Locally Advanced Breast Carcinoma Research Articles

Latissimus Dorsi Flap Revisited: Coverage of Large Chest Wall Defects Following Mastectomy for Locally Advanced Breast Carcinoma and Angiosarcoma.

The latissimus dorsi myocutaneous flap (LDMF) remains a significant tool in the armamentarium of the oncoplastic breast surgeon. Despite declining popularity for reconstruction, owing to the increasing use of implants and free flaps, it still has an important role in certain salvage situations and as a flap to cover large defects. We report our experience with the use of LDMF for immediate coverage of large mastectomy defects when options are limited. Retrospective series of prospectively collected patient records. Patient and tumour characteristics, length of stay, and post-operative and oncologic outcomes are reported. Patients with angiosarcoma were discussed at tertiary sarcoma centres as per national guidelines. Operations were carried out by oncoplastic breast surgeons. The case series was approved by the institutional information governance department in line with institutional requirements for patient data sharing. All patients provided written consent for photography. Descriptive statistics were used to report findings.Median (IQR) was used for continuous variables. Six women were included, with a median age of 62.5 years, from December 2019 to October 2022. Follow-up ranged from 15 to 49 months. Median tumour size was 72.5 (16.25) mm. Four patients had locally advanced breast carcinoma (LABC), and two had breast angiosarcoma. The donor site and chest wall defects were closed primarily in all cases. Median length of stay was three nights. All mastectomy wounds healed without issues and any delay to their adjuvant treatment. One patient had a minor latissimus dorsi (LD) donor site wound breakdown managed conservatively. Three patients had adjuvant radiotherapy after surgery. Four patients, one after high-grade angiosarcoma and three after aggressive breast carcinoma, had a locoregional recurrence or distant metastases and succumbed within 20 months of surgery. The LDMF can be a reliable option for the primary closure of large post-mastectomy wounds. Its use can lead to timely wound healing, allowing patients to undergo adjuvant treatment without delay. However, the overall oncologic outcomes in patients with LABC and angiosarcoma are poor due to the underlying aggressive tumour biology. Long-term outcomes are to be interpreted with caution due to the small number of patients with diverse pathologic features.

Assessment of Response to Neoadjuvant Chemotherapy in Locally Advanced Breast Carcinoma Using Image-Guided Clip Placement.

Background The present study aims to evaluate the response of locally advanced breast carcinoma (LABC) to neoadjuvant chemotherapy (NACT) using image-guided clip placement based on Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria. Methods Thirty-four patients with LABC were included in the study. Consent for three-dimensional titanium clip placement (400/300/200 mm Liga clips) under local anesthesia with USG guidance was obtained. Serial sonographic/X-ray evaluations of tumor bed size were conducted before every cycle of NACT. All data were recorded in millimeters of concentric tumor regression/non-regression. Tumor regression in a concentric or Swiss cheese pattern and non-responders were evaluated. Assessment of the response to NACT was performed using RECIST criteria, dividing it into four categories. Tumor response was confirmed with computerized tomography (CT) conducted before and after the completion of NACT. Patients underwent surgical management, mostly modified radical mastectomy (MRM), as they had locally advanced breast carcinoma. Following MRM, the clips in the specimen guided the original site of the tumor for histopathological evaluation and response to chemotherapy. Results Tumor response was classified into four types: complete response (CR), partial response (PR), progressive disease (PD), and stable disease. RECIST 1.1 criteria were elaborated and defined. Data for all patients were entered into an Excel sheet (Microsoft Corporation, Redmond, Washington)to prepare a master chart, and the following observations were made and analyzed using SPSS software. The duration of chemotherapy for the study population ranged from 32 to 206 days, with a mean (±SD) of 111.82 (± 52.64) days and a median (IQR) of 81 (63, 158) days. The mean period between clip insertion and completion of NACT was 111.82 days. The baseline sum diameters and post-NACT diameters of the tumors were 70.50 (±13.60) mm before NACT and 17.75 (±17.20) mm after NACT. Hence, the mean size of the lump was statistically significantly lower after NACT, with a mean difference of 52.75 (p<0.05). The mean rate of reduction in tumor diameter was found to be 74.32% (±23.44%) based on RECIST 1.1 criteria. Pathological response was observed in all patients except for 8.8% of the patients. Clinical complete response was seen in 35.29% of patients, and partial response was observed in 52.92% of the patients based on RECIST 1.1 criteria. The study thus demonstrates the effectiveness of NACT in LABC, with a mean reduction in tumor diameter of 74.32%, assessed with the help of RECIST 1.1 criteria. Conclusion NACT for patients with LABC has shown a significant reduction in tumor size. NACT should be the initial mode of management for patients with LABC. RECIST 1.1 criteria are effective and can be used to assess tumor response to NACT. This has aided in the stratification of the response of NACT for further management through systemic therapy (adjuvant chemotherapy) after the surgical excision of the tumor.

Pathological response of different molecular subtypes of locally advanced breast carcinoma to neoadjuvant chemotherapy

Background: This study was done on modified radical mastectomy (MRM) specimens of patients with locally advanced breast carcinoma (LABC) who were categorized into molecular subgroups based on Immunohistochemistry and underwent neoadjuvant chemotherapy (NACT). The purpose of the study was to look for the pathological response of the tumor to the NACT. The molecular subtypes include Luminal A, Luminal B, Human epidermal growth factor receptor 2 (HER2) enriched, and triple negative. For HER2 enriched subtype, trastuzumab was also given along with the chemotherapy regimen. Aims and Objectives: The primary objective of this study is to find out the pathological complete response (pCR) in various molecular subgroups of breast carcinoma following NACT. The secondary objective is to describe the cellular changes in tumor tissue following NACT. Materials and Methods: This is a descriptive study done on MRM specimens of patients with LABC received in histopathology lab of Government Medical College, Kottayam to look for the pCR of the tumor following NACT. Gross examination and histopathology study of the specimen including axillary lymph nodes were done. The trucut biopsies of these cases with immunohistochemistry study were reviewed for confirming the grade and molecular subtype. pCR was assessed based on Chevallier system. Results: Of the 131 MRM specimens studied, overall pathologic complete response rate was 24.4% and the pathologic complete response rate in Luminal A subtype, Luminal B subtype, HER2 enriched tumors, triple negative tumors were 23.6%, 24%, 33%, and 20%, respectively. Conclusion: 33% of HER2 enriched subtype showed a pCR, i.e., no residual foci of neoplasm seen in the MRM specimens following NACT. Following NACT, change in tumor cellularity, changes in the morphology of neoplastic cells, changes in the surrounding breast tissue, and a change in grade of tumor were also noticed.

Clinical study of outcome of operative management of locally advanced breast carcinoma after neoadjuvant chemotherapy at tertiary care hospital

Background: Locally advanced diseased of the breast is characterised clinically by features suggesting infiltration of the skin or chest wall by tumour or matted involved axillary nodes (AJCC-stage III). Successful reduction in the size of the tumor is associated with increased rate of operability i.e., modified radical mastectomy or breast conserving therapy (BCT). The aim of this study is to assess outcome of surgery in management of locally advanced breast carcinoma (LABC) after neoadjuvant chemotherapy.Methods: It is an observational retrospective study of 40 cases of LABC admitted at general surgery department.Results: The response to neoadjuvant chemotherapy was seen in 92.5% cases- with complete response in 10% cases (4 patients) and partial response in 82.5% (33 patients). No response was observed in 7.5% cases (3 patients) after 4 cycles of neoadjuvant chemotherapy. All patients were subjected to surgery after chemotherapy, out of whom 02 patients (5%) have surgical site infection and flap necrosis in 01 patient (2.5%) and no mortality; 02 patients subjected to toilet mastectomy without neoadjuvant chemotherapy resulted in 01 recurrence within 6 months of completion of adjuvant therapy and 01 death postoperatively.Conclusions: Majority of patients were subjected to neoadjuvant chemotherapy responded partially to it. Overall observations suggested that most of the LABC responds to neoadjuvant chemotherapy with minimum post-operative morbidity and mortality.

A prospective observational study of the clinical presentation and treatment modalities in locally advanced breast carcinoma

Breast cancer is the most common site specific cancer in women and is the leading cause of death from cancer for women aged 20 – 59 years. This study aimed at profiling cases of locally advanced breast carcinoma (LABC) with respect to incidence, age at presentation, most common presentation, histologic type and various modalities in management of locally advanced breast carcinoma (LABC). This prospective study followed 45 cases of Locally advanced breast carcinoma over 2 years. It showed almost 100 percent of females presented with palpable lump with other associated complaints. Peak incidence was noted in 4th to 6th decade. Major clinical presentation was lump in breast with most common involvement of upper outer quadrant of either breast. Diagnosis was with fine needle aspiration cytology with common histology of invasive carcinoma no special type (NST) followed by invasive ductal carcinoma. Most common treatment sequence used was Modified radical mastectomy followed by adjuvant chemotherapy followed by adjuvant radiotherapy.

Analysis of RPL37A, MTSS1, and HTRA1 expression as potential markers for pathologic complete response and survival.

Non-metastatic locally advanced breast carcinoma (LABC) treatment involves neoadjuvant chemotherapy (NCT). We evaluated the association of clinical-pathological data and immunoexpression of hormone receptors, HER2 and Ki67, and new biomarkers, RPL37A, MTSS1 and HTRA1, with pathological complete response (PCR) or tumour resistance (stable disease or disease progression), disease-free survival (DFS) and cancer-specific survival (CSS). This is a retrospective study of 333 patients with LABC who underwent NCT. Expression of MTSS1, RPL37A and HTRA1/PRSS11 was evaluated by immunohistochemistry in TMA slides. Cutoff values were established for low and high tumour expression. ROC plotter evaluated response to NCT. Chi-square test for factors related to PCR, and Kaplan-Meier test and Cox model for factors related to DFS and CSS were prformed. The mean follow-up was 70.0months and PCR rate was 15.6%. At 120months, DFS rate was 32.5% and CSS rate was 67.1%. In multivariate analysis, there was an association between: (1) necrosis presence, intense inflammatory infiltrate, ER absence, HER2 molecular subtype and high RPL3A expression with increased odds of PCR; (2) lymph node involvement (LNI), high Ki67, low RPL37A and high HTRA1 expression with increased risk for NCT non-response; (3) LNI, high proliferation, necrosis absence, low RPL37A and high HTRA1 expression with increased recurrence risk; (4) advanced LNI, ER negative tumours, high HTRA1, low RPL37A expression and desmoplasia presence with higher risk of cancer death. RPL37A is a potential biomarker for response to NCT and for prognosis. Additional studies evaluating HTRA1 and MTSS1 prognostic value are needed.

An AN OBSERVATIONAL STUDY OF SLN MAPPING IN PATIENTS OF LOCALLY ADVANCED BREAST CANCER FOLLOWING NCT

Background : Locally advanced breast carcinoma (LABC) includes a wide range of clinical scenarios- advanced primary tumors (T4), advanced nodal disease and inflammatory carcinomas(1). Traditionally, treatment of LABC included a combination of Chemotherapy, Radiation and Surgery(2). However, there has been a shift to Neoadjuvant Chemotherapy in recent times.(3)&#x0D; Histological status and the number of axillary lymph nodes with metastasis is one of the most important prognostic factors and most powerful predictor of recurrence and survival in patients of breast carcinoma and remains so, even after neo-adjuvant chemotherapy. (3) Information derived from the sentinel lymph node is considered valuable, with less discomfort to the patient when compared with axillary dissection.(4) However, its role in detecting nodal metastasis after neo-adjuvant chemotherapy in LABC is still debatable and definitive studies to evaluate its role are still evolving. (5)&#x0D; Materials and Methods: Patients of LABC were evaluated using ultrasonography (USG) of axilla. Neo-adjuvant chemotherapy (NACT) was administered and patients were reassessed by USG of axilla. Thirty patients with node negative axillary status were subjected to Sentinel lymph node mapping using isosulfan blue followed by Modified Radical Mastectomy and Axillary Lymph Node Dissection. Histopathological evaluation of stained and unstained lymph nodes done and the data, thus obtained, was statistically analysed.&#x0D; &#x0D; Results: Sentinel lymph node biopsy performed using Isosulfan Blue dye alone, after neo-adjuvant chemotherapy predicts the status of axillary lymph nodes with low accuracy.&#x0D; &#x0D; Conclusions: Further studies would be required to establish the role of sentinel lymph node biopsy in patients with LABC after NACT.

Role of neoadjuvant chemotherapy in downstaging locally advanced breast carcinoma, selection of surgical procedure and its outcome

Background: In clinical practice all cases of locally advanced breast carcinoma (LABC) warrant chemotherapy followed by multimodality care. Neoadjuvant chemotherapy (NACT) has been the mainstay in the management of LABC. The main aim of NACT is to downstage and prevent systemic micrometastasis early.Methods: This was a prospective study conducted on 36 diagnosed cases of stage III locally advanced breast cancer coming to the Dept. of Surgery, Dr. D. Y. Patil Medical College and hospital, Pune for a period of 2 years from 2017-2019. The effectiveness of neoadjuvant chemotherapy was assessed based on clinical, pathological and radiological response.Results: Among 36 LABC cases, maximum number of patients fell in the 41-50 years (41.6%) and presented in the Infiltrating ductal carcinoma group with a clinical stage IIIA disease. The response to NACT showed that a total of 12 patients (33.3%) showed complete clinical response and 30 patients were downstaged after neoadjuvant chemotherapy which was statistically significant. Only 4 out of the total 12 complete clinical responders went for Breast conservative surgery. Seroma formation was found to be the most common post-operative complication.Conclusions: LABC subjected to neoadjuvant chemotherapy based on taxanes/Anthracyclines show good clinical and radiological response. Patients preferred modified radical mastectomy due to the lack of awareness and low socioeconomic strata.The type of surgery did not increase the chance of recurrence in the follow up period.

Effect of neoadjuvant chemotherapy (NAC) on programmed cell death ligand (PD-L1) in patients of carcinoma breast: A prospective study in Indian tertiary care setting.

Context:Several studies have reported that PD-L1 has shown therapeutic activity in various tumor types. However, its expression changes in a person on administration of NAC which is reported by very few studies.Aims:To find out the difference in the expression of PD-L1 by tumor cells after the administration of NAC.Settings and Design:This prospective study was conducted on 30 patients who were diagnosed with locally advanced breast carcinoma (LABC) between 2017 and 2019 and those who received NAC followed by surgery.Methods and Material:Breast cancer specimens were collected using core needle biopsy prior to administration of NAC and IHC was performed. Frequency and staining intensity of PD-L1 by tumor cells were analyzed. PD-L1 expression was dichotomized into two groups according to the frequency distributions of the H-scores.Statistical Analysis Used:The differences in expression of PD-L1 along with various parameters were analyzed using Chi-square test and Student's t test.Results:The mean age of the patients in our study was 51.37 ± 11.37 years. The response of NAC according to the RECIST criteria showed that most of patients (83.3%) showed complete response. Of the 30 cases, 11 (36.7%) patients were PD-L1 positive before the administration of NAC. We found a significant change in expression from positive to negative status, i.e., seven patients changed from positive to negative (p = 0.036). Upon comparing the PD-L1 expression before NAC, significant association was observed between the primary tumor (T) and tumor stage with high PD-L1 expression (p = 0.020 and P = 0.034). After NAC, 18 (69.2%) patients who were ER positive and 18 (69.2%) patients who were PR positive showed negative PD-L1 expression while none of them were positive in PD-L1 positive patients (p = 0.018 and P = 0.018).Conclusion:PD-L1 expression in a same person changes upon administration of NAC which may indirectly be used as a predictor of response to NAC.

Role of flap fixation during modified radical mastectomy in locally advanced breast carcinoma patients: a randomised control study

Background: Treatment of locally advanced breast carcinoma (LABC) patients involves multimodal approach. Modified radical mastectomy (MRM) is preferred in them. Seroma and prolonged drainage are most common post-op complications. This study was conducted to evaluate the effect Flap fixation technique in reducing drain output and seroma in patients with LABC.Methods: 30 stage III breast cancer patients undergoing MRM were included. Prior to skin closure patients were randomised into: test (15) and control group (15). In Test group, skin flaps were sutured to chest wall with vicryl 3-0 at 3 cm intervals and skin was closed with nylon. In conventional group, only skin was closed with nylon sutures. In both the groups conventional closed suction drains were placed. Total drain output, clinically significant seroma, post-operative complications were compared between the two groups.Results: Total drain output in test group (4445 ml) was lesser compared to control group (4801 ml) but not statistically significant (p=0.548), however the percentage reduction of drain output on day 2 was significantly higher in test group (42%) as compared to control group (31.8%) (p=0.04). The clinically significant Seroma formation rates were similar in both groups but the volume of seroma aspirated was significantly lower in test group (p&lt;0.05).Conclusions: The flap fixation technique group had better approximation of skin flaps and chest wall, as evident with reduction of drain output, significant reduction in drain output on post op day 2 and reduction of seroma volume.

Effectiveness and Safety of Implant-Based Breast Reconstruction in Locally Advanced Breast Carcinoma: A Matched Case-Control Study

Background: Immediate implant-based breast reconstruction (IBBR) is rarely performed in patients with locally advanced breast carcinoma (LABC). It has not been considered the best indication, and the literature is scarce about this subject. Patients and Methods: A retrospective matched case-control study was performed in patients with LABC submitted to neoadjuvant chemotherapy (NCT). Forty-eight patients undergoing immediate IBBR were matched with 96 patients undergoing conventional mastectomy. Patients were matched according to 2 models based on prognostic characteristics prior to NCT and response to NCT. Local recurrence and disease-free survival were compared between the groups. In the IBBR group, local complications were evaluated. Results: In all, 196 patients were evaluated. The mean tumour size of IBBR patients was 5.8 cm. 83.3% (180/196) of the patients had clinical stage III. At a mean follow-up of 74.7 months, the local recurrence rate was 6.2% (3/48), 15.6% (15/96) and 13.7% (13/95) in the IBBR, model 1 and model 2 groups, respectively (p > 0.05). Disease-free survival was higher in the IBBR group than in the model 1 group (mean 88.8 vs. 73.7 months; p = 0.05). In the group submitted to IBBR, 14.6% (7/48) of patients presented loss of prosthesis and 48.8% (20/41) developed capsular contracture. Conclusion: Immediate IBBR may be a safe and effective surgical procedure in selected patients with LABC.

A study of Ki-67 labeling index in invasive nonmetastatic breast carcinoma.

e14001 Background: This study evaluates the predictive value of Ki-67 in patients with invasive breast cancer receiving neoadjuvant chemotherapy (NACT) and its correlation with established prognostic factors. Methods: This is a prospective observational study of 165 invasive nonmetastatic breast cancer patients. Clinicopathological characteristics and Ki-67 labeling index were assessed. Patients with locally advanced breast carcinoma (LABC) received NACT and response rates were evaluated. Statistical significance was calculated using Chi Square test, unpaired t test, and non-parametric Mann-Whitney test. Results: Amongst the Ki-67 high group a significantly large majority of patients had grade 3 tumor (86.8% vs. 13.1%, p value < 0.001), ER negativity (56.8% vs. 11.4% p value < 0.001), PR negativity (65.3% vs. 18.6%, p value < 0.001), HER2/neu overexpression (47.4 % vs11.4 % , p value < 0.001) and lymphovascular invasion (LVI) (29.4% vs. 14.7% p value= 0.024). In high Ki-67 group 24.3% achieved CR compared...

PR48 CLOSED SURGICAL MARGINS WERE STILL PREDICTOR OF IBTR ON LABCS AFTER PRIMARY SYSTEMIC CHEMOTHERAPY AND MASTECTOMY

Background: The current study identified determinants of systemic recurrence and ipsilateral breast tumor recurrence (IBTR) in patients with locally advanced breast carcinoma (LABC) treated with neoadjuvant chemotherapy and mastectomy. Methods: The study population consisted of 200 consecutive women with stages locally advanced breast carcinoma who underwent mastectomy after neoadjuvant chemotherapy between July 2009-July 2011. Clinical and pathologic characteristics evaluated included age, tumor size, tumor grade, estrogen and progesterone receptor status, surgical margins, axillary lymph node involvement, and use of adjuvant radiotherapy. Results: At a median follow-up time of 2 years, 42% had developed an ipsilateral breast tumor recurrence (IBTR), and 18% had developed a systemic recurrence. On multivariate logistic regression analysis, tumor size greater than 5 cm, positive lymph nodes, lack of adjuvant radiotherapy, triple negative type and closed margins (odds ratio [OR], 3.8; 95% confidence interval [CI],1.1-12.3; P = 0.033) were predictors of IBTR. When IBTR was added into the model, IBTR was dependent predictor of systemic recurrence. Conclusions: Positive surgical margins and biology molecular type of breast cancer are predictors of systemic recurrence and IBRT after primary systemic chemotherapy and mastectomy on LABCs. Aggressive local therapy is necessary to ensure adequate surgical margins and to minimize IBTR.

PR49 CHEST WALL RECONSTRUCTION USING EXTERNAL OBLIQUE MYOCUTANEOUS RETAIL IN PATIENTS WITH LOCALLY ADVANCED BREAST CANCER: 3 CASES REPORT

Background: The current study identified determinants of systemic recurrence and ipsilateral breast tumor recurrence (IBTR) in patients with locally advanced breast carcinoma (LABC) treated with neoadjuvant chemotherapy and mastectomy. Methods: The study population consisted of 200 consecutive women with stages locally advanced breast carcinoma who underwent mastectomy after neoadjuvant chemotherapy between July 2009-July 2011. Clinical and pathologic characteristics evaluated included age, tumor size, tumor grade, estrogen and progesterone receptor status, surgical margins, axillary lymph node involvement, and use of adjuvant radiotherapy. Results: At a median follow-up time of 2 years, 42% had developed an ipsilateral breast tumor recurrence (IBTR), and 18% had developed a systemic recurrence. On multivariate logistic regression analysis, tumor size greater than 5 cm, positive lymph nodes, lack of adjuvant radiotherapy, triple negative type and closed margins (odds ratio [OR], 3.8; 95% confidence interval [CI],1.1-12.3; P = 0.033) were predictors of IBTR. When IBTR was added into the model, IBTR was dependent predictor of systemic recurrence. Conclusions: Positive surgical margins and biology molecular type of breast cancer are predictors of systemic recurrence and IBRT after primary systemic chemotherapy and mastectomy on LABCs. Aggressive local therapy is necessary to ensure adequate surgical margins and to minimize IBTR.

Pathological predictive factors for tumor response in locally advanced breast carcinomas treated with anthracyclin-based neoadjuvant chemotherapy

Neoadjuvant chemotherapy (NACT) is used as a primary treatment for locally advanced breast carcinoma (LABC) and also extended to operable breast cancer. The aim of this study was to evaluate the predictive value of different histological parameters in core biopsy of LABC patients treated with anthracycline-based chemotherapy regimen. Pathological assessment of the excised tumor bed is the gold standard and is essential for identifying the group of patients with pathologic complete response (pCR) or pathologic noncomplete response (pNR). A total of 50 patients with stage II and III breast carcinoma were included in the study. Pretreatment core biopsy histological features include tumor type, histological grade, presence of tumor necrosis, lymphovascular emboli (LVE) and immunohistochemical stains for estrogen receptor (ER) and progesterone receptor (PR) were obtained. Patients were given 3-6 cycles of NACT. Pathological response was assessed. Seven out of 50 patients achieved pCR. A total of 71.4% patients who achieved pCR had tumor necrosis on initial core biopsy while only 30% pNR cases had this feature (P =0.035). Breast carcinoma other than ductal type was chemoresistant. Of 47 core biopsies, LVE was observed in 13 cases (28 %) of which 11 showed axillary node metastasis. None of these 13 cases had pCR, thus having poor predictive value. Pathological parameters like type of tumor, presence of LVE and tumor necrosis in the core biopsy can predict the response to NACT in routine stain. Tumor necrosis and type of breast carcinoma are predictive parameters for tumor responsiveness to NACT. LVE was reliable in predicting axillary lymph node metastasis.

Is locally advanced breast cancer a neglected disease?

Breast cancer is the second most common malignancy in India, and majority of patients present as a locally advanced breast carcinoma (LABC). Evaluating the prevalence of LABC and assessing the causes of local advancement and delayed presentation is the aim of the present study. This was a rural hospital-based prospective cross-sectional study. Descriptive statistics. Seventy-one cytologically/histopathologically confirmed cases of breast carcinoma were enrolled in the study. Breast sarcomas and lymphoma were excluded and, of them, prevalence of LABC and causes of delay and local advancement, i.e. patient factors, system factors and biological factors, were evaluated. LABC accounted for 50.7% of these patients. On assessing the cause of advancement of LABC, patient factor (69.8%) was the major cause for delayed presentation, followed by system delay (23.6%). Patient factors were lack of awareness of breast cancer (75%) and financial constraints (52.8%). The system factor was nonreferral by general practitioners to specialty centers or trying to treat these patients with other allied modalities of treatment. LABC in the Indian scenario is an outcome of neglect due to patient and system factors. These factors offer an excellent opportunity to plan a community-oriented preventive strategy for the general population and practitioners to decrease the incidence of LABC.

Inflammatory breast carcinoma and locally advanced breast carcinoma: characterisation with MR imaging

This study was done to identify the typical magnetic resonance (MR) imaging findings of inflammatory breast carcinoma (IBC) in comparison with noninflammatory locally advanced breast carcinoma (LABC). MR images of 30 patients with IBC (T4d) were compared with those of a cohort of 30 patients with LABC (T3/T4a-c). The age distribution was approximately equal in the two groups. MR images were assessed for the following features: skin thickening (>4 mm), skin oedema, architectural distortion, enhancement pattern (mass-like/non-mass-like), time-signal intensity curve (continuous-persistent type/wash-out type), skin enhancement. Fisher's exact text was used to compare MR imaging appearances of IBC and LABC (significant p value <0.05). Skin involvement and enhancement pattern differed between groups: skin thickening was present in 16/30 IBC (53%) vs 8/30 LABC cases (27%, p=0.06), skin oedema was present in 26/30 IBC (87%) vs 8/30 LABC (27%, p < 0.0001), and skin enhancement in 10/30 IBC (33%) vs 2/30 LABC (7%, p=0.02); non-mass-like enhancement was present in 22/30 IBC (73%) vs 12/30 LABC (40%, p=0.02). IBC is a distinct clinical and pathological entity resulting in typical MR imaging features. Skin changes (thickening, oedema, enhancement) related to neoplastic involvement of the dermal lymphatics are suggestive of IBC and should prompt a skin biopsy to confirm or rule out the diagnosis.

Tumor Metabolism and Blood Flow Changes by Positron Emission Tomography: Relation to Survival in Patients Treated With Neoadjuvant Chemotherapy for Locally Advanced Breast Cancer

Patients with locally advanced breast carcinoma (LABC) receive preoperative chemotherapy to provide early systemic treatment and assess in vivo tumor response. Serial positron emission tomography (PET) has been shown to predict pathologic response in this setting. We evaluated serial quantitative PET tumor blood flow (BF) and metabolism as in vivo measurements to predict patient outcome. Fifty-three women with primary LABC underwent dynamic [(18)F]fluorodeoxyglucose (FDG) and [(15)O]water PET scans before and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG) and transport (FDG K(1)) parameters were calculated; BF was estimated from the [(15)O]water study. Associations between BF, MRFDG, FDG K(1), and standardized uptake value and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model. Patients with persistent or elevated BF and FDG K(1) from baseline to midtherapy had higher recurrence and mortality risks than patients with reductions. In multivariable analyses, BF and FDG K(1) changes remained independent prognosticators of DFS and OS. For example, in the association between BF and mortality, a patient with a 5% increase in tumor BF had a 67% higher mortality risk compared with a patient with a 5% decrease in tumor BF (hazard ratio = 1.67; 95% CI, 1.24 to 2.24; P < .001). LABC patients with limited or no decline in BF and FDG K(1) experienced higher recurrence and mortality risks that were greater than the effects of clinical tumor characteristics. Tumor perfusion changes over the course of neoadjuvant chemotherapy measured directly by [(15)O]water or indirectly by dynamic FDG predict DFS and OS.

Inflammatory Breast Carcinoma in Magnetic Resonance Imaging: A Comparison with Locally Advanced Breast Cancer

Although inflammatory breast carcinoma (IBC) accounts for 1%-4% of all breast cancer cases, the appearance of this highly malignant tumor in magnetic resonance imaging (MRI) is still not well characterized. The aim of this study was to identify typical imaging features of IBC in comparison with noninflammatory locally advanced breast carcinoma (LABC).MRIs of 48 patients with IBC were compared with an equivalent cohort of 52 subjects with LABC. Age and histopathologic subtype were equivalent between the two groups. To delineate characteristic features, a multitude of dynamic and morphologic parameters were evaluated using T1- and T2-weighted sequences.No significant differences of prevalences could be found for the following criteria: dynamic tumor signal characteristics, prominent vessels, perifocal edema, axillary lymph node involvement, morphology of focal masses, and morphologic pattern of non-mass like enhancement. Otherwise, the quantity of focal masses and the spatial distribution of the tumoral infiltration significantly differed between the two cancer groups. The following parameters occurred more frequently in the IBC cases: edema (cutaneous/subcutaneous 81.3%, perimamillar 70.8%, diffuse 89.6%, prepectoral 72.9%, intramuscular pectoral 41.7%), thickening (75.0%) and pathologic enhancement (60.4%) of Cooper's ligaments, skin thickening (83.3%), punched-out sign (initially strong, focal increase of some dermal or subcutaneous parts followed by slow-continuous enhancement of the surrounding skin; 56.3%).Inflammatory breast carcinoma seems to represent a specific biological entity resulting in typical MRI characteristics. Some of the parameters are supposed to visualize the characteristic extensive lymphovascular infiltration and therefore may improve the diagnosis of IBC.

Tumor metabolism, blood flow changes, and prognosis by positron emission tomography: A prospective cohort of locally advanced breast cancer patients

506 Background: Breast cancer patients with locally advanced tumors receive preoperative chemotherapy to provide early systemic treatment and assess in-vivo tumor response. Positron emission tomography (PET) has been used to follow tumor response to therapy, as pathologic response is predictive of patient outcome. We evaluated the prognostic utility of serial quantitative PET tumor blood flow (BF) and metabolism measurements. Methods: Fifty-five women with a primary diagnosis of locally advanced breast carcinoma (LABC) underwent dynamic [18F]-FDG and [15O]-water PET scans prior to and at midpoint of neoadjuvant chemotherapy. The FDG metabolic rate (MRFDG), transport (K1), and flux (Ki) parameters were calculated, and tumor blood flow was estimated from the [15O]-water study. Associations between tumor BF and MRFDG measurements and disease-free survival (DFS) and overall survival (OS) were evaluated using the Cox proportional hazards model. Results: Patients that had an increase in BF and K1, from baseline to mid-therapy measurements, had elevated recurrence and mortality risks compared to patients that had reductions in BF and MRFDG values. In multivariate analysis, changes in BF and K1 remained independent prognostic indicators of DFS and OS survival. Conclusions: PET measurements of tumor response prior to completion of neoadjuvant chemotherapy were predictive of patient outcome. Patients that failed to have a decline in BF and K1 experienced higher risks of recurrence and mortality that was largely independent of clinical tumor characteristics assessed in this study. These results suggest that tumor perfusion, measured directly by [15O]-water or indirectly by dynamic FDG PET, is highly predictive of outcome in neoadjuvantly treated breast cancer. No significant financial relationships to disclose.