Abstract Purpose To evaluate the characteristics of low suspicion lesions (BI-RADS 0) at blinded and non-blinded double reading of screening mammograms and to determine the potential effect of ...arbitration of discrepant BI-RADS 0 recalls by a third reader on screening outcome. Methods We included a series of 84,927 consecutive digital screening mammograms, double read in a blinded (43,184 screens) or non-blinded (41,743 screens) fashion, between July 2009 and July 2011. Discrepant readings were routinely recalled for further evaluation. During 2 years of follow-up, radiology, surgical and pathology reports were collected of all recalled women. Arbitration of discrepant BI-RADS 0 recalls (only one radiologist assigning a BI-RADS 0 score) was retrospectively performed by a third screening radiologist. Results At blinded and non-blinded double reading, 32.0% and 32.5% of recalls were assigned BI-RADS 0 with a positive predictive value (PPV) of 7.2% and 6.8%, respectively. Compared to non-blinded double reading, BI-RADS 0 recalls at blinded double reading showed a higher discrepancy rate (9.0 versus 4.3 per 1000 screens, p < 0.001) and false positive recall rate (10.1 versus 8.4 per 1000 screens, p = 0.012). Arbitration of discrepant BI-RADS 0 recalls would have significantly lowered recall rate (from 3.4% to 2.8% at blinded double reading, p < 0.001, and from 2.8% to 2.5% at non-blinded double reading, p = 0.008), without a decrease in cancer detection rate (from 7.5‰ to 7.3‰, p = 0.751, and from 6.6‰ to 6.5‰, p = 0.832, respectively) and program sensitivity (from 83.2% to 81.2%, p = 0.453, and from 76.0% to 74.6%, p = 0.667, respectively). Arbitration would have significantly increased the PPV at blinded double reading (from 22.3% to 26.3%, p = 0.015). Conclusion We advise arbitration of discrepant BI-RADS 0 recalls, at (non-)blinded double reading of screening mammograms, to reduce recall rates and improve the PPV of recall at blinded double reading.
Aims: The use of axillary lymph node dissection (ALND) in women with breast cancer is associated with considerable morbidity. Sentinel node biopsy (SNB) removes the lymph node in the axillary basin ...indicative for receiving first lymphatic drainage from the breast. This study compares the nature and severity of physical morbidity among breast cancer patients who underwent primary surgery for breast cancer combined with either ALND or SNB. Also, it assesses influence of subsequent radiotherapy on morbidity.
Method: Two hundred and thirteen ALND patients were compared with 180 SNB patients retrospectively. Morbidity was measured using a disease-specific quality-of-life questionnaire.
Results:Patients' demographic characteristics were alike. The axillary procedure is the strongest and most consistent factor in explaining differences in a variety of self-reported complaints. Patients having had SNB have a 3.2-fold lower risk of experiencing pain, a 5-fold lower risk of lymph oedema, a 7.7-fold lower risk of numbness, a 3.7-fold lower risk of tingling sensations, a 7.1-fold lower risk of loss of strength in arm/hand, a 3.6-fold lower risk of loss of active motion range of the arm and a 2.9-fold lower risk of impaired use of the arm. Axillary radiation therapy adds to complaints next to the axillary surgical procedure by increasing the risk of lymph oedema 2.4-fold and enhancing the risk of impaired use of the arm by 2.6-fold. Axillary radiation therapy does not explain lymph oedema by itself.
Conclusion: SNB is associated with less morbidity compared to ALND in patients with primary breast cancer.
Most patients with locally recurrent breast cancer undergo axillary lymph node dissection (ALND). However, repeat sentinel node biopsy (SNB) could provide regional nodal staging and obviate the need ...for standard ALND. The Sentinel Node and Recurrent Breast Cancer (SNARB) study is a Dutch nationwide registration study conducted to determine feasibility, aberrant drainage rates, and clinical consequences of repeat SNB. A total of 536 patients with locally recurrent non-metastatic breast cancer underwent lymphatic mapping and repeat SNB in 29 Dutch hospitals. A repeat sentinel node (SN) was identified in 333 of 536 patients (62.1 %) and surgically harvested in 287 patients (53.5 %). Aberrant lymph drainage was observed in 180 (54.1 %) of the 333 patients, more often after previous ALND (81.9 %) than SNB (28.4 %;
P
< 0.001). In 230 patients (80.1 %), the retrieved SN was tumor negative; 17 SNs (5.9 %) contained a micrometastasis and 29 (10.1 %) a macrometastasis. Confirmation ALND in 31 repeat SN-negative patients revealed a macrometastasis in two patients (6.5 %). The negative predictive value (NPV) of repeat SNB was 93.6 %, and ALND was omitted in 109 of the 248 patients (44.0 %) with a negative repeat SN. In 29 of the 44 patients (63.0 %) with a positive SN, adjuvant treatment plans were altered based on the repeat SNB. Repeat SNB is a feasible procedure with a high NPV, leading to a change in management in a substantial proportion of patients. Therefore, repeat SNB should replace routine ALND and serve as the standard of care in recurrent breast cancer.
Abstract Background Axillary reverse mapping (ARM) is a technique that discerns axillary lymphatic drainage of the arm from the breast. In the current study, we retrospectively evaluated the ...incidence of metastatic axillary lymph node involvement, including ARM lymph nodes, in clinically node positive breast cancer patients (cN+ patients) in whom neo-adjuvant chemotherapy (NAC) was administered followed by primary ALND using breast MRI. Patients and methods Data from 98 cN+ breast cancer patients were analysed retrospectively. Patients without residual axillary disease at breast MRI following NAC (RAD−, n = 64) were compared with patients with residual axillary disease (RAD+, n = 34). Presence of suspect axillary lymph nodes on pre-NAC and post-NAC breast MRI was determined by experienced breast radiologists and was correlated to histopathological findings. Results In the RAD-group residual axillary disease on pathological analysis following NAC was found in 25 patients (39.1%), as compared to 24 patients (70.6%) in the RAD + group ( p = 0.003). Metastatic involvement of ARM lymph nodes following NAC was demonstrated in 5 patients (7.8%) in the RAD-group as compared to 10 patients (29.4%) in the RAD + group ( p = 0.005). Conclusion Breast MRI following NAC is not suitable to detect residual metastatic disease of the axilla. However, breast MRI post-NAC may be of use to identify cN+ patients with a low risk of ARM lymph node metastases. This may help to select a subgroup of cN+ patients in whom sparing of ARM lymph nodes during axillary lymph node dissection can be considered.
Trastuzumab in conjunction with adjuvant chemotherapy markedly improves outcome. In the Netherlands, a national guideline was released in September 2005 stating that trastuzumab should be given in ...conjunction with adjuvant chemotherapy in women with HER2-positive breast cancer. Aim of this study was to identify the number of women with HER2-positive breast cancer and to evaluate the level of implementation of adjuvant trastuzumab in clinical practice nationwide. Women diagnosed with primary breast cancer between September 2005 and January 2007 were selected from the Netherlands Cancer Registry (NCR). HER2 status, adjuvant treatment and reasons to withhold trastuzumab were registered. 14,934 Breast cancer patients were diagnosed in this period of whom 1,928 (13%) had a HER2-positive tumour. Of all HER2-positive women receiving adjuvant chemotherapy, 66 (6%) did not receive trastuzumab. This percentage decreased from 10% at the time of introduction of the guideline to 4% in the study period September 2005–December 2006. Most common reasons to withhold trastuzumab were cardiovascular disease (29%) and patient refusal (21%). Of all HER2-positive patients who received adjuvant chemotherapy, 94% received trastuzumab. The implementation of trastuzumab in clinical practice was realized within 8 months after introduction of the new guideline.
Abstract Background Axillary reverse mapping (ARM) is a technique that discerns axillary lymphatic drainage of the arm from the breast. This study was performed to evaluate both the feasibility of ...this technique and the proportion of metastatic involvement of ARM-nodes. Patients and methods Patients with invasive breast cancer and an indication for axillary lymph node dissection (ALND) were enrolled in the study: patients with a tumor-positive sentinel lymph node (SLN+ -group) and patients who had axillary metastases proven by preoperative cytology (CP-N+ -group) were distinguished. ARM was performed in all patients by injecting blue dye. During surgery ARM-nodes were identified and removed first, followed by ALND. Results Between October 2009 and June 2011 93 patients underwent ARM. There were 43 patients in the SLN+ -group and 50 patients in the CP-N+ -group. No significant differences in visualization rate of ARM-nodes between the groups (86 vs 94% respectively, P = 0.196) were identified. In the SLN+ -group none of the ARM-nodes contained metastases versus 11 patients (22%) in the CP-N+ -group ( P = 0.001). Patients receiving neoadjuvant systemic therapy had a significantly lower risk of additional axillary lymph node metastases (24.6 vs 44.4%, P = 0.046). Discussion The ARM procedure is technically feasible with a high visualization rate. The proportion of patients with metastases in the ARM-nodes was significantly higher in patients with proven axillary metastases than in patients with a positive SLN. Patients with SLN metastases appear to be good candidates for the ARM technique and possibly also patients with proven axillary metastases receiving neoadjuvant chemotherapy.
Abstract Aim A lack of consistency in the definition of breast cancer related lymphoedema (BCRL) and of uniform measurement criteria contribute to the wide prevalence range found in current ...literature. This report aims to describe the long-term prevalence of BCRL and secondly, to compare the long-term prevalence of BCRL when assessed by two objective measures and one subjective measure. Methods The upper-limbs of 145 post-surgical breast cancer patients were evaluated for the presence of lymphoedema using the water displacement method. Two circumference methods and patient perceived swelling were applied secondarily for comparison. Limb measurements were performed once, more than five years after surgery. Results The long-term prevalence of BCRL using water displacement was 8%. Prevalence varied when the sum of arm circumference (SOAC), the arm circumference and the self-report methods were used: 16, 31 and 17% P < 0.001, respectively. Of the women identified with BCRL using the water displacement technique, 82% were detected with the SOAC method, 82% with the arm circumference method and 91% by self-report. Using water displacement as the gold standard the methods with the highest specificities were the SOAC (90%) and self-report method (89%), arm circumference resulted in a low specificity of 73%. Conclusion The prevalence of BCRL more than five years after surgical treatment differs depending on the measuring method used. Our data underlines the necessity for consensus on the diagnostic criteria for BCRL.
Purpose and methods
Central venous catheter (CVC)-related thrombosis and infections are frequently occurring complications in patients with hematological malignancies. At present, heparin is most ...often used as a locking solution. Trisodium citrate (TSC) had been shown to be a very effective antimicrobial catheter locking in hemodialysis patients. We performed a prospective randomized phase III multicenter trial to determine the efficacy of TSC as a locking solution compared to heparin in preventing CVC-related thrombosis and infections in patients with hematological malignancies.
Results
Thirty-four episodes of CVC-related bloodstream infections (CVC-BSI) occurred in the 108 patients who were randomized to locking with heparin compared with 35 episodes in the 99 patients who were randomized to locking with TSC (
P
= 0.654). We did find seven times more CVC-BSI with gram-negative rods in CVCs locked with heparin (
P
= 0.041). The cumulative incidence of symptomatic thrombosis was 10 % in the heparin group and 5 % in the TSC group (hazard ratio 0.525; 95 % confidence interval 0.182–1.512).
Conclusion
This study shows that locking with TSC in patients with hematological malignancies significantly reduced the incidence of CVC-BSI with gram-negative rods. However, the incidence of CVC-BSI with coagulase-negative staphylococcus or CVC-related thrombosis was not reduced by TSC locking.
In the current study, mammography adherence of women who had experienced a false-positive referral is evaluated, with emphasis on the probability of receiving surveillance mammography outside the ...national screening programme.
We included 424,703 consecutive screens and collected imaging, biopsy and surgery reports of 3463 women who experienced a false-positive referral. Adherence to screening, both in and outside the screening programme, was evaluated.
Two years after the false-positive referral, overall screening adherence was 94.6%, with 64.7% of women returning to the national screening programme, compared with 94.9% of women re-attending the screening programme after a negative screen (P<0.0001). Four years after the false-positive screen, the overall adherence had decreased to 85.2% (P<0.0001) with a similar proportion of the women re-attending the screening programme (64.4%) and a lower proportion (20.8%) having clinical surveillance mammography. Women who had experienced a false-positive screen at their first screening round were less likely to adhere to mammography than women with an abnormal finding at one of the following screening rounds (92.4% vs 95.5%, P<0.0001).
Overall screening adherence after previous false-positive referral was comparable to the re-attendance rate of women with a negative screen at 2-year follow-up. Overall adherence decreased 4 years after previous false-positive referral from 94.6% to 85.2%, with a relatively high estimate of women who continue with clinical surveillance mammography (20.8%). Women with false-positive screens should be made aware of the importance to re-attend future screening rounds, as a way to improve the effectiveness of the screening programme.
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