Objective: To determine the feasibility of excluding MRI from the preoperative diagnostic pathway of invasive lobular carcinoma (ILC) in women with low and low to moderate density breasts on mammography.Methods: A total of 179 cases of ILC were diagnosed between 2009 and 2012.Forty-eight cases were identified as low and low to moderate density breasts.The study group includes 32 cases who underwent MRI.Parameters scrutinised include size and number of lesions on mammography, ultrasound and MRI, second-look ultrasound, type of surgery, further surgery and histology.Results: Twenty-nine cases had low to moderate density breasts and three had purely low density breasts.Average age of women was 64.Size of lesions ranged between 2 and 50 mm with an average of 20.14 mm.In 25/32 cases (78.12%) conventional imaging matched MRI.MRI identified additional disease in 7/32 (21.8%).This was predominantly in the form of satellites around the index lesion resulting in multifocality in 6/7.Four resulted appropriately in mastectomy.Two led to wider WLE appropriately.In one case, multicentric disease was correctly detected and subjected to mastectomy.Second-look ultrasound was recommended in 4/7 cases.All these cases had low to moderate density breasts on mammography and 6/7 cases measured more than 15 mm in size.Ultrasound matched MRI in one mammographically occult case and was subjected to appropriate WLE.In two cases there was much more disease than anticipated from conventional imaging and MRI (6.25%).Conclusion: Even in low and low to moderate density breasts where mammography has a higher exclusion value, MRI identified additional disease in 21.8% (7/32). O2Is ultrasound axillary staging less accurate in invasive lobular breast cancer than in ductal breast cancer?
To retrospectively investigate the effect of flip angle (FA) and k-space sampling on the performance of dynamic contrast-enhanced (DCE-) magnetic resonance imaging (MRI) breast sequences.
39 Background: Image-guided vacuum-assisted biopsy (VAB) is increasingly used after completion of neoadjuvant chemotherapy (NAC) to assess residual disease in the breast, facilitate risk-adaptive surgery and potentially identify exceptional responders who may not require surgical intervention. The aim of this analysis was to investigate the diagnostic performance of a standardized post-NAC VAB protocol, developed following retrospective analysis of institutional data (1). Methods: Prospective cohort study of patients with HER2 positive and triple negative (TN) invasive ductal carcinoma, treated with NAC, who had partial/complete imaging response and underwent post-NAC VAB to aid surgical planning between 02/2018 and 06/2019. The aim of VAB was to sample the site of residual imaging abnormality (breast residuum <2cm) previously marked by clip insertion. Pathologic complete response (pCR) was defined as no residual disease in the breast (ypT0). Diagnostic accuracy of VAB was calculated using final surgical pathology as the reference standard. Simple descriptive statistics were performed. Results: 26 eligible patients underwent post-NAC VAB. This was representative in 23 cases. The overall pCR rate was 46.2% (42.1% for HER2 positive, 57.1% for TN phenotypes). The post-NAC VAB false negative rate (FNR) was 9.1% (95% CI: 0-26.1) and the negative predictive value (NPV) was 90.91% (95% CI: 60.27-98.51) with an overall accuracy of 86.96% (95% CI: 66.41-97.22). Conclusions: This data suggests that post-NAC VAB may reliably predict pCR in patients with HER2 positive and TN invasive ductal carcinoma with good response to NAC. Further technical refinements in VAB technique, standardization in patient selection and prospective trials are warranted to further explore the role of post-NAC VAB in supporting minimal or no surgery trials. References 1. Tasoulis MK, Roche N, Rusby JE, Pope R, Allen S, Downey K, Nerurkar A, Osin P, Wilson R, MacNeill F. Post neoadjuvant chemotherapy vacuum assisted biopsy in breast cancer: Can it determine pathologic complete response before surgery? J Clin Oncol 2018;36 (Supplement): abstr 567.
Ultrasound (US) is the imaging modality of choice for staging the axilla prior to surgery in patients with breast cancer (BC). High pathological complete response rates in the axilla after NACT mean a more conservative approach to surgery can be considered. Radiological re-staging is important in this decision making. After the presentation of results from ACOSOG Z1071 in December 2012, formal ultrasound re-assessment of the axilla after primary therapy was specifically requested in our institution. We report on the accuracy of axillary US (aUS) for identifying residual axillary disease post-NACT.Data were collected on patients who had proven axillary disease prior to NACT and underwent axillary lymph node dissection after NACT between January 2013 and December 2015. Post-chemotherapy aUS reports and axillary pathology reports were classified as positive or negative for abnormal lymph nodes and for residual disease (cCR and pCR respectively).The sensitivity and specificity of aUS was 71% and 88% respectively. The negative predictive value (NPV) was 83%. The false negative rate was 29%.Axillary ultrasound provides clinically useful information post-NACT, which will guide surgical decision-making. Patients with aUS-negative axillae are likely to have a lower false negative rate of SLNB after NACT (Boughey et al.). However, aUS does not replace the need to identify and biopsy the nodes which were proven to be positive prior to NACT.
Antecedentes: Las guías de práctica clínica recomiendan tratar a los pacientes con oclusión casi completa de la arteria carótida interna (internal carotid artery near occlusion, ICANO) con el mejor tratamiento médico (best medical therapy, BMT) basado en una evidencia débil.En consecuencia, pacientes con ICANO han sido excluidos de ensayos aleatorizados.El objetivo de este metaanálisis de datos de pacientes individuales (individual patient data, IPD) fue determinar el planteamiento terapéutico óptimo.Métodos: Se realizó una búsqueda sistemática en las bases de datos de MEDLINE, EMBASE y Cochrane en enero de 2018.El resultado primario fue la aparición de cualquier accidente cerebrovascular o muerte dentro de los primeros 30 días de tratamiento, analizado mediante una regresión logística multivariada de efectos mixtos.El resultado secundario fue la aparición de cualquier accidente cerebrovascular o muerte más allá de los 30 días hasta 1 año del tratamiento, analizado mediante una curva de supervivencia de Kaplan-Meyer.Resultados: La búsqueda proporcionó 15.267 artículos, de los cuales 613 fueron recuperados para la revisión del texto completo.En 32 estudios se cumplían los criterios de inclusión y en 11 se disponía de los datos de pacientes individuales agrupados, incluyendo 703 pacientes con ICANO.Dentro de los 30 días, se describió cualquier accidente cerebrovascular o muerte en 8 pacientes (2,4%) del grupo de endarterectomía carotidea (carotid endarterectomy, CEA), en 5 pacientes (2,2%) del grupo con colocación de stent en la carótida (carotid artery stenting, CAS), y en 7 pacientes (4,9%) del grupo BMT.Esto dio lugar a una tasa más elevada de accidente cerebrovascular/muerte a los 30 días después de BMT que tras CEA (razón de oportunidades, odds ratio, OR 5,63, i.c.del 95% 1,3-24,45, P = 0,021).No se hallaron diferencias entre CEA y CAS.La tasa de supervivencia libre de accidente cerebrovascular/muerte a 1 año fue del 96,1% para CEA, 94,4% para CAS y 81,2% para BMT.Conclusión: Estos datos sugieren que BMT por si solo no es superior a CEA o CAS con respecto a la prevención de accidente cerebrovascular/muerte a los 30 días o a 1 año en pacientes ICANO.Estos pacientes no parecen constituir un subgrupo de alto riesgo para la cirugía y convendría tener en cuenta incluirlos en futuros ensayos clínicos aleatorizados de intervenciones para la arteria carótida interna. Meta-analysis of completion lymph node dissection in sentinel lymph node-positive melanomaMetaanálisis sobre completar la exéresis ganglionar en el melanoma con ganglio centinela positivo
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