% CI 0.59–0.73), and 0.696 (95% CI 0.59–0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63–0.81).
The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.
Sentinel lymph node biopsy; MSKCC nomogram; Tenon score; Turkish nomogram; Non-sentinel lymph node metastasis
In this multicenter study, we aimed to compare concurrent 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) and bone scan results of breast cancer patient.
Patients and Methods
162 patients with breast cancer (158 female, 4 male; mean age 50.6 years) were included in the study. FDG PET/CT examination was performed in all patients, and concurrent bone scintigraphy in 68 patients. The results of FDG PET/CT and bone scan were compared.
132 of the 162 patients were operated on because of breast cancer. 89 patients had metastasis, and 4 had recurrent disease according to FDG PET/CT results. Metastatic sites in order of frequency were lymph nodes, bone, lung, liver, adrenal gland, local skin or muscle, brain, and peritoneum (peritonitis carcinomatosa). The sensitivity, specificity, accuracy, and negative and positive predictive value of bone scintigraphy versus FDG PET/CT were 96 vs. 100%, 100 vs. 98%, 100 vs. 83%, 100 vs. 100%, and 90 vs. 100%, respectively.
Although the 2 modalities were in concordance with each other, in 5 (21%) cases, FDG PET/CT could not show bone metastasis which were detected on bone scintigraphy. Hence, bone scintigraphy was superior to FDG PET/CT in the determination of bone metastasis derived from breast cancer. However, FDG PET/CT should be considered for soft tissue metastasis.
Breast cancer; Bone metastasis; FDG PET/CT; Bone scintigraphy
Breast tuberculosis is an uncommon disease even in countries where the incidence of tuberculosis is high.
This is a case series concerning 4 postmenopausal breast tuberculosis cases encountered in Moulay Youssef Hospital between January 2007 and December 2010. Breast tuberculosis represents 0.25% of all hospitalized tuberculosis patients in our department. The mean age of our patients was 62.5 ± 5.8 years. Clinical findings were heterogeneous; 1 case was multifocal tuberculosis, and another case was coexistent tuberculosis and malignancy of the breast. Mammography and ultrasonography findings were suspicious for malignancy in all 4 cases. Fine needle aspiration was negative in 3 cases. The diagnosis was made in all patients by histological examination of biopsy specimens, which revealed typical tuberculous lesions. Anti-tuberculosis therapy formed the mainstay of treatment.
The clinical and radiological features of mammary tuberculosis can be very confusing and easily mistaken for breast cancer. Symptoms suggestive of tuberculosis warrant a biopsy to exclude possible cancer.
Breast; Lump; Tuberculosis; Menopause
BRCA mutation carriers have a life-long breast cancer risk between 55 and 85% and a high risk of developing breast cancer at a very young age, depending on the type of mutation. The risk of developing contralateral breast cancer after a first breast cancer is elevated up to 65%, especially in case of BRCA1 mutation and young age at the first breast cancer. Since bilateral prophylactic mastectomy is associated with a risk reduction of 90–95% of developing primary or contralateral breast cancer, this option is a key point within the counseling process for patient information and shared decision-making of mutation carriers. Although the local control after breast-conserving therapy in mutation carriers seems to be comparable to that of sporadic breast cancer patients, individual patient information and counseling should include all alternative procedures of oncologically adequate mastectomy techniques and immediate reconstruction. Excellent cosmetic results, high levels of life quality, and good patient acceptance can be achieved with the recent developments in reconstructive surgery of the breast.
BRCA mutation carrier; Mastectomy techniques; Reconstructive surgery of the breast; Prophylactic mastectomy
The goal of this population-based study was to determine the impact of post-mastectomy radiation therapy on long-term overall survival (OS) of male patients with breast cancer.
Patients and Methods
We investigated 20-year OS rates of 664 patients diagnosed with primary stage I–III breast cancer in former East Germany between 1970 and 1989. Patients had a radical mastectomy with axillary lymph node dissection without systemic adjuvant therapy.
Median follow-up time was 26.2 years (range 19–38 years). 52.4% of the patients had post-mastectomy radiotherapy. Radiotherapy showed different effects in each stage group after 20 years. Whereas there was an OS trend for radiotherapy to harm patients with stage I disease (hazard ratio (HR) 1.45; 95% confidence interval (CI) 0.98–2.15; p = 0.065), radiotherapy showed no benefit in patients with stage II disease (HR 0.82; 95% CI 0.62–1.1; p = 0.15). There was a significant survival benefit for patients with stage III disease receiving radiotherapy (HR 0.60; 95% CI 0.41–0.88; p = 0.008).
Post-mastectomy radiotherapy is associated with longer OS in male patients with stage III breast cancer. Male breast cancer patients at stages I and II do not seem to benefit from radiotherapy, but obsolete irradiation techniques might explain adverse long-term effects in earlier stages.
Male breast cancer; Adjuvant radiotherapy; Adjuvant Therapy; Overall survival
Idiopathic granulomatous mastitis (IGM) is a rare benign inflammatory disease of the breast. It is related to various etiological factors. The treatment of IGM is challenging as there is a lack of consensus in the literature and treatment options vary widely. Conservative treatment with antibiotics, glucocorticoids and immunosuppressive drugs, and surgery are used in the management of the disease. In this article we report our experience with IGM patients receiving immunosuppressive treatment.
Patients and Methods
The medical records of patients with IGM receiving systemic therapy at the Hacettepe University Hospital between October 2007 and May 2010 were reviewed. 15 cases of histopathologically proven IGM were identified. The data was examined for risk factors and success of treatment.
14 patients were given prednisolone together with azathioprine, and 1 patient who was pregnant at the time of diagnosis received only prednisolone (30 mg/day). 11 (73%) patients had a complete response to systemic therapy. 2 patients had a relapse, of whom 1 required surgical drainage and 1 was treated with a higher dose of glucocorticoids.
Systemic therapy is a safe and effective treatment for IGM. The addition of azathioprine to glucocorticoid therapy permits quick tapering of the steroid doses and increases the treatment success.
Granulomatous mastitis, idiopathic; Corticosteroids; Azathioprine
The targets for the immune system are antigens present on cancer cells; however, many are not cancer-specific and may also be found on normal tissues. These antigens are often products of mutated cellular genes, aberrantly expressed normal genes, or genes encoding viral proteins. Vaccines constitute an active and specific immunotherapy designed to stimulate the intrinsic antitumor immune response by presenting tumor-associated antigens expressed on normal tissues that are overexpressed on tumor cells.
Breast cancer; Tumor antigen; Vaccine
Cancer vaccines are an emerging therapeutic and prophylactic modality that may play a more important role in cancer prevention and treatment in the future. Therapeutic cancer vaccines are designed to generate a targeted, immune-mediated antitumor response. Successful prophylactic vaccines are those against oncogenic viral infections, such as the human papillomavirus and cervical cancer. However, a tough challenge for the majority of tumor vaccines is the self-nature of tumor antigens. Ongoing studies are investigating methods to enhance vaccine strategies including immune-modulating agents. The present review analyzes the potential use of vaccines in the primary prevention of breast cancer, focusing on the recent extension of vaccine target selection to self-proteins that are overexpressed during the early stages of tumor development but whose expression no longer occurs as we age, a feature that may avoid clinically significant autoimmune sequelae.
Vaccines; Breast cancer prevention
Breast cancer is the most common cancer diagnosed during pregnancy.
We report on a case of a 26-year-old woman who was diagnosed with right-sided breast cancer in her 15th week of gestation. We discussed possible treatment scenarios and the patient opted for neoadjuvant therapy with taxanes and anthracyclines during pregnancy, followed by delivery and then followed by surgery, antibody therapy, and radiotherapy. The patient received neoadjuvant chemotherapy with paclitaxel 80 mg/m2 weekly for 12 cycles, followed by 4 cycles of epirubicin and cyclophosphamide (90/600 mg/m2) every 3 weeks. Complete clinical response was seen after preoperative chemotherapy. After delivery of a healthy child at 40 weeks of gestation, she received breast-conserving surgery and axillary dissection. Anti-HER2 antibody treatment with trastuzumab was started concomitantly with adjuvant radiotherapy. Endocrine treatment with a gonadotropin-releasing hormone (GnRH) analog and tamoxifen for 5 years was planned to be started after radiotherapy.
Treatment of breast cancer during pregnancy requires an interdisciplinary approach and careful consideration of the patient's stage of disease, the gestational age, and the preferences of the patient and her family.
Pregnancy-associated breast cancer; Outcome of pregnancy; Neoadjuvant chemotherapy; Interdisciplinary care
Organized mammography screening was implemented in Bavaria in 2003, with a target population of about 1.5 million women (aged 50–69 years). We evaluated the population-based effects of mammography screening on the distribution of tumor-node-metastasis (TNM)-T categories with regard to different histological subgroups of breast cancer.
Patients and Methods
Women diagnosed with breast cancer between 2002 and 2008 were included. The annual age-specific incidence rates separated by T category were calculated for different histological subgroups and plotted against time. Time trends were analyzed not only in the screening population but also based on women aged 15–49 and ≥70 years, respectively. Furthermore, correlation coefficients were calculated in order to evaluate the possible association between participation rate and incidence of certain TNM-T categories.
With ductal carcinomas, the incidence of early-stage tumors shows a strong increase in the screening population and a significant correlation with the participation rate, whereas with lobular carcinomas there is a stagnation of incidence in women aged 50–69 years irrespective of TNM-T category.
Short-term effects of mammography screening can already be demonstrated. However, depending on breast cancer type, not all women appear to benefit from screening. The expected long-term reduction of breast cancer mortality remains to be seen.
Mammography; Screening; Breast cancer; Histological types
Glycogen-rich clear cell carcinoma of the breast is a rare histological subtype of breast cancer, accounting for 0.9–2.8% of all breast cancer cases. Fewer than 100 cases have been reported in the literature. Most of these tumors are invasive carcinomas. The intraductal glycogen-rich clear cell carcinoma is a very rare occurrence.
Herein is described a case of a pure intraductal glycogen-rich clear cell carcinoma of the breast in a 42-year-old premenopausal woman. A literature review has also been carried out. Mammography was inconclusive due to the presence of dense breast tissue, but magnetic resonance imaging (MRI) showed several nodular lesions measuring 7 × 6 cm in diameter and involving the upper aspect of the right breast suggestive of multifocal malignancy. A modified radical mastectomy was performed. The patient started hormonal therapy with tamoxifen and is currently well 16 months after surgery.
A pure intraductal glycogen-rich clear cell carcinoma of the breast is a very rare occurrence. The case presented here exhibited uncommon MRI features, whereas the tumor size is one of the largest reported in the literature. Mammography may be inconclusive in the presence of dense breast tissue, but MRI is of great importance in the preoperative evaluation of the patient.
Clear cell breast carcinoma: glycogen-rich, intraductal
Cytotoxic chemotherapy in the treatment of tumors has traditionally been thought to be immunosuppressive. Increasing evidence suggests the contrary and has introduced the concept of ‘immunogenic’ chemotherapy or, in other words, the concept that the innate and adaptive immune systems are critical in determining the long-term efficacy of some cytotoxic-based (and radiotherapy-based) regimens. The underlying mechanisms how these therapies can stimulate an antitumor immune response have been demonstrated recently. In this article, we review the background of this new paradigm and how combinations of traditional agents with the new immunotherapeutic therapies may significantly advance our treatment of breast cancer.
Breast cancer; Tumor-infiltrating lymphocytes; Prognosis; Immunotherapy
Advances in DNA sequencing technologies, as well as refined bioinformatics methods for interpretation of complex datasets, have provided the opportunity to comprehensively assess gene expression in tumours and their surrounding microenvironment. More recently, these advances have highlighted the interplay between the immune effector mechanisms and breast cancer cell biology, emphasizing the long-recognized link between immunity and cancer. Studying immune-associated genes has not only resulted in further stratification within the broad pathological types of breast cancers, but also provided further biological insights into the complex heterogeneity within breast cancer subgroups. On the basis that anti-cancer therapies can modify the host-tumour interaction, investigators have focused their attention on the predictive value of immune parameters as markers of therapeutic anti-tumour response. We discuss the current status of immune signatures in breast cancer and some of the fundamental limitations that need to be overcome to move these discoveries into clinic.
Genomic biomarkers; Immune stromal interface; Breast cancer
Male breast cancer is rare and represents less than 1% of all breast cancers. Considering the fact that the male breast most often does not consist of lobules and acini, lobular carcinoma of the male breast is exceptionally rare.
In this paper we present a unique case of alveolar variant of lobular male breast cancer in a 56-year-old patient.
According to our knowledge this is the first presentation of an alveolar variant of lobular male breast cancer that appeared 14 years after chemo- and radiotherapy for the treatment of Hodgkin's disease.
Male breast cancer; Histology; Immunohistochemistry; Pathology
Data from meta-analyses have shown taxane-containing therapies to be superior to anthracycline-based treatments for high-risk breast cancer.
Patients and Methods
The ADEBAR trial was a multicenter phase III trial in which patients with lymph node-positive breast cancer were prospectively randomized for either sequential anthracycline-taxane or FEC120 therapy. Patients received 4× epirubicin (90 mg/m2) and cyclophosphamide (600 mg/m2) every 3 weeks (q3w), followed by 4× docetaxel (100 mg/m2) q3w (EC-Doc arm), or 6× epirubicin (60 mg/m2) and 5-fluorouracil (500 mg/m2) on days 1 and 8 and cyclophosphamide (75 mg/m2) on days 1–14, q4w (FEC arm). We compared both arms with respect to toxicity and feasibility.
Hematological toxicity was found significantly more often in the FEC arm. Febrile neutropenia was seen in 11.3% of patients in the FEC arm and in 8.4% of patients in the EC-Doc arm (p = 0.027). Non-hematological side effects of grade 3/4 were rarely seen in either arm. Therapy was terminated due to toxicity in 3.7% of the patients in the EC-Doc arm and in 8.0% of the patients in the FEC arm (p = 0.0009).
The sequential anthracycline-taxane regimen is a well-tolerated and feasible alternative to FEC120 therapy.
Breast cancer; Taxane; Anthracycline; Toxicity; ADEBAR trial
Granulomatous mastitis is a benign recurrent disease. Accurate diagnosis is only by histopathology.
Patients and Methods
31 cases with histological diagnosis were retrospectively analyzed.
Mean follow-up was 42.4 months for recurrent and 27.8 months for non-recurrent cases. Etiology was tuberculosis in 1 case. 5 cases (16%) relapsed. 6 patients (19.3%) treated with abscess drainage healed completely, but 50% relapsed. Relapses were treated with excision or steroids. Steroid therapy was the initial treatment in 12 cases (38.7%), with 1 relapse (8.3%) which was treated in the same manner. 2 patients had incomplete response necessitating excision, and another 2 developed abscesses which were treated with steroids or excision after drainage. Surgical excision was preferred in 12 cases (38.7%) due to suspicion for carcinoma in 8 patients (25.8%) and/or low probability of poor cosmetic outcome. All healed without complication, and recurrence was observed in 1 case (8.3%) which was treated with re-excision.
Both excision and steroid therapy had low and similar relapse rates, but excision was superior to steroid therapy in providing strict diagnosis with much faster healing and fewer complications. In refractory cases, and when deformity is inevitable, steroid therapy should be preferred.
Mastitis; Granulomatous mastitis, idiopathic; Treatment