bluuebunny/crossref_metadata_2025_split huggingface dataset:
Time-resolved gadolinium-enhanced MR imaging of the breast: Impact on accuracy of diagnosis of breast carcinoma.
Authors: Sherif Hanan , Al-Obaidly Amal , Albosom Issam , Mahfouz Ahmed-Emad 
Published: February 2017

33 Background: The purpose of the study is to differentiate benign and malignant breast lesions based on very early enhancement of the lesion on time-resolved gadolinium-enhanced MR imaging. Methods: 100 women with breast lesions were examined at 1.5 T (Siemens, Erlangen, Germany), by fast T1-weighted GRE images every 5 s for 1 min after injection of Gd-DOTA (Dotarem, Guerbet, France), followed by 5 spacially-resolved MR image series every 30 s. Images were subtracted; maximum-intensity-projection images were obtained; and images were randomized and reviewed by two blinded readers, who reviewed only the spacially-resolved MR images and gave BIRADS diagnosis. After one month, they evaluated only the time-resolved MR images and noted the time of first appearance of enhancement. Results: The patients had 249 enhancing lesions: 66 malignant on histopathology and 183 benign on basis of histopathology or 1-year imaging follow-up. On time-resolved MR imaging, 15 lesions enhanced at 0-5 s (all malignant), 23 at 5-10 s (21 malignant, 2 benign), 34 at 10-15 s (28 malignant, 6 benign), and 117 at 15-20 s (2 malignant, 115 benign). All malignant lesions enhanced before 20 s. Taking 15s as the cut-off point, early enhancement had sensitivity of 96.9%, specificity of 95.6%, positive predictive value of 88.8%, negative predictive value of 98.8%, and accuracy of 95.9% for diagnosis of carcinoma. Enhancement before 15 s corrected BIRADS diagnosis of the spacially-resolved MR imaging in 14 lesions (5.6%). Conclusions: Lesion enhancement in the first 15s on time-resolved MR imaging is a useful sign for the diagnosis of breast carcinoma.
Novel factor to improve prediction of sentinel node positivity in patients with clinical T1/T2 breast cancer.
Authors: Shah-Khan Miraj G. , Torstensen Tiffany , Hoskin Tanya L. , Morton Marilyn , Adamczyk Darcy , Jones Katie N. , Chartier Stephane , Boughey Judy Caroline 
Published: February 2017

49 Background: Predicting nodal positivity can guide surgical planning in breast cancer. Memorial Sloan-Kettering Cancer Center (MSKCC) and MD Anderson Cancer Center (MDACC) have established nomograms to predict sentinel node positivity. We propose that addition of distance of tumor from the nipple (DFN) can improve their performance. Methods: With IRB approval clinical T1/T2 tumors with pre-biopsy ultrasound were reviewed. MSKCC and MDACC nomogram predictions and the AUC-ROC were calculated. The addition of DFN was examined using multiple logistic regression and comparison of AUC-ROC values. Results: 401 breast cancers with clinical T1 (85%) or T2 (15%) tumors in 395 patients were included; of which 79/401 (19.7%) were node positive. Tumors were significantly closer to the nipple in those with positive nodes. 17/33 (51.5%) tumors within 2 cm of the nipple were node-positive versus 62/368 (16.8%) tumors > 2 cm from the nipple (p<0.0001). The MSKCC and MDACC nomograms each demonstrated good discrimination between node positive and negative patients with AUC-ROC values of 0.71 (95% CI: 0.64-0.77) and 0.74 (95% CI: 0.68-0.81), respectively. When added to the MSKCC nomogram, DFN ≤2 cm contributed significantly (OR 4.78, p=0.0001) to prediction of node positivity and improved the AUC-ROC to 0.73 (95% CI: 0.67-0.80). Similarly, DFN ≤2 cm was significant (OR 4.73, p=0.0002) when added to the MDACC nomogram and improved the AUC to 0.76 (95% CI: 0.70-0.82). Within nomogram probability categories, the proportion with positive nodes was consistently higher with DFN ≤2 cm. Conclusions: Tumor distance from nipple is associated with nodal positivity. When added to nomograms it improves prediction of node positivity. DFN should be considered when considering likelihood of nodal positivity for treatment planning. [Table: see text]
Resource and quality information provided by compliance with NCCN hereditary breast cancer guidelines.
Authors: Levonian Peter J. , Landercasper Jeffrey , Vang Choua , Marcou Kristen , Al Hajj Rima , Al-Hamadani Mohammed 
Published: February 2017

5 Background: NCCN provides guidelines for breast cancer genetic risk assessment and testing. Measuring compliance with NCCN Guidelines (NG) can identify quality gaps. Methods: After IRB approval, a retrospective review of a prospective database of breast cancer patients was conducted to measure compliance with NG for genetic counseling and BRCA testing. Entry criteria were breast cancer patients with diagnosis and treatment at our center, during the 3 year period ending 12/31/11. Genetic counselors (GC) used NG and BRCAPRO modeling in all patients. Surgeon and GC pedigree analyses were compared. Results: Surgeons constructed pedigrees in 675 breast cancer patients and referred 42% (286/675) to the GC. The decision to refer was NCCN compliant in 671/675 (99%). The GC corrected the pedigree in 14% (39/286); nearly all due to the GC identifying extra breast or ovarian cancers. The mean BRCAPRO probability in referred patients was 7.2%. Fifty-nine percent (170/286) of patients seen by the GC received a recommendation for BRCA testing. The NG compliance rate for testing was 98% (170/174). Of 174 BRCA tests offered to patients, 74% (128/174) underwent testing. In tested patients, there were 4% BRCA1+, 5% BRCA 2+, and 1% uncertain variants. Total patient charges for 128 tests were $696,000 ($4,000/test). If the threshold for testing was BRCAPRO > 5% or >10%, then 69 ($276,000) and 45 ($180,000) (p<0.001) patient charges would have occurred, and no patient with BRCA + status would have been missed. Conclusions: High rates of NCCN guideline compliance for genetic counseling and testing are achievable. Our GC's improve accuracy of pedigree assessment and demonstrate adherence to NCCN guidelines, resulting in more testing compared to BRCAPRO modeling. The balance between different methods to trigger testing, their sensitivity, and cost deserves more study, but the observational data contained herein provides information for provider and payer stakeholders regarding estimated GC resources and cost of care.
Triple-negative breast cancer and likelihood of nodal metastates.
Authors: Gangi Alexandra , Mirocha James , Leong Trista , Giuliano Armando E. 
Published: February 2017

50 Background: Axillary lymph node metastases are a prognostic indicator for breast cancer. Studies suggest that breast cancer subtypes are associated with the presence of lymph node (LN) metastases. The purpose of this study was to determine if patients with triple negative breast cancer (TNBC) have a higher risk of LN metastases than those with non-TNBC. Methods: Prospective database review identified 2,967 female patients with invasive breast cancer treated with mastectomy or breast conserving surgery (BCS) between January 2000 and May 2012. Only patients who underwent sentinel node biopsy (SNB) and/or axillary lymph node dissection (ALND) were included. Those receiving neoadjuvant therapy were excluded. Patient and tumor characteristics evaluated included age, race, tumor size, grade, stage, histologic subtype, presence of lymphovascular invasion (LVI), estrogen (ER), progesterone (PR), and human epidermal growth factor receptor 2 (HER2) status. Results: BCS was performed in 1,889 and mastectomy in 1,078 patients. Breakdown by subtype included 2,201 (74%) patients with Luminal A, 344 (12%) with Luminal B, 144 (5%) with HER2, and 278 (9%) with TNBC. SNB was performed in 1,094 (37%), ALND in 756 (25%), and 1,117 (38%) patients had both. LN metastases were detected in 1050 (35%) patients. The LN positivity rate varied across subtypes with 734/2,201 (33%) in Luminal A, 143/344 (42%) in Luminal B, 108/278 (39%) in TNBC, and 65/144 (45%) in HER-2 (p = 0.0007). However, on multivariable analysis, there was no difference in LN positivity among subtypes (p=0.24). Only age < 50 (HR 1.5, CI 1.3 to 1.8), grade 2 or 3 tumors (HR 1.8, CI 1.4 to 2.5), size greater than 2cm (HR 3.2, CI 2.7 to 3.9), and presence of LVI (HR 3.9, CI 2.4 to 6.3) were significant predictors of LN positivity. Four or more involved nodes were seen most commonly in the HER2 (28/144; 19%) and Luminal B (47/344; 14%) subtypes, but not TNBC (26/278; 9%) or Luminal A (199/2201; 9%) (p < 0.0001). Conclusions: Predictors of LN metastases include younger age, higher grade, larger tumor size, and presence of LVI. Patients with TNBC are not more likely to have involved nodes than those with non-TNBC.
Mean radiation dose to the heart in patients with breast cancer.
Authors: Jacobson Geraldine Meerbott , Wen Sijin , Zhang Jianjun , Hazard Hannah , Abraham Jame 
Published: February 2017

56 Background: Breast irradiation may expose a portion of the heart to radiation. Heart irradiation is associated with late risk of ischemic heart disease, proportional to dose. A recent publication of patients treated with 2-D planning prior to 2001 noted average mean heart dose (MHD) of 6.6 Gy for left breast tumors, 2.9 Gy for right breast. Current treatment planning can minimize the MHD, reducing the risk of late heart injury. Methods: We reviewed treatment plans of 78 patients (86 breasts) treated 1/2012-3/2013 to obtain MHD. Treatment plans were CT-based, field-in-field forward planning with heart blocking. Two treatment regimens were used; hypofractionation (HF) (16 x 2.66 Gy, no boost) or standard (SF) (46.8-50.4 Gy +/- 10 Gy boost). Statistics were obtained for MHD based on right (N = 44) or left breast (N = 42); HF (N = 31) vs SF (N = 55), and total dose. Results: Average (av) MHD for left breast was 1.45 Gy (range 0.19-3.12), for right breast 0.70 Gy (0.12-1.54). For HF patients av MHD left was 1.16 Gy (0.19-1.90), MHD right was 0.48 Gy (0.12-0.91). For SF av MHD left was 1.60 Gy (0.80-3.12), MHD right was 0.84 Gy (0.39-1.54). There was a significant difference in MHD between left and right breasts (p = 0.002) and significant correlation between breast dose and MHD (p = 0.026). Conclusions: MHD from breast RT with current treatment planning is much lower than published reports from 2-D planning. MHD correlates with total breast dose and is greater for the left than right side. Techniques to reduce MHD should be utilized, especially for left-sided breast cancer.
Cardiovascular morbidity and mortality in patients treated for ductal carcinoma in situ of the breast.
Authors: Boekel Naomi B. , Schaapveld Michael , Gietema Jourik A. , Rutgers Emiel J. , Versteegh Michel I.M. , Visser Otto , Aleman Berthe M. , van Leeuwen Flora E. 
Published: February 2017

58 Background: Recent concerns about potential overdiagnosis and overtreatment of ductal carcinoma in situ of the breast (DCIS) render evaluation of late effects of treatment, such as cardiovascular disease (CVD), of great importance. We studied cardiovascular morbidity and mortality in a large population-based cohort of DCIS patients. Methods: Data on all incident DCIS diagnosed before the age of 75 years between 1989 and 2004 in the Netherlands were obtained (n = 10,468). Cardiovascular morbidity and mortality data was acquired through linkage with population-based registries. Risk of CVD in the study cohort was compared with general population rates and evaluated in Cox proportional hazards regression models. Results: Compared with the general population, five-year survivors of DCIS had a similar risk of dying due to any cause (standardized mortality ratio (SMR)=1.04 95% confidence interval (CI) 0.97-1.11), but a lower risk of dying of CVD (SMR=0.77 95% CI 0.67-0.89). When comparing treatment groups within the cohort, no difference in risk of CVD was found when comparing patients treated with radiotherapy to surgery only. Left- versus right-sided radiotherapy did also not increase this risk (hazard ratio (HR)=0.93 95% CI 0.67-1.30). In a subgroup analysis of patients diagnosed between 1997 and 2005, accounting for overall history of CVD before DCIS diagnosis, we did not observe a risk difference between treatment groups (left- versus right-sided radiotherapy HR=0.95 95% CI 0.69-1.30). When taking into account CVD that occurred two years prior to DCIS diagnosis only, however, a statistically non-significantly increased risk was seen for patients with a history of CVD (HR=1.84 95% CI 0.45-7.50). Conclusions: After a median follow-up of ten years, we did not find an increased risk for cardiovascular morbidity or mortality after radiotherapy for DCIS when comparing surgery and radiotherapy versus surgery only, nor when comparing radiotherapy for left- versus right-sided DCIS. Compared to the general population, DCIS patients have a decreased risk of cardiovascular death, independent of treatment.
Does the number of surgical excisions before delivering intraoperative radiotherapy (IORT) affect skin toxicity?
Authors: Dai Kubicky Charlotte , Donovan Cory , Diggs Brian S. , Naik Arpana , Marquez Carol , Pillai Susha , Vetto John T. , Pommier Rodney F. 
Published: February 2017

72 Background: The TARGIT-A trial allowed administration of IORT both pre- and post-pathology. The advantage of post-pathology is the ability to determine eligibility based on margins, pathologic tumor size and nodal status, prior to delivering radiation. However, it is unclear whether having more than one operation before IORT is associated with worse skin toxicity. In this study, we aimed to examine the relationship of the number of operations and skin toxicities in women receiving IORT. Methods: We conducted a retrospective analysis of 57 consecutive patients who underwent IORT from 2009-2013. All patients received 20 Gy in 1 fraction prescribed to the applicator surface using the Carl Zeiss Intrabeam System. Skin toxicities were determined using CTCAE 4.0 and RTOG criteria. In addition, infection, skin erythema, desquamation, symptomatic seroma, and necrosis were scored individually and used as outcome measures. Pearson’s Chi-squared test was used to assess the association of the number of operations and skin toxicities. A multivariate analysis was performed and included age, applicator size, max skin dose, number of operations, DM, HTN, BMI, co-morbidity, and depth from skin on mammogram as variables. Results: The median follow-up was 11 months (range 1-33). The median age and applicator size were 68 yrs (range 49-85) and 4 cm (range 2.5-5). 20 (35%) patients had 1 operation (lumpectomy, SLNB and Intrabeam all in 1 setting). 36 (63%) patients had 2 operations (initial surgery, followed by Intrabeam +/- margin re-excision). One (2%) patient had 3 operations (initial surgery, re-excision, followed by Intrabeam). On univariate analysis, the number of operations was associated with increased infection (p = 0.044), but not other skin toxicities. On multivariate analysis, the association was no longer significant (p = 0.97). Conclusions: Our study suggests that delivering IORT post-pathology was not associated with worse acute or late skin complications. Delivering IORT after the initial operation decreases the uncertainty of margin status and avoids the controversy of excising an irradiated positive margin and/or the need for additional whole breast radiation.
Significance of core needle biopsies with ductal carcinoma in situ suspicious for microinvasive carcinoma.
Authors: Namm Jukes P. , Mueller Jeffrey , Kulkarni Swati 
Published: February 2017

86 Background: Sentinel lymph node biopsy (SLNB) is not routinely recommended for women diagnosed with ductal carcinoma in situ (DCIS); however, when the pathologist cannot rule out microinvasion on core biopsy (CB), the surgeon must decide whether to perform a SLNB at the time of surgical excision. Up to 10% of patients with T1mi are found to have breast cancer cells in the axillary lymph nodes, but less than 2% contain macrometastasis making the utility of SLNB in this setting unclear. Methods: The University of Chicago pathology database was queried for patients whose CB showed DCIS suspicious for microinvasion (Smic) or definite microinvasion (Mic) from 2000 to 2012. We analyzed histology, imaging, nodal status, core needle size, and the use of myoepithelial immunohistochemistry (IHC) markers to identify microinvasion. Results: We identified 60 women with Smic and 19 women with Mic on CB. In the Smic group, 33% had infiltrating ductal carcinoma (IDC) in the surgical specimen (35, 30, 30, 1 and 0% for T1mi, T1a, T1b, T1c, and T2 respectively compared to 58, 21, 0, 10.5 and 10.5% in the Mic group). A SLNB was performed at the initial surgery in 38/60 (63%) of Smic and in all Mic biopsies; they were positive in 3/42 (7%) and 2/19 (11%) respectively (p=0.64). When N1mic was excluded, the incidence of macroscopic nodal disease was 1/42 (2.4%) and 1/19 (5.3%) p=0.53. Of those with Smic, we observed a higher proportion of IDC associated with a lesion size ≥ 14 mm on imaging (75% versus 15% for < 14 mm, p<0.02); smaller CB needle size (69% with 11, 12 and 14 gauge versus 0% with 9 gauge, p<0.01); and the use of IHC on the CB to identify microinvasion (58% versus 22% without IHC, p<0.01). There was no association to IDC with respect to grade, necrosis, mass on imaging, or biopsy guidance. Conclusions: The incidence of clinically positive nodal disease in patients with Smic on CB is extremely low. However, those with tumors ≥ 14 mm, the use of smaller gauge CB needles, and Smic based on myoepithelial IHC may be at higher risk for IDC. Of the Smic group with DCIS after excision, none harbored nodal disease; therefore, the use of SLNB only after a definitive diagnosis of IDC may prevent overtreatment.
Predicting the extent of nodal disease in early breast cancer.
Authors: Caudle Abigail Suzanne , Kuerer Henry Mark , Le-Petross Huong T. , Yang Wei Tse , Bedrosian Isabelle , Krishnamurthy Savitri , Lucci Anthony , Hunt Kelly , Mittendorf Elizabeth Ann 
Published: February 2017

95 Background: In early-stage breast cancer patients, the number of positive lymph nodes (LN) is considered in decisions regarding surgery and radiation. The goal of this study was to characterize the extent of axillary nodal involvement based on clinicopathologic and imaging features. Methods: A prospective database was used to identify T1-2 patients who underwent regional nodal ultrasound (US) and axillary lymph node dissection (ALND) from 2002-2012. Patients who received neoadjuvant chemotherapy or had extra-axillary LN metastases were excluded. Subjects were grouped by whether axillary metastases (AxM) were identified by US confirmed by needle biopsy or by sentinel lymph node dissection (SLND) after a negative US, then compared using X2 and Rank-Sum tests as appropriate. Results: AxM were identified by US in 190 patients and SLND in 518 patients. When compared to US-detected patients, SLND patients had fewer positive nodes (2.2 vs. 4.1, p < 0.0001), smaller metastases (5.3 vs. 13.8 mm, p < 0.0001), and a lower incidence of extranodal extension (ENE) (24% vs. 53%, p < 0.0001). Limiting analyses to patients with ≤ 2 abnormal LN on US, US-detected patients still had more positive LN (3.6, p < 0.001), larger metastases (13.4 mm, p < 0.0001), and a higher incidence of ENE (50%, p < 0.001) with more than 2 positive LN found in 45% of the US group versus 19% of the SLND group (p < 0.001). In patients with lobular histology there were no differences in number of positive LN (4 in SLND vs. 3.6 in US, p = 0.36), or ENE (34% SLND vs. 36% US, p = 0.9). Positive non-SLN were found in 23% (96/415) of patients with ductal tumors and 36% (21/59) of those with lobular tumors. In multivariate analysis, having metastases found by US (OR 4.01, 95% CI 2.75-5.84) and lobular histology (OR 1.77, 95% CI 1.06-2.95) predicted having > 2 positive LN adjusting for tumor size, receptor subtype, and histology. Conclusions: Patients with AxM found by US have more positive nodes, larger metastases, and higher risk of ENE, even if ≤ 2 suspicious LN are seen on US compared to patients with SLND-detected AxM. Tumor histology also predicts nodal burden. Clinicians can use imaging and clinicopathologic features to predict extent of nodal involvement and appropriately counsel patients regarding treatment decisions.
Quality cancer-survivorship care: Receipt of guideline-recommended cardiovascular disease (CVD) preventive care among healthy cancer survivors in the United States.
Authors: Pearlstein Kevin A. , Hendrix Laura H. , Chen Ronald C. 
Published: February 2017

108 Background: Improving cancer survivorship care is a high priority research area. CVD is a major cause of mortality in cancer survivors. Preventive care reduces CVD mortality and is part of guideline recommended care for all individuals. We examined receipt of CVD preventive measures among healthy cancer survivors compared to the non-cancer population using the National Health Interview Survey (NHIS). Methods: NHIS is a population-based, annual survey designed to provide data representative of the health care received by the U.S. population. For this analysis, 1,860 survivors without CVD risk factors (hypertension, diabetes, or hyperlipidemia) were matched to 7,393 controls without CVD risk factors based on age, race, gender, and survey year. Multivariate logistic regression models examined factors associated with receipt of each preventive measure. Results: Cancer survivors were more likely than controls to visit a general doctor and a specialist during the past year (Table). Further, survivors were more likely to have received CVD preventive care (blood pressure and cholesterol check) and undergone behavior modification (tobacco cessation and exercise). Survivors > 5 years versus < 2 years from diagnosis were no better in CVD preventive measures, except slightly higher rate of exercise (51 vs. 48%, p < 0.001). On multivariate analysis, general doctor visitation was associated with receipt of blood pressure check (OR 7.0), cholesterol check (OR 2.9), smoking cessation attempt (OR 1.4) and exercise (OR 1.3); survivors vs. control were no different in CVD preventive care. Conclusions: Care by a general doctor improves receipt of CVD preventive measures for cancer survivors and non-cancer individuals alike. This study supports the integral involvement of primary care physicians in a “shared care model” for the delivery of quality cancer survivorship care. [Table: see text]