Halil Kara

Evolving Concepts and Contemporary Management of Early-Stage Breast Cancer: An Evidence-Based Approach to Grey Zones from a Comprehensive Breast Unit Part 1: Locoregional Therapy, Pathology, Radiology - European Journal of Breast Health

Background/Objectives: Triple-negative breast cancer (TNBC) is a highly aggressive subtype with limited therapeutic options, and identifying reliable biomarkers for diagnosis and prognosis is crucial for improving patient outcomes. Mitochondrial DNA (mtDNA) copy number has been linked to an increased risk of developing various types of cancer, including breast cancer. However, there is a lack of understanding regarding how mtDNA copy number variations may influence the development and progression of TNBC. Methods: This study investigated mtDNA copy number in TNBC tumors and corresponding normal breast tissues from 23 TNBC patients who received neoadjuvant chemotherapy. The relative mtDNA copy number was estimated using quantitative PCR for the NADH dehydrogenase subunit 1 (ND1) and subunit 5 (ND5) regions. Results: The results showed a significant decrease in mtDNA copy number in TNBC tumor tissues compared to corresponding normal breast tissue. However, no significant correlation was found between mtDNA content and clinical parameters such as age, tumor size, or chemotherapy response. Conclusions: These results suggest that while mtDNA content decreases in TNBC tumors, it may not directly influence these clinical characteristics. Despite some inconsistencies in the literature regarding mtDNA dynamics in cancer, this study supports the potential of mtDNA as a biomarker for TNBC. Larger cohort studies are needed to further validate these results and explore the role of mtDNA in guiding personalized treatment strategies for TNBC patients.

Objective: This study aimed to evaluate the relationship between PREDICT tool overall survival (OS) scores and high-risk patients according to TAILORx risk categorization in elderly hormone reseptor (HR) positive human epidermal growth factor negative early breast-cancer patients. Materials and Methods: We conducted a retrospective study, extracting data from medical records of 64 patients diagnosed with breast cancer. A retrospective analysis was performed on all patients who had Oncotype Dx Recurrence Scores across five medical centers between 2017 and 2022. PREDICT scores were defined as calculated 10-year OS rates via PREDICT tool. Results: The median age of the patients was 67, with a range between 65-75 years. Low-risk patients had a slightly higher two PREDICT scores compared to high-risk patients (78% vs. 73%), (81% vs. 77%), which were statistically significant. The progesterone receptor (PR) level was significantly lower in the high-risk group (3.5% vs. 80%). A unit decrease in the PREDICT scores was associated with a 11% increase in the odds of being in the high-risk group. However, these effects weren't statistically significant in the multivariate analysis. A unit decrease in the PR level was significantly associated with increased odds (by 5% in the multivariate analysis) of being in the high-risk group. Conclusion: Our study underscores the importance of using a combination of tools, including the PREDICT tool, PR levels, and TAILORx risk categorization, for a comprehensive risk assessment in these patients, especially in the older population. Accurate risk assessment is crucial for tailoring the treatment and optimizing outcomes in this vulnerable population. Future studies are warranted to further validate these findings in larger cohorts and to explore additional biomarkers and genomic signatures that may aid in the risk assessment and management of breast cancer in older patients.

Background: Axillary lymph node status is one of the most important prognostic factors for breast cancer. Sentinel lymph node biopsy (SLNB) after mastectomy is highly controversial. There is not enough data about SLNB in the early period after nipple-sparing mastectomy (NSM). This study investigated the feasibility of SLNB in the early postoperative period of NSM. Materials and Methods: Patients who were operated on for breast cancer in Acibadem Maslak Hospital between 2009 and 2018 were searched retrospectively. Results of SLNB as the second session in patients whose final pathology report revealed breast carcinoma after contralateral/bilateral prophylactic mastectomy and mastectomy for benign lesions were evaluated. Results: In the early period (median 14 days) after NSM, SLNB was performed by intradermal radioisotope injection in five patients with occult breast cancer in contralateral/bilateral prophylactic mastectomy and in one patient with preoperatively suspicious mass which yielded breast cancer at final pathology. In five (80%) patients, SLNB was performed, whereas in one patient axillary lymph node dissection (ALND) was performed due to the undetectability of SLN. In one patient, micrometastasis was observed, whereas no metastasis was observed in other patients including the one who underwent ALND. No complication due to SLNB was detected. No recurrence and distant metastasis were detected in a mean follow-up of 42.82 (19–70) months. While SLNB did not change the treatment of patients with contralateral occult carcinoma, other patients had hormonal therapy due to negative SLNB. Conclusion: SLNB in the early postoperative period of NSM can be performed by intradermal radioisotope injection. However, further studies are needed to determine the feasibility of SLNB in the early postoperative period of NSM.

Purpose: The most important discussion about the direct-to-implant (DTI) reconstruction is the risk of ischemic problems. Therefore, there is an ongoing debate about the effectiveness and reliability of DTI reconstruction. The current study aimed to compare the outcomes of patients undergoing DTI and expander implant (EI) reconstruction and to determine the factors that may affect the occurrence of complications. Methods: Sixty patients who underwent immediate implant reconstruction over a two-year period were included in the study. Demographic characteristics, operative characteristics and postoperative complications of the patients were retrieved retrospectively from patient records. Results: Reconstruction was performed on 34 and 27 breasts in the DTI and EI groups, respectively. The mean follow-up period of the patients was 13.8 months (range 6–28 months). Although the postoperative complication rates were high in the DTI group, no statistically significant difference was found between the two groups (p = 0.585). No statistically significant difference was found between the two groups in terms of implant failure (p = 0.579). Implant volumes of patients with complications in the DTI group were significantly higher than those without complications (p = 0.049). Conclusion: While DTI was similar to EI reconstruction in terms of implant failure, overall complication rates were higher than those in EI reconstruction. The volume of the implant is a factor that affects the development of complications in DTI reconstruction. DTI reconstruction is a reliable method that can achieve similar results to EI reconstruction with fewer surgical procedures in suitably selected patients.

Background: This study investigates the effects of COVID-19 on the breast cancer stage and the volume of breast cancer surgery in a specialized breast institute.Methods: Data of 332 patients who were diagnosed and treated for breast cancer between December 2019 and November 2020 were evaluated retrospectively according to periods of pandemic.Results: A significant decrease in the number of operations, especially upfront surgeries rather than surgeries after neoadjuvant chemotherapy, was detected in the early period of the COVID-19 pandemic. It was found that patients with complaints were mostly admitted during this period (p = 0.024). No statistical significance was found for age, sex, side of the tumor, type of tumor, surgery to breast, and axilla. Following the early period of the pandemic, it was observed that patients with mostly luminal, early-stage, and less axillary nodal involvement (p < 0.05) were admitted, and as a result, it was founded that upfront surgeries increased, although no change in TNM staging was observed. However, it did affect the decision of initial treatment. Thus, the number of upfront surgeries was significantly higher than the NCT group (p = 0.027) following the early period.Conclusion: Surgical volume is significantly affected in the early period of the COVID-19 pandemic. To overcome overload due to delayed surgeries related to pandemics, some hospitals should be spared for oncological treatments. Following the early period, mostly luminal type, early-stage patients were admitted, probably because of increased self-awareness and short wave duration, but the breast cancer stage was not affected.

Despite the high prevalence of lung cancer among other primary tumors, metastasis of this particular malignancy in the breast is very rare. We report three new cases of lung cancer with breast metastases and discuss radiological and clinical findings. Radiologically, each case displayed different characteristics. First, one of them had bilateral superficially and deeply located irregular lesions. Second, the patient presented with findings similar to inflammatory breast cancer. The third case had a circumscribed mass, resembling a benign complicated cyst. To guide clinicians for proper patient management, radiologists should be aware of the scope of typical and atypical imaging findings of metastatic involvement of the breast.

Detachment and embolization (DE) is a rare complication of totally implantable central venous access devices (TIVADs). This study aimed to analyze clinical findings, etiology, and treatment options in DE of TIVADs. Patients who experienced DE between 2010–2019 were included. Indications, implantation techniques, time to diagnosis, patient complaints, diagnostic methods, rupture site, location of embolization, treatment methods, and chest X-rays prior to detachment were analyzed retrospectively. DE of TIVAD was detected in 12(1.2%) patients. Eleven patients had breast cancer and one had colon cancer. Mean age at implantation was 45.3 ± 9.6(31–61.3) years. Seven (58%) patients were asymptomatic, four (33.3%) had TIVAD malfunction, and one (8.3%) had pain and swelling at port site after injection. Mean time from implantation to diagnosis was 1149.92(16–2795) days. The etiologies comprised Pinch-off Syndrome (POS) in eight (66%) patients, detachment directly adjacent to the lock mechanism in three (25%) patients, and probable iatrogenic injury during explantation in one (9%) patient. The most common site of embolism was the superior vena cava (25%). While the embolized fragment was removed percutaneously in 11 patients, medical follow-up was treatment choice for one patient. DE is a rare complication with an incidence rate of 1.2% in this study. Since most patients were asymptomatic, chest radiography plays an important role in diagnosis. The most common cause was POS, and it can be prevented by inserting the catheter from lateral third of the clavicle during subclavian vein catheterization. The first-choice treatment was percutaneous femoral retrieval. However, if not technically possible, alternative treatment options are thoracotomy or follow-up with anticoagulant therapy.

Loss of breast, which is an important body marking of women, causes a huge decrease in quality of life (QoL) after treatment. In order to overcome this morbidity and increase QoL, nipple sparing mastectomy (NSM) has been developed. Even though the demand for better cosmetic results has yielded endoscopic nipple sparing mastectomy, limitations like unsuitable optical window and limited manual control of rigid-tip instruments, and struggling to keep dissection space have led robotic nipple sparing mastectomy (rNSM) to be developed. Records of three patients who underwent to rNSM for invasive breast carcinoma with DaVinci Xi (Intuitive Surgical, Sunnyvale, CA) in affiliated hospitals of xxxxx xxxxx xxx xxxx University, Research Institute of xxxxx in 2018 were investigated retrospectively. In all breasts (n=4), dissection was started from the posterior side of breast. In the unit, 738 breast cancer patients underwent surgery between 2018 and 2019 with an NSM ratio of 31.4% (n=232). Of these patients, three underwent rNSM with DaVinci Xi robotic system. The operation was performed on the left breast in one patient, right in one, and bilateral in one patient. Only in patient #2, who was a neoadjuvant chemotherapy recipient, seroma was observed six weeks after surgery (3 weeks after removal of drains) and spontaneously resolved in 4 weeks. No other complication was seen in all patients. In the follow-up period of median 21 months, no loco-regional recurrence or distant metastasis was seen. A single incision robotic mastectomy can be performed easily and safely when the dissection starts from the pre-pectoral plane rather than the subcutaneous plane.