1/20. The incidence of occult nipple-areola complex involvement in breast cancer patients receiving a skin-sparing mastectomy.BACKGROUND: Surgical treatment of breast cancer traditionally has included resection of the nipple-areola complex (NAC), in the belief that this area had a significant probability of containing occult tumors. The purpose of this study was to investigate the true incidence of NAC involvement in patients who underwent a skin-sparing mastectomy (SSM) and to determine associated risk factors. methods: A retrospective chart review was conducted of 326 patients who had a SSM at our institution from 1990 to 1993. NAC involvement was reviewed in 286 mastectomy specimens. The charts were analyzed for tumor size, site, histology, grade, nodal status, recurrence, survival, and NAC involvement. RESULTS: Occult tumor involvement in the NAC was found in 5.6% of mastectomy specimens (16 patients). Four patients would have had NAC involvement identified on frozen section if they had been undergoing a skin-sparing mastectomy with preservation of the NAC. There were no significant differences between NAC-positive (NAC ) and NAC-negative (NAC-) patients in median tumor size, nuclear grade, histologic subtype of the primary tumor, or receptor status. There were significant differences in location of the primary tumor (subareolar or multicentric vs. peripheral) and positive axillary lymph node status. NAC involvement was not a marker for increased recurrence or decreased survival. CONCLUSIONS: Occult NAC involvement occurred in only a small percentage of patients undergoing skin-sparing mastectomies. NAC preservation would be appropriate in axillary node-negative patients with small, solitary tumors located on the periphery of the breast.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
2/20. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How?CONTEXT: The clinical breast examination (CBE) is widely recommended and practiced as a tool for breast cancer screening; however, its effectiveness is dependent on its precision and accuracy. OBJECTIVE: To collect evidence on the effectiveness of CBE in screening for breast cancer and information on the best technique to use. DATA SOURCES: We searched the English-language literature using the medline database (1966-1997) and manual review of all reference lists, as well as contacting investigators of several published studies for clarifications and unpublished data. STUDY SELECTION AND DATA EXTRACTION: To study CBE effectiveness, we included all controlled trials and case-control studies in which CBE was at least part of the screening modality; for technique, we included both clinical studies and those that used silicone breast models. All 3 authors reviewed and agreed on the studies selected for inclusion in the pooled analyses. DATA SYNTHESIS: Randomized clinical trials demonstrated reduced breast cancer mortality rates among women screened by both CBE and mammography. Evidence of CBE's independent contribution was less direct; CBE alone detected between 3% and 45% of breast cancers found that screening mammography missed. The precision of CBE was difficult to determine because of the lack of consistent and standardized examination techniques. Studies on CBE precision reported fair agreement (kappa = 0.22-0.59). Pooling trial data, we estimated CBE sensitivity at 54% and specificity at 94%. The likelihood ratio of a positive CBE result is 10.6 (95% confidence interval [CI], 5.8-19.2), while the likelihood ratio of a negative test result is 0.47 (95% CI, 0.40-0.56). Longer duration of CBE and a higher number of specific techniques used were associated with greater accuracy. The preferred technique for CBE includes proper positioning of the patient, thoroughness of search, use of a vertical-strip search pattern, proper position and movement of the fingers, and a CBE duration of at least 3 minutes per breast. The value of inspection is unproved. Professional and lay examiners improved their sensitivity on silicone breast models after being taught this technique. CONCLUSIONS: Indirect evidence supports the effectiveness of CBE in screening for breast cancer. Although the screening clinical examination by itself does not rule out disease, the high specificity of certain abnormal findings greatly increases the probability of breast cancer.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
3/20. Risk in numbers--difficulties in the transformation of genetic knowledge from research to people--the case of hereditary cancer.Difficulties in communicating diagnostic information are exacerbated when the 'diagnosis' is a 'genetic risk' for cancer. The risk estimation demanded in this situation differs from other types of probability estimations. Observations of participants in 45 consultation sessions between physicians and potential patients were conducted at a clinic for hereditary cancer to explore the communication of genetic information. Thirty-three sessions were audiotaped, transcribed verbatim and analyzed, along with notes from the other sessions. A dominant theme was found to be numerical discussion of risk. Further analysis resulted in the description of problems for practitioners in the process of translating scientific knowledge into clinical management. Problems in providing information include unclear aims of the consultation sessions, mixing various types of background information and probabilities, recognizing how low the predictive values are, and difficulties in communicating the relationship between probability and conclusions. Problems in communicating information about the genetic risk for cancer are of at least two types: dilemmas arising from uncertainties implicit in the nature of the information itself and difficulties in communicating information in a manner that those concerned can interpret. These issues need clarification, so that information with far-reaching consequences can be made as clear and comprehensible as possible for those involved.- - - - - - - - - - ranking = 2keywords = probability (Clic here for more details about this article) |
4/20. Investigation of the added value of high-energy electrons in intensity-modulated radiotherapy: four clinical cases.PURPOSE: Intensity-modulated radiotherapy (IMRT) with photon beams is currently pursued in many clinics. Theoretically, inclusion of intensity- and energy-modulated high-energy electron beams (15-50 MeV) offers additional possibilities to improve radiotherapy treatments of deep-seated tumors. In this study the added value of high-energy electron beams in IMRT treatments was investigated. methods AND MATERIALS: In a comparative treatment planning study, conventional treatment plans and various types of IMRT plans were constructed for four clinical cases (cancer of the bladder, pancreas, chordoma of the sacrum, and breast). The conventional plans were used for the actual treatment of the patients. The IMRT plans were optimized using the orbit optimization code (Lof et al., 2000) with a radiobiologic objective function. The IMRT plans were either photon or combined electron and photon beam plans, with or without dose homogeneity constraints assuming standard or increased radiosensitivities of organs at risk. RESULTS: Large improvements in expected treatment outcome are found using IMRT plans compared to conventional plans, but differences in tumor control probability (TCP) and normal tissue complication probabilities (NTCP) values between IMRT plans with and without electrons are small. However, the use of electrons improves the dose-volume histograms for organs at risk, especially at lower dose levels (e.g., 0-40 Gy). CONCLUSIONS: This preliminary study indicates that addition of higher energy electrons to IMRT can only marginally improve treatment outcome for the selected cases. The dose-volume histograms of organs at risk show improvements for IMRT with higher energy electrons, which may reduce tumor induction but does not substantially reduce NTCP.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
5/20. Perioperative brachytherapy for pretreated chest wall recurrence of breast cancer.PURPOSE: To demonstrate the technical aspects of high-dose-rate afterloading (HDR-AL) brachytherapy for isolated local chest wall recurrence of breast cancer pretreated with mastectomy and axillary node dissection plus postoperative radiotherapy. CASE REPORT: A 63-year-old female patient with left ductal breast cancer, pT2pN1biM0, was reoperated for an isolated local chest wall recurrence 13 years after primary treatment (mastectomy, axillary dissection, and 50 Gy postoperative irradiation). Radical surgery would have involved extreme mutilation. Reoperative surgical margins of 3 mm width were involved, and four parallel afterloading catheters were placed intraoperatively in this histologically positive margin site. Perioperative HDR-AL (Ir-192 stepping source, 370 GBq activity, dose rate: reference air kerma rate at 1 m 40.84 mGy/h kg) was performed. Dose per fraction: 6 Gy to the reference line, two fractions per week, total dose 30 Gy. Follow-up after secondary treatment: 5 years. RESULTS: Firm local control and 5-year disease-free survival were obtained with perioperative HDR-AL therapy; staging procedures (clinical exam, MRI, abdominal ultrasound, and bone scan) showed no evidence of disease. The development of radiodermatitis did not exceed grade 2 level and healed spontaneously within 6 weeks. CONCLUSIONS: Isolated local chest wall relapse can be effectively controlled by wide surgical excision and perioperative reirradiation with HDR-AL. This technique may represent a treatment alternative to ultraradical surgery, with equal healing probability and a better quality of life. Small-volume irradiation of the postoperative scar can be performed with HDR-AL brachytherapy, and long-term local control can be achieved with a total dose of 30 Gy.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
6/20. Interactive detection and visualization of breast lesions from dynamic contrast enhanced MRI volumes.mammography is currently regarded as the most effective and widely used method for early detection of breast cancer, but recently its sensitivity in certain high risk cases has been less than desired. The use of Dynamic Contrast Enhanced magnetic resonance imaging (DCE-MRI) has gained considerable attention in the past 10 years, especially for high risk cases, for smaller multi-focal lesions, or very sparsely distributed lesions. In this work, we present an interactive visualization system to identify, process, visualize and quantify lesions from DCE-MRI volumes. Our approach has the following key features: (1) we determine a confidence measure for each voxel, representing the probability that the voxel is part of the tumor, using a rough goodness-of-fit for the shape of the intensity-time curves, (2) our system takes advantage of low-cost, readily available 3D texture mapping hardware to produce both 2D and 3D visualizations of the segmented MRI volume in near real-time, enabling improved spatial perception of the tumor location, shape, size, distribution, and other characteristics useful in staging and treatment courses, and (3) our system permits interactive manipulation of the signal-time curves, adapts to different tumor types and morphology, thus making it a powerful tool for radiologists/physicians to rapidly assess probable malignant volumes. We illustrate the application of our system with four case studies: invasive ductal cancer, benign fibroadenoma, ductal carcinoma in situ and lobular carcinoma.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
7/20. Paravertebral infection (phlegmon) demonstrated by FDG dual-head coincidence imaging in a patient with multiple malignancies.A 66-year-old woman was referred for a bone scan to assess back pain on a background of breast cancer, melanoma, and rheumatic heart disease. The scan appearance was suspicious for a localized soft tissue neoplasm. An FDG coincidence positron emission tomography (PET) study demonstrated a large FDG-avid soft tissue abnormality. staphylococcus aureus was isolated from a subsequent needle biopsy. This case illustrates the use of FDG-PET in infection imaging, as well as demonstrating the potential pitfalls in nuclear oncology. Because FDG is not tumor-specific, accumulation in benign lesions may give rise to false-positive results despite a high pretest probability for malignancy.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
8/20. Capecitabine-induced severe hypertriglyceridemia: report of two cases.OBJECTIVE: To report 2 cases of severe hypertriglyceridemia associated with the use of oral capecitabine. CASE SUMMARIES: The first patient was a 73-year-old woman with metastatic breast carcinoma who received capecitabine 2500 mg/m2/day in 2 divided doses for 2 weeks followed by a one week rest period. The baseline triglyceride level was 324 mg/dL; after 2 cycles of capecitabine, levels increased to 916 mg/dL. Although lipid-lowering treatment was initiated, triglyceride levels peaked at 1782 mg/dL by the end of the seventh cycle. Eight weeks after capecitabine treatment was stopped, triglyceride levels decreased to 118 mg/dL. The second patient was a 59-year-old man with metastatic colorectal carcinoma who was placed on capecitabine treatment at a dosage of 2500 mg/m2/day in 2 divided doses for 2 weeks followed by a one week rest period. The baseline triglyceride level was 244 mg/dL; levels peaked at 1455 mg/dL at the end of the fifth cycle. Capecitabine treatment was discontinued due to disease progression, and triglyceride levels decreased to 154 mg/dL after 11 weeks. DISCUSSION: The most frequently reported adverse effects of capecitabine are gastrointestinal and hematologic effects and palmar-plantar erythrodysesthesia. Drug-induced hyperlipidemia may appear more readily in individuals with hereditary lipoprotein lipase deficiency because decreased lipoprotein lipase activity might make these individuals more susceptible to a rise in triglyceride levels. The Naranjo probability scale indicated a probable relationship between capecitabine and severe hypertriglyceridemia. CONCLUSIONS: Capecitabine should be prescribed with care, especially in patients with preexisting hypertriglyceridemia. The question of whether capecitabine actually causes hypertriglyceridemia needs careful consideration, and the possible mechanism by which it may cause this adverse effect requires further investigation.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
9/20. Drug interaction between capecitabine and warfarin: a case report and review of the literature.OBJECTIVE: To report on possible adverse interaction between capecitabine and warfarin in a patient with cancer, who developed subconjunctival and nose bleeding during treatment with these drugs and review of the previously reported five cases in the literature. CASE SUMMARY: In the second week of capecitabine treatment the patient was hospitalized owing to subconjunctival hemorrhage and nose bleeding. Her international normalized ratio (INR) level was found to have increased, and both drugs were discontinued. Fresh frozen plasma replacement was administered. warfarin and capecitabine treatment were restarted again but the warfarin dose was decreased. The patients INR was kept between 2.5-3 with the reduced dose of warfarin. DISCUSSION: Capecitabine is an orally active prodrug of fluorouracil (FU) and is extensively used as an antineoplastic agent. It is converted to 5-FU in the liver and tumor tissues. warfarin is an antithrombolytic agent and is metabolized by liver cytochorom P450 (CYP) isoenzymes in liver. Preclinical in vitro studies using human liver microsomes report no inhibitory effects between capecitabine and substrates of CYP. However, the concomitant administration of capecitabine and warfarin resulted in gastrointestinal, retroperitoneal bleeding and hemorrhagic blisters in the five cases previously reported. The exact mechanism of this interaction is unknown; however, a significant pharmacokinetic interaction between capecitabine and S-warfarin resulting in exaggerated anticoagulant activity has recently been demonstrated. Here, we describe another case and use of the Naranjo adverse drug reaction (ADR) probability scale, which indicated a probable relationship between subconjunctival bleeding and epistaxis in this patient after concomitant warfarin and capecitabine use. CONCLUSION: Capecitabine is extensively used in outpatient clinics, and physicians should be aware of ADRs arising from combined used of capecitabine and warfarin. In the light of the current data, INR levels should be closely monitored in patients using this medication regimen.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
10/20. Local recurrence of breast cancer after skin-sparing mastectomy following core needle biopsy: case reports and review of the literature.The latest advances in diagnostic and therapeutic procedures for breast cancer have provided valuable technological breakthroughs. Yet the long-term consequences of these modern methods are still quite unclear. Such is the case for stereotactic or ultrasound-guided histologic needle biopsy and skin-sparing mastectomy. We report on three patients who presented with multicentric breast cancer diagnosed by stereotactic needle biopsy and treated by skin-sparing mastectomy. All three patients developed recurrence at the core needle entry site. Records of 58 patients with breast cancer who were treated by skin-sparing mastectomy followed by immediate reconstruction (with transverse rectus abdominis muscle [TRAM] flap or tissue expander) at the breast diseases Division of Buenos Aires British Hospital between December 1999 and December 2003 were reviewed retrospectively. Eleven of these patients were diagnosed by histologic needle biopsy. The mean follow-up was 28 months (range 5-60 months). Three (skin or subcutaneous) local recurrences at the needle entry site, diagnosed in a mean time of 23.6 months (16, 22, and 23 months), were reported. The three patients underwent complete resection with clear margins, radiation therapy to the "neobreast," and tamoxifen. All three patients are disease free with a mean postrecurrence follow-up of 24.3 months (30, 23, and 22 months). Based on the evidence of displacement of tumor cells and the potential nonresection of such tumor seeding at the time of skin-sparing mastectomy, as well as the poor probability of postoperative radiation therapy, we recommend surgical resection of the needle biopsy tract, including the dermal entry site, at the time of mastectomy.- - - - - - - - - - ranking = 1keywords = probability (Clic here for more details about this article) |
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