Archives of Breast Cancer
Volume:10 Issue: 1, Feb 2023

Treatment of breast cancer (BC) remains a constant and rapidly evolving issue for multidisciplinary breast cancer teams. Considering the emerging understanding and advances in the biological course of this disease, new trends in radiotherapy fractionation, systemic therapies, and oncoplastic surgical techniques are revolutionizing adjuvant treatment approaches to BC. Novel challenges are questioning the integration of adjuvant radiotherapy (ART) into the real-world clinical setting.

PubMed literature search was conducted in order to extract data supporting the role of new trends in breast cancer adjuvant approach according to rising issues in the multidisciplinary team discussion such as sequencing with chemotherapy (CT) plus whole breast hypofractionated radiotherapy (HF-WBRT); the role of ART after neoadjuvant CT (NACT) followed by breast conservative surgery (BCS) in early BC achieving pathological complete remission (pCR); and the integration of ART in immediate autologous breast oncoplastic reconstruction after mastectomy (a-IBR). Furthermore, there are still several concerns about toxicity with adjuvant trastuzumab emtansine (T-DM1) or breast re-irradiation after BCS relapse in long-term survivors refusing mastectomy.

Among 40 hits, only 12 studies answered these issues. Many of them were retrospective studies. Less than 500 patients met the criteria for these issues and several conclusions were found exhaustive.

Few issues seem to have a literature solution, while there are still open questions in regard to these new trends. Novel strategies through prospective or randomized studies and new consensus guidelines are required.

Alteration of the expression of human epidermal growth factor receptor2 gene as an oncogenic pathway in breast cancer was first explored in the 1980s. Since then, tremendous progress has been made in treating HER2-positive breast cancer.

We performed a narrative type review of the existing literature using as a starting point the PubMed database, using keywords, with the search being refined later and the relevant articles being selected. As the approaches to the topic under discussion were different in various studies, we were convinced of the inappropriateness of a metaanalysis. As a secondary method of analysis, we evaluated the bibliography of each of the selected studies and from this we identified other publications of interest.

At present, there are three major classes of FDA-approved anti-HER2 agents: monoclonal antibodies (Trastuzumab, Pertuzumab and Margetuximab), TKIs (Lapatinib, Neratinib and Tucatinib) and antibody-drug conjugates (T-DM1 and TDXd). The treatment of HER2+ breast cancer has suffered some changes in the last few years. If in 2018, progression under first-line treatment with taxanetrastuzumab/pertuzumab and second line with T-DM1 was a big challenge, and it was up to the oncologist to choose from lapatinib-capecitabine, trastuzumab-lapatinib or different chemotherapeutic agents depending on toxicities and therapies available in the country, nowadays we have a new third- and fourth-line FDA approved standard, which consists of tucatinib-trastuzumab-capecitabine and trastuzumab-deruxtecan.

The question of how to improve novel therapies to treat HER2-positive disease remains a topic of discussion in the future, because we are only getting closer to an optimal version of treatment for HER2+ breast cancer, hoping that the introduction of new drugs and the establishment of new indications for old drugs will allow us to standardize the treatment of these patients.

Female breast cancer (BC) remains the most common cause of total cancer deaths around the world. Several studies have investigated BC biomarkers, but vital circulating biomarkers for early diagnosis of malignancy are still scarce. Thus, finding sensitive, selective and accurate biomarkers is required to get better BC outcome and to prolong patients’ survival. Therefore, this review investigated the feasibility of using circulating trace elements (TEs) as the new promising biological biomarkers for BC diagnosis and prevention.

We systematically searched EMBASE, Medline, Google Scholar, PubMed, SciELO, Scopus databases or Web of Science for original studies presenting the significant changes in the concentrations of circulating TEs in terms of serum, plasma or blood from female breast cancer patients.

The search yielded 2697 articles, of which 39 were considered for this review. The study showed that four essential TEs (Se, Cu, Zn and Mn) significantly decreased when only one essential trace element (Fe) increased consistently, while five toxics circulating TEs (Cd, Cr, Pb, Co, Mo) increased significantly with a significant difference compared to healthy groups. The essential TEs, Se and Cu were reported to decrease the most in fifteen and twenty-one studies, respectively. However, regarding the toxic circulating TEs, Cd and Pb were found to increase most significantly in seven studies. Among the essential TEs, Se and Zn were reported to have the most potential, with Cd and Pb having the most potential for use as new promising biomarkers to diagnose or prevent BC.

The findings provide an insight into the TEs circulating biomarkers for early BC diagnosis and prevention. Due to its high heterogeneity, meta-analysis was not assessed; hence, further investigation may be required on their clinical outcomes in BC with high sensitivity and specificity for accurate therapeutic response.

Idiopathic granulomatous mastitis (IGM) is a rare benign breast disease that mostly occurs in reproductive ages in parous women. Hormonal, autoimmune, and microbial causes have been implicated as causes. We carried out this prospective study to investigate the reproductive factors and underlying disease states in IGM.

This study was conducted in two phases. In the first phase, we evaluated the reproductive factors, anthropometric parameters and past medical histories of participants of an ongoing multicentric clinical trial. In the second phase, we performed an extensive review of the literature for studies that had considered patients with a histologic-proven diagnosis of IGM without date limitations, and extracted the data about parity, breastfeeding, oral contraceptive pill use and past medical histories. We then carried out a meta-analysis.

Data of 123 patients were included. The mean age was 35.11±7.07 years, and the mean body mass index was 27.41±4.74. Overall, %93.8, 90.27% and 28.7% of patients were parous, had breastfed, and had used OCP, respectively. Hypothyroidism represented the most common (18.94%) previous medical disease. We included 89 studies in our search. Considering these studies and ours, the pooled prevalence of rates of parity, breastfeeding and oral contraceptive pill consumption were 96%, 89%, and 29%; and the pooled prevalence of hypothyroidism, diabetes and hypertension were 9%, 5% and 5%, respectively. Although not exactly comparable, these rates of hypothyroidism were higher than those reported in women in the general population (4.2% in one large study in Iran).

Our study suggests a possible relation between a past history of hypothyroidism and IGM. We propose a study that investigates the occurrence of IGM in some large cohorts of healthy women, and the retrospective assessment of thyroid tests in the primary serum samples.

Breast cancer affects several aspects of a woman’s life. It can adversely affect a woman’s sexual function as well as her relationship with her spouse, which in turn can reduce the quality of her married life. The present study aimed to investigate the mediating role of sexual satisfaction in the relationships of body mass index (BMI) and spiritual well-being with the quality of married life in women with breast cancer.

This descriptive-correlational study used convenience sampling to enroll all 250 married women with breast cancer visiting specialized clinics in Tehran in 2022. The research instruments included the Revised Dyadic Adjustment Scale (RDAS), the Spiritual Well-Being Scale (SWBS), the Body Mass Index (BMI), and the Index of Sexual Satisfaction. The proposed model was evaluated using structural equation modeling (SEM).

The direct paths from all variables (except for spiritual well-being) to quality of married life were significant (P<0.001). In addition, sexual satisfaction was found to mediate the relationships between BMI and spiritual well-being with the quality of married life in the participants (P<0.01).

The proposed model fitted the data well; therefore, the results may be used to help improve the quality of married life in women with breast cancer.

Granulomatous lobular mastitis (GLM) is a rare inflammatory disease of the breast. Its clinical features and imaging findings often mimic malignancy. The aim of this study is to review the mammographic and ultrasound features of granulomatous lobular mastitis to help differentiate it from other diagnoses.

In our study, imaging data of 51 patients were reviewed retrospectively, who were diagnosed with granulomatous lobular mastitis by core needle biopsy and culture analysis.

The mammographic findings of granulomatous lobular mastitis observed in our study group were focal or global asymmetry (52.6%), oval or round lesions with obscured margins (15.7%), irregular mass with indistinct margins (15.7%) and associated skin thickening (26.3%) with no specific pointers to differentiate from malignancy.The most common morphological abnormality on ultrasound was single or multiple collections with or without tracts (72.5%). Other morphological abnormalities were non-mass areas with tracts (25.5%), dilated ducts with debris (13.7%) and mass (3.9%). The common associated abnormalities were perilesional increased echogenicity (86.3%), increased peripheral vascularity (88.2%), intercommunicating tracts (76.5%) and axillary adenopathy (68.6%) and these ultrasound features were pointers to differentiate granulomatous mastitis from malignancy.

Granulomatous lobular mastitis has non-specific clinical and imaging features. Imaging, especially ultrasound as in our study, is found to be indispensable in diagnosing GLM and excluding other causes such as infective mastitis and malignancy.

The survival of patients with triple-negative breast cancer subtype undergoing chemotherapy along with weight management, physical activity, and diet was examined. In addition, the relationship between the Overall Survival (OS) of patients and the expression of P53 and Ki 67 was investigated.

The study was conducted on 110 patients admitted to oncology clinics between October 2009 and July 2018. The patients underwent five chemotherapy cycles, including Docetaxel, Epirubicin, and Cyclophosphamide once every 21 days followed by two cycles of Epirubicin, Cyclophosphamide, and 5-Fluorouracil. The patients also received guidelines for physical exercise, diet, and lifestyle change.

The median and mean follow-ups were 52.3 and 45.6 months respectively. Eight patients were metastatic and 103 were under adjuvant therapy, 13 of whom had relapses. The median relapse-free survival and mean OS were 44.4 months and 49.2 months, respectively. OS for P53-negative patients was 64.2 months, eight patients relapsed in the P53-positive group, and two relapsed in the P53-negative group. Survival was more favorable in the negative group (P=0.021). The mean DFS in the P53-negative group was 96.1% and 76.3% in the P53-positive group, suggesting a more favorable status in the P53-negative group. Out of 110 patients, 20 died and 90 are still alive.

Combining physical exercise, diet, and lifestyle change with chemotherapy increases the chance of a better response to treatment and a reduction in the rate of relapse during the first three years. The survival rate was better in p53- negative patients.

The modified five-item frailty index (mFI-5) is a valuable tool for preoperative risk stratification of patients. There is a paucity of literature regarding the use of the mFI-5 in regard to males undergoing mastectomy. The aim of this study was to determine if the mFI-5 can predict negative postoperative outcomes.

The 2005-2016 NSQIP database was queried to identify males aged 60 or older who underwent total mastectomy. Patient demographics, comorbidities, perioperative factors, and postoperative complications were collected. Patients were divided into cohorts based on whether their mFI-5 score was <2 or >2. Primary outcomes included prolonged postoperative length of stay (LOS), defined as greater than 75th percentile of the study population, and postoperative complications.

A total of 1,251 patients were identified, of whom 958 patients (76.6%) had mFI-5 scores <2 and 293 patients (23.4%) had mFI-5 scores >2. A significantly higher prevalence of medical complications occurred in the higher mFI group (6.1% vs. 1.6%, p<0.001). The mFI-5 was an independent risk factor for postoperative medical complications (OR 2.70, 95% CI, 1.28-5.68, p=0.009).

This is the first study to evaluate the utility of mFI in predicting postoperative complications in males undergoing total mastectomies. We demonstrate that mFI has utility and is applicable as a risk stratification tool for males undergoing mastectomy

B3 category mainly consists of lesions that provide benign histology on core biopsy, but either are known to show heterogeneity or have increased risk of associated malignancy. However, the level of risk is very different for different entities. All the cases should be looked for atypia. The objective of this study is to compare various B3 lesions in two audits, to calculate the median rate and upgrade rates (the rate at which they turn into malignancy on subsequent excision) for different B3 lesions and to compare them with the national standards and published literature. The study aims to see whether vacuum assisted excision or surgical excision has been done in such lesions.

This is a retrospective study and encompasses two audits done in 2017- 18 and 2020-21 at Queen's hospital, Barking, Havering and Redbridge NHS trust. A total of 4478 cases were reviewed and 206 cases were graded as B3 on core biopsy.

Overall, 113 cases were graded as B3 in 2020-21 and 93 cases in 2017- 18 giving the median rate of 5% and the overall upgrade rate of 12%. Intraductal papilloma was the most commonly seen lesion in both audits. Also, 31 cases underwent vacuum assisted excision and 62 cases underwent surgical excision, with 38 cases not undergoing further excision.

The median rate was within the 'preferred median rate'- 4.5-8.5% and the upgrade rate was comparable (16.57%) with those of National Breast Cancer screening audit, 2016-2019. The type of excision for various lesions was in line with the criteria stated by the Royal College of Pathologists. The lesions which were not excised did not turn into malignancy on follow-up

Breast cancer remains the most frequent malignancy in women, with the two most common histological subtypes of breast cancer being the invasive ductal carcinomas (IDC) and invasive lobular carcinomas (ILC). The most common sites of breast cancer metastases are the liver, lung, pleura, brain and bone. Gastrointestinal, peritoneal, gynaecological and renal metastases are less common, often masquerading as primary malignancies and causing diagnostic confusion, mostly occurring in ILC as compared to IDC.

We report a case of a young woman presenting with an enlarging abdominal mass which was suspicious of a primary abdominal malignancy. Endoscopy and gastric biopsy revealed poorly differentiated carcinoma. On the top-most slices of her abdominal CT, bilateral enhancing breast lesions were detected, suspicious of metastases. Ultrasound and biopsy done for the breast lesions showed bilateral ILCs. Further staining of the gastric biopsy specimen confirmed the final diagnosis of gastric metastases from bilateral breast ILCs rather than a primary gastric tumour with breast metastases.

This case highlights how breast cancer metastases to the GI tract may mimic primary GI cancers as well as the importance of breast examination, family history, radiological and pathological examination in detecting the breast origin of advanced carcinomas. Awareness of the different patterns of metastatic spread of ILC and IDC is also important due to the infiltrating nature and nonspecific imaging findings of these tumours, requiring a high index of suspicion from the surgeons, oncologists, radiologists and pathologists.

Adjuvant chemotherapy has been an integral component of breast cancer care for decades. Advances in supportive care have been made, but despite this, infective complications of therapy remain a significant toxicity concern.

A premenopausal patient presented to the emergency department during the third wave of the Covid-19 pandemic with sepsis after a second course of adjuvant docetaxel-cyclophosphamide chemotherapy. Overnight she developed tetraplegia. An urgent MRI cervical spine revealed a pre-vertebral, vertebral, and epidural abscess. This was treated with an emergency C4-C7 posterior cervical laminectomy and decompression. Her inpatient care involved a protracted ICU admission followed by rehabilitation. She remains tetraplegic and requires continued inpatient care over a year after presentation. Restricted pandemic-related hospital visiting has compounded the impact of her illness.

Infective complications of adjuvant breast cancer chemotherapy remain an issue despite advances in supportive care. This case highlights the devastating, life-altering impact that these complications can have as emphasized by the inclusion of the patient’s perspective.