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Risk Factors for Papillary Thyroid Carcinoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO

  • Radiation exposure:
    • Radiation exposure of the thyroid during childhood:
      • Is the most clearly defined environmental factor:
        • Associated with benign and malignant thyroid tumors
    • Potential sources of radiation exposure include:
      • Therapeutic uses of radiation (eg, treatment of childhood malignancies)
      • Environmental exposure secondary to:
        • Fallout from atomic weapons (eg, Nagasaki / Hiroshima, Japan)
        • Nuclear power plant accidents (eg, Chernobyl)
      • In the past, ionizing radiation was used to treat a wide variety of benign conditions of the head and neck:
        • Although this practice essentially ceased in the late 1950s to early 1960s due to increased appreciation of the carcinogenic effects of radiation on the thyroid
  • Family history:
    • A history of thyroid cancer in a:
      • First-degree relative
    • Family history of a thyroid cancer syndrome:
      • Familial polyposis
      • Carney complex
      • Multiple endocrine neoplasia type 2 [MEN2]
      • Werner syndrome
      • Cowden syndrome
  • A family history:
    • Increases the risk that a nodule may be malignant
    • In one study, there was a 10-fold increased risk of thyroid cancer in relatives of thyroid cancer patients
    • In a second report, the standardized incidence ratio for papillary cancer was 3.2 with an involved parent, 6.2 with an involved sibling, and 11.2 for a female with an involved sister
  • Other:
    • A number of other possible (but not proven) risk factors have been reported
    • Their relative importance appears to be small but not completely defined
    • Potential risk factors include the following:
      • Occupational and environmental exposures
      • Hepatitis C-related chronic hepatitis (odds ratio [OR] 12.2 in one report)
      • Increased parity and late age at first pregnancy
      • Obesity or overweight 

BRCA Mutation Carriers

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Carriers of the BRCA1 deleterious mutation are more likely than both controls and carriers of the BRCA2 mutation:
    • To have high-grade, receptor-negative tumors (and, in particular, triple-negative tumors):
      • Containing necrosis, with higher mitotic counts and shorter tumor-doubling times
  • Carriers of the BRCA1 mutation have lesions that are more likely to have:
    • Pushing margins and that are less likely to be spiculated:
      • Making them harder to detect on mammography and more likely to be detected by MRI than mammography
  • Women with a strong family history of both early-onset breast cancer and ovarian cancer in first-degree relatives:
    • Is consistent with hereditary breast and ovarian cancer syndrome, and the presence of triple-negative disease is most consistent with the history and diagnosis for a carrier of the BRCA1 deleterious mutation
  • Although few studies have evaluated preoperative breast MRI in BRCA carriers after breast cancer has already been diagnosed:
    • Breast MRI has been shown to have a survival benefit in the high-risk screening setting, and the lifetime risk of cancer developing in the contralateral breast (which can also be mammographically occult):
      • Is nearly 40% in this population
    • Breast MRI is a reasonable preoperative option to evaluate the contralateral breast if the woman has dense breasts, risk of being a BRCA carrier, and consequent risk of disease being present or developing in the contralateral breast:
      • However, for patients who opt for bilateral mastectomy, breast MRI preoperatively is not mandatory
  • Although genetic testing has become more widespread and easier to perform in recent years:
    • Performing a genetic test without counseling by someone who has genetic training and expertise is not appropriate
  • As some BRCA mutations are known to be deleterious, others are variants of undetermined significance:
    • This means, as the name suggests, that it is unclear whether the patient is at any greater risk of cancer, and if so, by how much
    • This must be part of the discussion because 5% to 10% of mutations are these variants of undetermined significance, and patient perceptions of their own risk in that setting are high, mandating proper education
  • Although women with BRCA mutations have bilateral mastectomy as an option to treat a known cancer and prevent a contralateral one:
    • The American Society of Clinical Oncology / Society of Surgical Oncology consensus statement on prophylactic mastectomy considers a significant family history an appropriate indication for prophylactic mastectomy, even in the absence of a diagnosed mutation
  • Women who have a diagnosed deleterious mutation and those who have not been tested but have a strong family history are also considered appropriate for risk-reducing surgery
  • References:
    • Guillem JG, Wood WC, Moley JF, et al. ASCO/SSO review of current role of risk-reducing surgery in common hereditary cancer syndromes. Ann Surg Oncol. 2006;13:1296-1321.
    • Kaas R, Kroger R, Peterse JL, Hart AA, Muller SH. The correlation of mammographic and histologic patterns of breast cancers in BRCA1 gene mutation carriers, compared to age-matched sporadic controls. Eur Radiol. 2006;16:2842-2848.
    • Lakhani SR, Reis-Filho JS, Fulford L, et al. Prediction of BRCA1 status in patients with breast cancer using estrogen receptor and basal phenotype. Clin Cancer Res. 2005;11:5175-5180.
    • Murray ML, Cerrato F, Bennett RL, Jarvik GP. Follow-up of carriers of BRCA1 and BRCA2 variants of unknown significance: variant reclassification and surgical decisions. Genet Med. 2011;13:998-1005.
    • Plevritis SK, Kurian AW, Sigal BM, et al. Cost-effectiveness of screening BRCA1/2 mutation carriers with breast magnetic resonance imaging. JAMA. 2006;295:2374-2384.

Incidence of Papillary Thyroid Carcinoma

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • In a report based upon the Surveillance, Epidemiology, and End Results (SEER) database from 1975 to 2018:
    • The incidence of papillary cancer:
      • Increased from 4.8 to 14.9 per 100,000:
        • Stabilized:
          • Then appeared to decline to approximately 13.5 per 100,000 by 2018
  • The death rates:
    • 0.5 per 100,000 male and female per year:
      • Did not change significantly
  • The 5-year relative survival:
    • Remains quite high:
      • At 98.3 percent (2011 to 2017 data)
  • The precise reasons for the increase, apparent plateau, and subsequent decrease in incidence rate in papillary thyroid cancer are unknown
  • The initial increase in thyroid cancer incidence in the United States:
    • Was seen in males and females, and in persons of all racial and ethnic backgrounds
  • The usual female-to-male ratio of papillary thyroid cancer is:
    • Approximately 2.5:1:
      • With most of the female preponderance occurring during the:
        • Fourth and fifth decades of life
  • The increased incidence was thought to partially reflect earlier detection of subclinical disease (ie, small papillary cancers):
    • Secondary to more widespread use of neck ultrasonography and fine-needle aspiration (FNA) of very small thyroid nodules:
      • However, an analysis of the National Cancer Institute’s SEER database:
        • Found an increase in the rates of differentiated thyroid cancer of all sizes, including tumors greater than 4 cm
    • Subsequently, there has been a move in the medical community away from the previous widespread practice of immediate biopsy of very small asymptomatic suspicious nodules incidentally detected on imaging
    • More selective use of FNA in small thyroid nodules along with more judicious use of thyroid ultrasonography, in general, could lead to a decrease in incident rates:
      • However, another primary cause of thyroid cancer (as yet unidentified) has not been excluded

BRCA Mutation Carries Screening Recommendations and Risk Reducing Strategies

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Women with BRCA1 / BRCA 2 mutations:
    • Are at an increased lifetime risk of both:
      • Breast and ovarian cancer
  • Patients with a known BRCA 1 / BRCA 2 mutation:
    • Are recommended to undergo increased imaging surveillance with:
      • Annual breast MRI screening from age 25 to 29
      • Annual mammogram and breast MRI screening from age 30 to 75
  • Options for risk reduction among BRCA carriers include:
    • The use of chemoprevention or risk-reducing surgery:
      • The subset of patients with a BRCA2 mutation receiving tamoxifen in the NSABP P1 study:
        • Had a 62% reduction in breast cancer risk relative to placebo (relative risk [RR] 0.38, 95% CI 0.06-1.56)
    • A more recent case-control study of women with BRCA mutations:
      • Showed a 50% reduction in breast cancer risk associated with tamoxifen use, and was effective in both BRCA1 and BRCA2 mutation carriers (odds ratio [OR] 0.63 [BRCA 2] vs. 0.38 [BRCA 1])
  • Because the onset of ovarian cancer for BRCA2 carriers tends to be up to 10 years later than that in BRCA1 carriers:
    • BSO is recommended at the completion of childbearing or age 40 to 45
  • The recommended age for BRCA1 mutation carriers:
    • To undergo BSO is age 35 to 40
  • In the PROSE study:
    • Women with BRCA 1 / BRCA 2 mutations who underwent bilateral risk reducing mastectomy (RRM) for breast cancer risk reduction:
      • Were compared to controls who did not undergo prophylactic surgery
    • Bilateral RRM reduced the risk of breast cancer by approximately 90% in women with intact ovaries and 95% in women with prior or concurrent BSO
  • While retrospective analyses have confirmed a similar degree of breast cancer risk reduction in BRCA1 / BRCA 2 mutation carriers following bilateral RRM:
    • This procedure is not significantly associated with reduced all-cause mortality
  • A recent prospective study of 3,722 women with BRCA 1 and 2 mutations demonstrated that BSO was associated with a significantly reduced risk of breast cancer for BRCA 2 mutation carriers diagnosed prior to age 50 (age-adjusted HR 0.18, p = 0.007):
    • However, the same effect was not seen for BRCA1 mutation carriers undergoing BSO (age-adjusted HR 0.79, p = 0.051)
  • References
    • National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology. Genetic/familial assessment: breast and ovarian, Version 1.2018. October 3, 2018 https://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdfAccessed November 8, 2019.
    • Fisher B, Costantino JP, Wickerham DL, Redmond CK, Kavanah M, Cronin WM, et al. Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst. 1998;90(18):1371-1388.
    • Narod SA, Brunet JS, Ghadirian P, Robson M, Heimdal K, Neuhausen SL, et al. Tamoxifen and risk of contralateral breast cancer in BRCA1 and BRCA2 mutation carriers: a case-control study. Lancet. 2000;356(9245):1876-1881.
    • Rebbeck TR, Friebel T, Lynch HT, Neuhausen SL, van ‘t Veer L, Garber JE, et al. Bilateral prophylactic mastectomy reduces breast cancer risk in BRCA1 and BRCA2 mutation carriers: the PROSE Study Group. J Clin Oncol. 2004;22(6):1055-1062.
    • Li X, You R, Wang X, Liu C4, Xu Z5, Zhou J, et al. Effectiveness of prophylactic surgeries in BRCA1 or BRCA2 mutation carriers: a meta-analysis and systematic review. Clin Cancer Res. 2016;22(15):3971-3781
    • Kotsopoulos J, Huzarski T, Gronwald J, Singer CF, Moller P, Lynch HT, et al. Bilateral oophorectomy and breast cancer risk in BRCA1 and BRCA2 mutation carriers. J Natl Cancer Inst. 2016;109(1).

BRCA 1 and BRCA 2 Mutations

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Women with pathogenic BRCA1 or BRCA 2 germline variants:
    • Have a high lifetime risk of breast cancer as well as a high risk of ipsilateral second breast cancer and contralateral breast cancer events
  • A subgroup analysis of high-risk women on chemoprevention with tamoxifen showed:
    • A reduction in the incidence of breast cancer in women with pathogenic BRCA2, but not BRCA1, gene variants [1,2] 
  • The majority of women with pathogenic BRCA2 gene variants who develop breast cancer:
    • Will have ER+ tumors:
      • Unlike women with pathogenic BRCA1 variants:
        • Who have a higher percentage of ER- and PR- breast cancers
  • Denosumab (Prolia®, Xgeva®):
    • Is a human, anti-RANKL monoclonal antibody:
      • That blocks the progesterone-induced increase in Ki-67 and may have a future role as a chemoprevention agent:
        • However, the FDA has not yet approved denosumab for chemoprevention [1]
  • Bilateral risk-reducing mastectomy:
    • Is the most effective means to prevent BRCA1- or BRCA 2-associated breast cancer:
      • But it does not impact all-cause mortality
    • In addition, breast-conserving therapy is a safe option with similar mortality rates [1]
  • Bilateral risk-reducing oophorectomy:
    • Prior to development of a breast cancer in premenopausal women with pathogenic BRCA1 or BRCA 2 variants:
      • Is associated with a 77% reduction in all-cause mortality [1]
    • Other studies have also shown a 25% to 50% reduction in breast cancer risk in patients with pathogenic BRCA1 or BRCA 2 variants after bilateral risk-reducing oophorectomy [4]
  • Women with BRCA1 and BRCA 2 pathogenic variants diagnosed with unilateral breast cancer under the age of 50:
    • Have an increased risk of contralateral breast cancer
  • Aromatase inhibitor use was associated with decreased contralateral breast cancer risk among patients with BRCA1 or BRCA 2 pathogenic variants (HR 0.44, p=0.004):
    • Whereas tamoxifen was not [5] 
  • References:

Risk of Contralateral Breast Cancer in BRCA Positive Patients

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The annual risk for BRCA mutation carriers to develop breast cancer is:
    • Estimated to be 2.1%
  • The risk of contralateral breast cancer:
    • At 20 years post initial breast cancer diagnosis is:
      • 41% in BRCA1 mutation carriers
  • Age at diagnosis:
    • Does affect risk of contralateral breast cancer:
      • Women under 40 are at highest risk
  • Tamoxifen:
    • Has been shown to decrease the risk of contralateral breast cancer overall
  • Phillips et al:
    • Report that estrogen receptor status of the initial breast cancer diagnosis:
      • Did not affect contralateral breast cancer risk:
        • However the status was missing in over 50% of the cohort
    • In addition, women found to be at the highest risk were:
      • Those diagnosed with initial breast cancer under age 50
      • Those with 2 or more family members with history of breast cancer
      • Intact ovaries
        • The 15-year risk of contralateral breast cancer was 68% in these women:
        • These women should be counseled about risk reducing contralateral mastectomy and salpingo-oopherectomy
  • The strongest predictor of contralateral risk was oophorectomy
  • Contralateral prophylactic mastectomy is a controversial area in breast surgical oncology, and patient decision-making around this process continues to be studied
  • References
    • Metcalfe K, Gershman S, Lynch HT, et al. Predictors of contralateral breast cancer in BRCA1 and BRCA2 mutation carriers. Br J Cancer. 2011;104(9):1384–1392.
    • Phillips KA, Milne RL, Rookus MA, et al. Tamoxifen and risk of contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. J Clin Oncol. 2013;31(25):3091-3099.
    • Kuchenbaecker KB, Hopper JL, Barnes DR, et al. Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. JAMA. 2017;317(23):2402-2416.

Are Thyroid Nodules in the Isthmus Cytologically or Molecularly Different from Nodules in the Thyroid Lobes?

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Jasim S, Golding A, Bimston D, et al. Cytologic and molecular assessment of isthmus thyroid nodules and carcinomas. Thyroid. Epub 2024 Nov 11; doi: 10.1089/thy.2024.0254. PMID: 39527399.
  • Background:
    • Isthmus thyroid nodules:
      • While less frequent than lobar nodules may carry a higher risk of thyroid cancer and be associated with more aggressive histopathologic features than nodules in either thyroid lobe
    • The underlying reasons for these could be the anatomical location, thin thyroid tissue, and unique lymphatic drainage
    • However, a recent study demonstrated potentially different molecular signatures:
      • With higher ERK and lower thyroid differentiation scores (TDSs) in isthmus as compared to lobar papillary thyroid carcinoma (PTC)
    • Whereas most thyroid nodules are cytologically benign:
      • Approximately 20% to 30% have a Bethesda III or IV cytology:
        • Considered indeterminate thyroid nodules (ITNs):
          • Demonstrating a risk of malignancy ranging from 13% to 34%
    • Historically, surgical intervention was the mainstay for these ITNs:
      • Though most are histopathological benign:
        • Hence, molecular testing has emerged to guide the management of ITNs, of which the Afirma genomic sequencing classifier (GSC) uses exome-enriched RNA sequencing:
          • Providing data on gene and exon expression, mitochondrial expression, loss of heterozygosity, and detection of expressed gene variants and fusions to provide diagnostic information for Bethesda III /IV, and potentially prognostic information for Bethesda V and GSC-suspicious nodules
    • This study demonstrates the cytologic and molecular differences between nodules and PTC based on isthmus or lobar location
  • Methods:
    • This observational study analyzed two cohorts in a complementary manner:
      • Afirma thyroid nodule database (n = 177,227) with genome wide differential expression analysis to decipher transcriptomic differences between isthmus and lobar nodules
      • Histopathology reports (n = 583) of classic PTC (n = 389) and infiltrative follicular subtype of PTC (IF-PTC) (n = 194) from Afirma discovery cohorts and thyroid cancer patients treated at an integrative endocrine surgery community care practice for molecular differences between isthmic and lobar cancers
      • For molecular difference assessment, 54 gene expression signatures were evaluated, including activity scores of 50 hallmarks of cancer pathways, BRAF-like to RAS-like molecular score (BRS), ERK signaling, TDS, and follicular to mesenchymal transition score
      • For pathway enrichment analysis, transcriptome-wide differential expression analysis using 26,268 genes was conducted to identify genes upregulated and downregulated in isthmus nodules by using the Wilcoxon rank-sum statistical test. Deconvolution of bulk gene expression data was used to estimate levels of infiltrating immune cells
  • Results:
    • There were 8527 (4.8%) isthmus nodules identified in the Afirma database
    • Isthmus nodules were twice as likely to be Bethesda V / VI (8.2% vs. 4.3%, P<0.0001) and had twice the frequency of BRAF V600E (21% vs. 10.6%, P<0.0001), an increased frequency of ALK/NTRK/RET fusions (4.6% vs. 2.5%, P<0.0001) and SPOP variants (1.5% vs. 0.8%, P<0.0001):
      • While demonstrating a lower frequency of NRAS mutations (7.8% vs. 13.2%, P<0.0001), PAX8/PPAR-gamma fusions (1.1% vs. 2.3%, P<0.0001, and RET variants (0.06% vs. 0.53%, P = 0.001) than lobar nodules
    • Isthmus nodules also demonstrated higher BRS, ERK activity, and FMT scores (P<0.0001 for all) but lower inflammation immune activity scores on transcriptome and genomewide analysis
    • Complementarily, isthmus nodules showed downregulation of immune response regulation genes on pathway enrichment analysis (OR, 0.74; P<0.001) relative to lobar nodules
    • As compared to lobar IF-PTCs (n = 181), those from the isthmus (n = 13) demonstrated higher BRS, ERK activity, and FMT scores (P<0.01 for all)
    • Analysis of clinical outcomes from 454 samples did not show differences in the frequency of vascular or capsular invasion, extrathyroidal extension, positive surgical margins, or lymph node metastases by cancer location
  • Conclusions:
    • Isthmus nodules were more likely to be malignant and to have increased rates of higher-risk molecular alterations compared to lobar nodules
    • IF-PTC from the isthmus was molecularly different than lobar IF-PTC
    • More investigation is needed to validate these findings before impacting the management of isthmus thyroid nodules
  • COMMENTARY:
    • The location of a nodule in the thyroid may provide a clue to the likelihood of malignancy and to the possibility of an aggressive type, but the current data supporting this are limited
    • Using the Afirma molecular test on validation and clinical data sets, this study found isthmus thyroid nodules to be more likely to have Bethesda V/VI cytology and higher rates of BRAF-like molecular signatures and other molecular markers associated with aggressive behavior than lobar nodules
    • When restricted to cancerous nodules, isthmus IF-PTC showed higher BRAF-like, ERK, and FMT expression scores consistent with aggressive molecular profiles than lobar IF-PTC
    • This study builds on prior work using The Cancer Genome Atlas demonstrating molecular differences between isthmus and lobar PTC, confirming previous literature demonstrating higher risk and histopathologic aggressiveness of PTC in isthmus nodules
    • The authors acknowledge study limitations, including its retrospective observational nature, making it prone to selection bias, low number of cancerous isthmus nodules, and lack of longterm outcome data, limiting their ability to potentially demonstrate histopathologic and clinical differences as compared to lobar nodules
    • While the molecular signatures associated with aggressive PTC behavior were statistically higher in isthmus nodules, their clinical significance needs further investigation
    • In summary, this study provides insights into different malignancy and aggressiveness risk of isthmus thyroid nodules based on molecular signatures
    • The findings should guide future investigations into the underlying reasons for these molecular differences and prospective analyses across different cohorts to improve the management of thyroid nodules

Multifocal or MultiCentric Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Multiple ipsilateral breast cancers include both:
    • Multifocal and multicentric disease
  • The term multifocal (MF):
    • Typically refers to two or more foci of disease:
      • Within a single quadrant of the breast
  • The term multicentric (MC):
    • Refers to two or more foci:
      • In more than one quadrant of the breast
  • When staging, an “m” modifier is added to TNM classification:
    • To identify MF / MC disease
  • In the setting of multifocal or multicentric breast cancer (MIBC):
    • The size of the largest focus is used for staging:
      • Rather than a cumulative measurement of the tumor sizes
  • Historically, it was believed that multiple ipsilateral breast cancers:
    • Should be treated surgically with mastectomy:
      • This thought is based on early retrospective studies (1980s-90s):
        • That reported a higher locoregional recurrence (LRR) in patients with MF / MC disease who underwent breast conserving therapy (BCT)
    • More current studies, which include patients treated in a contemporary multidisciplinary setting:
      • Have demonstrated a more promising role for BCT in MF or MC disease:
        • A systematic review included six retrospective studies evaluating patients with multiple ipsilateral breast cancers undergoing BCT vs. mastectomy:
          • The rate of LRR overall was 2% to 23% for BCT:
            • With similar rates of LRR for BCS compared to mastectomy
          • The largest of these compared 887 patients who underwent mastectomy vs. 300 who underwent BCT:
            • They found that BCT was not inferior to mastectomy with respect to 5-year (2.5% vs. 4.5%) and 10-year (6.5% vs 5.7%) LRR
  • In a study reviewing surgical management of 6,134 patients undergoing neoadjuvant chemotherapy:
    • 1,401 (23%) were found to have MF / MC disease:
      • 617 patients (44%) underwent BCT
    • Local recurrence-free survival, disease-free survival (DFS), and overall survival (OS):
      • Were not inferior in patients with MF / MC compared with unifocal disease if negative margins or a pathologic complete response was obtained
  • In a study evaluating 110 patients with MF / MC disease compared to 263 matched-case controls with unifocal disease:
    • MF / MC disease had worse local control and DFS:
      • But was not impacted by the type of surgery performed
  • The heterogeneity of findings related to the management of multiple ipsilateral breast cancers underscores the need for a prospective clinical trial to address this issue:
    • The Alliance Z11102 prospective trial aimed to evaluate the feasibility and safety of breast conservation in women with multiple ipsilateral breast cancers:
      • Defined as having tumors separated by:
        • 2 cm or more of normal breast tissue
      • The authors found that of the 198 patients enrolled:
        • 93% underwent successful lumpectomy:
          • 67% underwent lumpectomy in a single operation
      • Conversion to mastectomy occurred in:
        • 7.1% of patients due to positive margins
      • Results:
        • Among 270 women enrolled between November 2012 and August 2016:
          • There were 204 eligible patients who underwent protocol-directed BCT
        • The median age was 61 years (range, 40 to 87 years)
        • At a median follow-up of 66.4 months (range, 1.3-90.6 months):
          • Six patients developed LR for an estimated 5-year cumulative incidence of LR of:
            • 3.1% (95% CI, 1.3 to 6.4):
              • Patient age, number of sites of preoperative biopsy–proven BC, estrogen receptor status and human epidermal growth factor receptor 2 status, and pathologic T and N categories were not associated with LR risk
          • Exploratory analysis showed that the 5-year LR rate:
            • In patients without preoperative magnetic resonance imaging (MRI; n = 15) was 22.6% compared with 1.7% in patients with a preoperative MRI (n = 189; P = .002)
      • Conclusion of the Alliance Z11102:
        • The Z11102 clinical trial demonstrates that breast-conserving surgery with adjuvant radiation that includes lumpectomy site boosts yields an acceptably low 5-year LR rate for MIBC
        • This evidence supports BCT as a reasonable surgical option for women with two to three ipsilateral foci, particularly among patients with disease evaluated with preoperative breast MRI.
  • When considering the appropriateness for breast conservation in multiple ipsilateral breast cancers:
    • The distance between the lesions, location, and breast size must be considered
  • Oncoplastic techniques can be considered as needed for an improved cosmetic outcome:
    • With good disease-free survival and low risk of local recurrence
  • References:
    • Kurtz JM, Jacquemier J, Amalric R, et al. Breast-conserving therapy for macroscopically multiple cancers. Ann Surg. 1990;212(1):38-44.
    • Winters ZE, Horsnell J, Elvers KT et al. Systematic review of the impact of breast-conserving surgery on cancer outcomes of multiple ipsilateral breast cancers. BJS Open. 2018;2(4):162-174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069349/. Accessed August 25, 2019.
    • Yerushalmi R, Tyldesley S, Woods R, et al. Is breast-conserving therapy a safe option for patients with tumor multicentricity and multifocality? Ann Oncol. 2012;23(4):876-881.
    • Ataseven B, Lederer B, Blohmer JU, et al. Impact of multifocal or multicentric disease on surgery and locoregional, distant and overall survival in 6134 breast cancer patients treated with neoadjuvant chemotherapy. Ann Surg Oncol. 2015;22(4):1118–1127.
    • Shaikh T, Tam T, Li T, et al. Multifocal and multicentric breast cancer is associated with increased local recurrence regardless of surgery type. Breast J. 2015;21(2):121-126.
    • Rosenkranz, K.M., Ballman, K., McCall, L. et al. The feasibility of breast-conserving surgery for multiple ipsilateral breast cancer: an initial report from ACOSOG Z11102 (Alliance) Trial. Ann Surg Oncol. 2018;25(10):2858-2866.
    • De La Cruz L, Blakenship SA, Chatterjee A, et al. Outcomes after oncoplastic breast-conserving surgery in breast cancer patients: a systematic literature review. Ann Surg Oncol. 2016;23(10):3247-3258.
    • Rastogi P, Anderson SJ, Bear HD. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol. 2008;10;26(5):778-785.
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The Ten Signs of Malignancy on Ultrasound of the Breast

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The 10 signs of malignancy include:
    • Shadowing
    • Hypoechoic echotexture
    • Spiculation
    • Angular margins
    • Thick echogenic halo
    • Microlobulation
    • Taller than wide dimensions
    • Duct extension
    • Branching pattern
    • Calcifications
  • Well-defined smooth border and posterior acoustic enhancement:
    • Are found in both malignant and nonmalignant lesions
  • Layering / teacup mammographic microcalcifications:
    • Are usually associated with benign disease
  • Sonographic mass with a benign mammographic imaging:
    • Is managed based on ultrasound features
Ultrasound imaging of a palpable breast lesion. Marked hypoechogenicity with immobile echogenic foci (representing calcifications)
  • References
    • Evaluation and imaging features of malignant breast masses. In: Cardenosa G. Clinical Breast Imaging: The Essentials. Philadelphia, PA: Wolters Kluwer; 2015:234-282.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
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Intraoperative Radiation Therapy for Breast Cancer has the Highest Risk of Local Recurrence of all the Partial Breast Irradiation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Standard whole breast irradiation (WBI):
    • Historically represented the gold standard technique and was utilized in all randomized trials comparing mastectomy and breast conservation surgery
    • It is traditionally delivered over 5 to 6½ weeks and may incorporate a boost to the tumor bed
  • More recently, hypofractionated WBI has been evaluated in several randomized trials:
    • Whelan et al. compared 50 Gy in 25 fractions to 42.5 Gy in 16 fractions:
      • Eligibility criteria included patients with T1, T2, N0 disease and negative margins
      • At 10 years, no difference in the rate of local control was noted with comparable cosmetic and toxicity profile’s
  • Similarly, the UK Standardisation of Breast Radiotherapy (START) A and B trials:
    • Compared hypofractionated WBI with standard fractionation WBI:
      • With no difference in local recurrence and a suggestion for improved cosmetic outcomes in the hypofractionated regimens
  • With the most recent update to the National Comprehensive Cancer Network guidelines and American Society for Radiation Oncology (ASTRO) guidelines:
    • Both WBI and hypofractionation are considered standard regimens, with hypofractionation preferred in appropriate patients
  • Accelerated partial breast irradiation:
    • Includes interstitial, applicator, and external beam techniques
    • Randomized data from the Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO), which used interstitial brachytherapy:
      • Have demonstrated no difference in the rates of local control at 5 and 10 years, respectively, compared with standard fractionation WBI, with no difference in toxicity or cosmetic outcomes
    • Intraoperative radiation therapy:
      • Although a form of partial breast irradiation, is not the same as APBI:
        • Data from APBI should not be utilized to validate the use of IORT off-protocol
      • The targeted intraoperative radiotherapy (TARGIT) study was a non-inferiority study that included 3,451 patients who were randomized to IORT (50 Kvp x-rays) or standard fractionation WBI
        • Remedial WBI was given to 15% to 20% of the IORT cohort
        • Despite follow-up of only 29 months, 5-year outcomes have been reported and demonstrate higher rates of local recurrence with IORT (3.3% vs. 1.3%)
    • The intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT):
      • Study utilized intraoperative electrons, enrolling 1,305 patients with tumors < 2.5 cm
      • No remedial WBI was given
      • At 5 years, IORT was associated with an increase in local recurrence rates (4.4% vs. 0.4%).5
    • ASTRO IORT guidelines state that the electron beam IORT should be restricted to women with invasive disease considered suitable to partial breast irradiation (PBI) (age > 50 years, margins > 2 mm, T1)
    • Low energy X-ray IORT should be used within the context of a prospective registry or clinical trial:
      • When used, it should be restricted to suitable PBI patients
  • References
    • Whelan TJ, Pignol JP, Levine MN, et al. Long-term results of hypofractionated radiation therapy for breast cancer. N Engl J Med. 2010;362(6):513-520.
    • Haviland JS, Owen JR, Dewar JA, et al; START Trialists’ Group. The UK Standardisation of Breast Radiotherapy (START) trials of radiotherapy hypofractionation for treatment of early stage breast cancer: 10-year follow-up results of two randomised controlled trials. Lancet Oncol. 2013;14(11):1086-1094.
    • Strnad V, Ott OJ, Hildebrandt G, et al; Groupe Européen de Curiethérapie of European Society for Radiotherapy and Oncology (GEC-ESTRO). 5-year results of accelerated partial breast irradiation using sole interstitial multicatheter brachytherapy versus whole-breast irradiation with boost after breast-conserving surgery for low-risk invasive and in-situ carcinoma of the female breast: a randomised, phase 3, non-inferiority trial. Lancet. 2016;387(10015):229-238.
      • Vaidya JS, Wenz F, Bulsara M, et al; TARGIT Trialists’ Group. Risk-adapted targeted intraoperative radiotherapy versus whole-breast radiotherapy for breast cancer: 5-year results for local control and overall survival from the TARGIT-A randomised trial. Lancet. 2014;383(9917):603-613
      • Veronesi U, Orecchia R, Maisonneuve P, et al. Intraoperative radiotherapy versus external radiotherapy for early breast cancer (ELIOT): a randomised controlled equivalence trial. Lancet Oncol. 2013;14(13):1269-1277.
      • Correa C, Harris EE, Leonardi MC, et al. Accelerated partial breast irradiation: executive summary for the update of an ASTRO evidence-based consensus statement. Pract Radiat Oncol. 2017;7(2):73-79.