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ABSTRACT: Background: Identification of reliable predictors of axillary metastases (ALNM) may be useful in selecting appropriate management for patients with T1-size breast cancer. This study was undertaken to determine the degree of correlation between ALNM and several variables, including age, race, menopausal status, palpability, tumor size, positive margin on initial excision, histology, grade, lymphatic invasion (LI), estrogen receptor status (ER), progesterone receptor status, S-phase, and ploidy.Methods: Data from 1416 patients with T1 breast cancers treated at Columbia-Presbyterian Medical Center between 1989 and 1998 was reviewed. Patients with multifocal tumors were excluded.Results: Mean patient age was 57.5 years (SD = 12.0); 65% of the patients were postmenopausal. One hundred thirty-one patients with T1a (0.5 cm), 435 with T1b (0.6–1.0 cm), and 850 patients with T1c (1.1–2.0 cm) lesions were studied. The overall rate of ALNM was 23%. AM was identified in 11% of T1a, 15% of T1b, and 29% of T1c patients. Statistically significant factors from univariate analysis were age, palpability, skin changes, tumor size, LI, histology, grade, ER status, and positive margin on initial excision.Conclusions: Axillary staging by either sentinel lymph node biopsy or level I/II axillary dissection is indicated for most T1 breast cancer patients. Omission of axillary staging can be considered for highly selected patients with T1a cancers.
Annals of Surgical Oncology 04/2012; 8(5):432-437. · 4.17 Impact Factor
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ABSTRACT: To evaluate any differences between the percentages of involved breast volume, pathologic attributes, and tumor marker expression of T3 and T4a-c tumors in locally advanced breast cancers (BC).
All patients with T3N > 0 and T4a-c BC without evidence of distant metastasis (M0), presenting to the Breast Clinic from 1980 to 2010, were examined to determine whether their BC's involved ≥ 50% of their breast volumes, defined by gross replacement of at least one hemisphere. Core needle biopsy or post-mastectomy specimens from tumors involving a known percent of breast volume were evaluated for: (1) pathological grades and lympho-vascular invasion (LVI); (2) hormone receptor (ER/PR) expression > 0; and (3) epidermoid growth factor 2 (her2) over-expression (3+) by immune-histochemical staining or fluorescent in situ hybridization.
The data base included 98 patients with T3N> 0 M0 and 120 with T4a-c, any N disease, M0 disease. T3 tumor masses involved 50% or more of the breast in 23/98 (24%), and T4a-c tumors 65/120 (54%) (P < 0.001). Only 1% of T3 tumors and 23% of T4a-c tumors presented with total breast replacement. There were no significant differences between the pathological attributes and marker expression of the T3 and T4a-c tumors.
These data suggest that erosion of the overlying skin or underlying chest wall by some BC may be due to neglect and delay, rather than inherent biological aggressiveness.
World journal of clinical oncology. 03/2012; 3(3):43-7.
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Annals of Surgical Oncology 08/2011; 18(11):3021-3. · 4.17 Impact Factor
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ABSTRACT: Atypical ductal hyperplasia and atypical lobular neoplasia are common benign breast diseases that increase breast cancer risk. We performed a cohort analysis that compared atypia patients for additional risk factors to asses the effect on breast cancer risk by atypia status.
This longitudinal cohort study used data from the Women At Risk High-Risk Registry at Columbia University Medical Center, New York. Women with atypia were compared to women without atypia across known risk factors to determine the combined effect on breast cancer development. Odds ratios (ORs) stratified by atypia status were calculated for each risk factor of interest with 95% confidence intervals (95% CIs). P values were calculated to determine statistical significance.
The study population included 1598 high-risk women, 921 (57.6%) of whom had a history of biopsy-proven atypia. The remaining 677 high-risk women (42.4%) did not have atypia. Fifty women (3.1%) developed breast cancer. Alcohol was significantly associated with the development of breast cancer (P = 0.02) and increased breast cancer risk among women with atypia (OR, 2.13; 95% CI, 0.95-4.81) compared to women without atypia (OR, 1.71). The odds of breast cancer were higher for atypia patients with first-degree relatives (OR, 1.48; 95% CI, 0.64-3.35) compared to women with a relative and no atypia diagnosis (OR, 0.98; 95% CI, 0.41-2.63). The other risk factors of interest did not differ significantly by atypia status.
Atypia patients who drank alcohol and had a first-degree relative with breast cancer have an increased risk of breast cancer compared to those without atypia. Continued understanding of the high-risk population will lead to more individualized protocols for risk reduction and prevention.
Annals of Surgical Oncology 09/2010; 18(2):463-7. · 4.17 Impact Factor
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Felice A Tager,
Paula S McKinley,
Freya R Schnabel, Mahmoud El-Tamer,
Ying Keun K Cheung,
Yixin Fang,
Claire R Golden,
Margery E Frosch,
Ulya Habif,
Margaret M Mulligan,
Ivy S Chen,
Dawn L Hershman
Breast Cancer Research and Treatment 01/2010; · 4.43 Impact Factor
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Felice A Tager,
Paula S McKinley,
Freya R Schnabel, Mahmoud El-Tamer,
Ying Keun K Cheung,
Yixin Fang,
Claire R Golden,
Margery E Frosch,
Ulya Habif,
Margaret M Mulligan,
Ivy S Chen,
Dawn L Hershman
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ABSTRACT: Studies suggest that adjuvant chemotherapy for early stage breast cancer (BC) is associated with cognitive impairment related to attention, memory, and visuospatial functioning. However, other studies have failed to confirm that relationship. We report one of the first longitudinal, controlled studies of cognitive effects of chemotherapy in older post-menopausal women. Sixty-one post-menopausal women with non-metastatic BC were administered neuropsychological tests before adjuvant therapy (Time1), six months after treatment (Time2), and at a final 6-month follow-up (Time3). Thirty women were treated with chemotherapy; thirty-one women who received no chemotherapy were controls. Cognitive domains measured included motor, language, attention/concentration/working memory, visuospatial, and memory (verbal and visual). Time-by-treatment interaction was significant in the motor domain (P = 0.007) with poorer performance in women treated with chemotherapy. For the other domains, scores did not significantly vary over time by group. In post-menopausal women, chemotherapy was not associated with changes in cognitive function in areas reported by BC survivors: attention, memory, and information processing. Motor slowing in women treated with chemotherapy could be secondary to peripheral neuropathy rather than an indication of more general declines in cognitive processing. Future studies should control for the independent effects of slowed motor functioning when looking to study possible chemotherapy related cognitive processing deficits.
Breast Cancer Research and Treatment 11/2009; 123(1):25-34. · 4.43 Impact Factor
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Leukemia & lymphoma 05/2009; 50(5):831-3. · 2.40 Impact Factor
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ABSTRACT: Information is lacking regarding the interaction of established breast cancer risk factors and patient age. We attempted to study this interaction in high-risk women at the extremes of age in our population. The Women-At-Risk Registry was queried for women who were < or =35 and > or =70 years of age. Enrollment criteria included: strong family history of breast cancer (FHBC), and/or biopsy-proven history of atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). Descriptive analyses and Fisher's exact tests were used to analyze these factors and to assess their influence on breast cancer development. Our population included 1,412 high-risk women with median follow-up of 4 years. Of 195 women < or =35 years, 3 (1.5%) developed breast cancer. All three had strong FHBC and none had a prior high-risk lesion. Of 82 women > or =70 years, 6 (7.3%) developed breast cancer. Mean Gail score for women > or =70 years was 4.3, as compared with 4.7 in the subset of older women diagnosed with cancer. Fisher's tests demonstrated that ADH (p = 0.15), ALH (p = 1.0), LCIS (p = 1.0), and FHBC (p = 1.0) were not associated with breast cancer development in older women. We conclude that, for women < or =35 years, a significant FHBC may be a stronger predictor for breast cancer development than high-risk lesions. For women > or =70 years, FHBC and history of ADH, ALH, and LCIS were not predictors of breast cancer. This study emphasizes the importance of defining age-appropriate recommendations for breast cancer risk management, including surveillance and chemoprevention.
Annals of Surgical Oncology 11/2008; 16(1):96-9. · 4.17 Impact Factor
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ABSTRACT: Cancer is the second leading cause of death worldwide. Although great advancements have been made in the treatment and control of cancer progression, significant deficiencies and room for improvement remain. A number of undesired side effects sometimes occur during chemotherapy. Natural therapies, such as the use of plant-derived products in cancer treatment, may reduce adverse side effects. Currently, a few plant products are being used to treat cancer. However, a myriad of many plant products exist that have shown very promising anti-cancer properties in vitro, but have yet to be evaluated in humans. Further study is required to determine the efficacy of these plant products in treating cancers in humans. This review will focus on the various plant-derived chemical compounds that have, in recent years, shown promise as anticancer agents and will outline their potential mechanism of action.
Current Drug Metabolism 10/2008; 9(7):581-91. · 5.11 Impact Factor
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ABSTRACT: Epidemiological evidence indicates that prolonged lifetime exposure to estrogen is associated with elevated breast cancer risk in women. Oxidative stress and estrogen receptor-associated proliferative changes are suggested to play important roles in estrogen-induced breast carcinogenesis. In the present study, we investigated changes in breast morphology and oxidative stress following estrogen exposure. Female ACI rats were treated with 17beta-estradiol (E(2), 3 mg, s.c.) for either 7, 15, 120 or 240 days. Animals were euthanized, tissues were excised, and portions of the tissues were either fixed in 10% buffered formalin or snap-frozen in liquid nitrogen. Paraffin-embedded tissues were examined for histopathologic changes. Proliferative changes appeared in the breast after 7 days of E(2) exposure. Atypical ductal proliferation and significant reduction in stromal fat were observed following 120 days of E(2) exposure. Both in situ and invasive carcinomas were observed in the majority of the mammary glands from rats treated with E(2) for 240 days. Palpable breast tumors were observed in 82% of E(2)-treated rats after 228 days, with the first palpable tumor appearing after 128 days. No morphological changes were observed in the livers, kidneys, lungs or brains of rats treated with E(2) for 240 days compared to controls. Furthermore, 8-isoprostane (8-isoPGF(2alpha)) levels as well as the activities of antioxidant enzymes, such as glutathione peroxidase, superoxide dismutase and catalase, were quantified in the breast tissues of rats treated with E(2) for 7, 15, 120 and 240 days and compared to activity levels in age-matched controls. 8-isoPGF(2alpha) levels displayed time-dependent increases upon E(2) treatment and were significantly higher than control levels at the 15, 120 and 240 day time-points. 8-isoPGF(2alpha) observed in E(2)-induced mammary tumors were significantly higher than levels found in control mammary tissue from age-matched animals. Similarly, alterations in glutathione peroxidase and superoxide dismutase activities were detected in both mammary and tumor tissue from E(2)-treated rats. Taken together, our data reveal that proliferative changes in the breast tissue of ACI rats are associated with increases in 8-isoPGF(2alpha) formation as well as changes in the activities of antioxidant enzymes. These oxidative changes appear to be a function of E(2) exposure and occur prior to tumor development.
Toxicology and Applied Pharmacology 10/2008; 232(1):78-85. · 4.45 Impact Factor
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ABSTRACT: Numerous series demonstrate the benefits of laparoscopic versus open adrenalectomy, but fail to adjust for confounding factors. This study uses the Veterans Affairs National Surgical Quality Improvement Program database to compare these two approaches, adjusting for baseline differences.
Laparoscopic (n=358) and open (n=311) adrenalectomy data were collected at 123 Department of Veterans Affairs and 14 university hospitals from October 1, 2001 to September 30, 2004. Preoperative characteristics, operative data, and 30-day outcomes were compared using the chi-square or Fisher's exact test for categorical variables and the t-test for continuous variables. Unadjusted odds ratio (OR) and 95% confidence interval (CI) were computed for the effect of operative approach on postoperative morbidity. Adjusted odds ratios and 95% CI were computed for this same effect, adjusting for variables that were predictive of outcomes or imbalanced at baseline. Data are reported as means +/-SD, unless otherwise indicated.
Patients undergoing open adrenalectomy were more likely to be older (57.8+/-11.9 years versus 53.5+/-13.2 years, p < 0.0001), harbor malignancy (44.5% versus 13.5%, p < 0.0001), have higher American Society of Anesthesiologists classifications (p=0.0037), smoke (35.4% versus 22.6%, p=0.0003), and have lower serum albumin levels (3.9+/-0.5 g/dL versus 4.0+/-0.5 g/dL, p=0.0241). Open procedures had increased operative times (3.9+/-1.8 hours versus 2.9+/-1.3 hours, p < 0.0001), transfusion requirements (0.7+/-1.8 U versus 0.1+/-0.5 U, p<0.0001), reoperations (4.8% versus 1.4%, p=0.0094), length of stay (9.4+/-11.0 days versus 4.1+/-4.7 days, p < 0.0001) and 30-day morbidity rates (17.4% versus 3.6%, p < 0.0001) with unadjusted and adjusted odds ratio (95% CI) of 5.52 (2.94, 10.33), and 3.97 (1.92, 8.22), respectively. Open procedures resulted in more pneumonia, unplanned intubation, unsuccessful ventilator wean, systemic sepsis, cardiac arrest, renal insufficiency, and wound infections.
Even after adjustment for confounding factors, 30-day morbidity was much higher for patients having open adrenalectomy.
Journal of the American College of Surgeons 06/2008; 206(5):953-9; discussion 959-61. · 4.55 Impact Factor
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ABSTRACT: Although black women develop invasive breast cancer at a lower incidence than white women, the cancers they develop tend to be of a higher grade and are more likely estrogen receptor negative. There is very little information with regard to black women and ductal carcinoma in situ (DCIS). In addition, although various reasons have been proposed for the delay to screening for black women, a delay after diagnosis has also been recognized.
The purpose of this study was to investigate disparities in time to treatment between black women and white women once DCIS has been diagnosed.
A retrospective analysis of 37 black women and 37 matched white women treated for DCIS was performed. Matches were made based on the date of birth, date of diagnosis, date and type of surgery, and age at diagnosis. The time from the date of diagnosis to the date of surgery was ascertained.
Black women were 64% more likely to undergo a delay to surgery (>50 days) compared with white women (21% versus 13%, P < .05).
Black women are more likely not to reach surgery within 50 days of diagnosis, which is concerning, and further studies to investigate the cause of these delays are warranted.
American journal of surgery 10/2007; 194(4):521-3. · 2.36 Impact Factor
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ABSTRACT: Data from the Patient Safety in Surgery Study were used to compare preoperative risk factors, intraoperative variables, and surgical outcomes of adrenalectomy procedures performed in 81 Veterans Affairs (VA) hospitals with those performed in 14 private-sector (PS) hospitals.
This study is a retrospective review of prospectively collected data on all patients undergoing adrenalectomy in the VA and PS for fiscal years 2002 through 2004. Bivariate analysis compared VA and PS preoperative risk factors, intraoperative variables, and 30-day morbidity and mortality. Regression risk-adjustment analysis was used to compare 30-day postoperative morbidity in the VA and PS.
During the 3 years studied, 178 VA patients and 371 PS patients underwent adrenalectomy procedures with a median per site of 2 (range 1-9) and 21 (range 8-70) procedures per VA and PS hospital, respectively. The VA patients had considerably more comorbidities than PS patients. The unadjusted 30-day morbidity rate was significantly higher in VA (16.29%) than PS (6.74%) hospitals (p = 0.0003); after controlling for the higher rate of comorbidities, the adjusted odds ratio for morbidity in the VA versus the PS hospitals was no longer significant (odds ratio = 1.328; 95% CI, 0.488-3.613). Unadjusted mortality rate was VA 2.81%, PS 0.27%, p = 0.0074. The low event rate overall precluded risk adjustment for mortality.
The VA adrenalectomy population has more preoperative risk factors and substantially higher unadjusted 30-day postoperative morbidity and mortality rates than the PS population. After risk adjustment, there is no significant difference in morbidity between the VA and the PS. A larger study population is needed to compare risk-adjusted mortality between the VA and PS.
Journal of the American College of Surgeons 07/2007; 204(6):1273-83. · 4.55 Impact Factor
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ABSTRACT: Breast cancer is a common diagnosis. We compare perioperative characteristics and outcomes between male and female patients undergoing treatment for breast cancer and between hospital systems (Department of Veterans Affairs [VA] and private sector [PS]) as part of the Patient Safety in Surgery (PSS) Study.
We performed an analysis of a prospectively collected clinical database. Data collected from 128 VA hospitals and 14 PS academic medical centers as part of the Patient Safety in Surgery Study for fiscal years 2002 through 2004 were used. Analysis included calculation of crude and adjusted odds ratios for morbidity.
A total of 3,823 patients were included. Female VA patients at baseline had higher rates of smoking, steroid use, COPD, acute renal failure, dialysis, weight loss > 10%, preoperative chemotherapy, and abnormal laboratory values than female PS patients did. Male patients were older than the female patients in both hospital systems. Mortality rates were very low and similar among groups. All VA patients in this study had substantially longer lengths of stay than the patients in the PS. The unadjusted overall complication rate was 5.21%; the VA female patients experienced an unadjusted complication rate twice that of the PS female patients. When adjusted for confounding variables and differences in preoperative comorbidities, the odds ratio comparing VA with PS females was no longer markedly different (1.404; 95% CI, 0.894, 2.204).
VA patients with breast cancer have higher incidences of most comorbidities than patients in the PS. Differences in complication rates females disappear when adjustment is made for the higher rates of comorbidities in the VA patients.
Journal of the American College of Surgeons 07/2007; 204(6):1235-41. · 4.55 Impact Factor
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ABSTRACT: Surgical site infection (SSI) is a potentially preventable complication. We developed and tested a model to predict patients at high risk for surgical site infection.
Data from the Patient Safety in Surgery Study/National Surgical Quality Improvement Program from a 3-year period were used to develop and test a predictive model of SSI using logistic regression analyses.
From October 2001 through September 2004, 7,035 of 163,624 (4.30%) patients undergoing vascular and general surgical procedures at 14 academic and 128 Department of Veterans Affairs (VA) medical centers experienced SSI. Fourteen variables independently associated with increased risk of SSI included patient factors (age greater than 40 years, diabetes, dyspnea, use of steroids, alcoholism, smoking, recent radiotherapy, and American Society of Anesthesiologists class 2 or higher), preoperative laboratory values (albumin<3.5 mg/dL, total bilirubin>1.0 mg/dL), and operative characteristics (emergency, complexity [work relative value units>/=10], type of procedure, and wound classification). The SSI risk score is more accurate than the National Nosocomial Infection Surveillance score in predicting SSI (c-indices 0.70, 0.62, respectively).
We developed and tested an accurate prediction score for SSI. Clinicians can use this score to predict their patient's risk of an SSI and implement appropriate prevention strategies.
Journal of the American College of Surgeons 07/2007; 204(6):1178-87. · 4.55 Impact Factor
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ABSTRACT: Malignant phyllodes tumors are an extremely rare breast tumor. Prognostic features and overall survival data have not been consistent across studies.
Retrospectively, we examined the clinicopathologic features of 27 breast cancer patients treated for malignant phyllodes tumors from 1995 to 2004 and analyzed their recurrence and survival outcomes using contingency tables, a logistic regression model, or a proportional hazard model.
The mortality rate was 12% (n = 3) of the cohort and 75% of the group with distant metastases. The median follow-up period was 51 months (range, 12-192 mo). A mitotic index greater than 10 per high-powered field, the presence of stromal overgrowth, mastectomy at initial surgery, and larger tumor size were associated with an increased incidence of distant metastases. Larger tumor size also was associated with an increased incidence of death.
Most patients with malignant phyllodes tumors will enjoy significant long-term survival if treated appropriately with local excision with clear margins.
The American Journal of Surgery 11/2006; 192(4):492-5. · 2.78 Impact Factor
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ABSTRACT: The purpose of this study was to investigate the strongest predictors of breast cancer in a high-risk population and to increase our understanding of the possible interactions between risk factors.
The Women At Risk High-Risk Registry provided the study population. The variables of interest included age at enrollment, presence of lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), atypical lobular hyperplasia, family history of breast cancer, body mass index, and Gail scores (5-year high-risk > or =1.7%). Univariate and multivariate analyses were conducted with the Cox proportional hazards regression model and years of follow-up evaluation as the time scale.
Out of 1553 high-risk women, 79 (5%) developed breast cancer during a median follow-up period of 5 years. Results from the multivariate Cox model demonstrated that FHBC (hazard ratio [HR] = 1.76; 95% confidence interval [CI], 1.05-2.97), ADH (HR = 1.90; 95% CI, 1.16-3.13), LCIS (HR = 1.71; 95% CI, .99-2.95), and a body mass index > or =30 (HR = 2.22; 95% CI, 1.14-4.35) were statistically significant predictors of breast cancer within this high-risk population.
These results support current literature showing the synergistic increase in risk for patients with ADH, LCIS, and a positive family history of breast cancer. Obesity was also a strong predictor of breast cancer risk, which suggests that there may be a potentiating effect of obesity on other risk factors. Obesity may represent a modifiable risk factor, providing women with an opportunity to reduce their risk with lifestyle modification. Women with a strong family history of breast cancer or a diagnosis of ADH or LCIS may benefit most from risk-reduction strategies, chemoprevention, and surveillance.
The American Journal of Surgery 11/2006; 192(4):474-7. · 2.78 Impact Factor
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ABSTRACT: Non-Hodgkin lymphoma of T-cell lineage involving the breast is rare. We report on a 41-year-old woman with T-cell lymphoblastic lymphoma who presented with multiple bilateral breast masses. The patient was treated with intensive chemotherapy and mediastinal and whole-brain irradiation. She remains in complete remission 24 months after diagnosis. The clinical, histologic, phenotypic, and cytogenetic features are described, with a review of the literature.
American Journal of Hematology 12/2005; 80(3):216-22. · 4.67 Impact Factor
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ABSTRACT: The purpose of this study was to determine the utility of breast-imaging studies in identifying cancer and high-risk lesions among patients with spontaneous, single-duct, nipple discharge (SSND).
The medical records of 168 cases with SSND treated with duct excision between June 1998 and May 2004 were reviewed. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, and ductogram in predicting high-risk lesions and cancer were calculated.
The sensitivity of mammography was 10%, the specificity 94%, the NPV 88%, and the PPV 18%. Ultrasonography had a sensitivity of 36%, specificity of 68%, PPV of 14%, and NPV of 89%. Ductography had a sensitivity of 75%, specificity of 49%, and NPV and PPV of 93% and 18%, respectively.
Conventional imaging studies do not accurately identify cancer or high-risk lesions in patients with SSND. All patients with SSND should be offered duct excision.
The American Journal of Surgery 11/2005; 190(4):644-6. · 2.78 Impact Factor
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ABSTRACT: Gross cystic disease (GCD) is a common benign breast condition. Previous studies have reported conflicting results regarding the relationship of GCD and subsequent risk of developing breast cancer. This cohort study was conducted to investigate the association of GCD and breast cancer among women at high risk for breast cancer.
The Women At Risk Registry provided the study population. The variables of interest included age at enrollment, age at breast cancer diagnosis, body mass index (BMI), presence of lobular carcinoma in situ (LCIS), and Gail scores. Statistical significance was determined by calculating multivariable-adjusted rate ratios using Cox proportional hazards regression model with years of follow-up as the time scale.
The study population included 1317 high-risk women, including 363 (28%) with GCD. The mean follow-up was 5.9 years for the GCD cohort, and 5.1 years for the non-GCD cohort (P < .001). The GCD and non-GCD groups differed by Gail score (P < .001), BMI (P < .01), presence of atypical hyperplasia (P < .001), presence of LCIS (P < .001), and family history of breast cancer (P < .001). Within the total population of 1317 women, 79 (6%) developed breast cancer; 28 (35%) out of the 79 had a prior history of GCD. Results from the Cox proportional hazards regression model showed a nonstatistically significant association of GCD and breast cancer (hazard ratio = 1.48, 95% confidence interval 0.88-2.51). The Kaplan-Meier overall survival estimate between the exposed and unexposed groups indicate that there are no differences in overall survival between the 2 groups (P = .5).
These results do not support the contention that gross cystic disease is a significant risk factor for breast cancer.
The American Journal of Surgery 10/2005; 190(4):583-7. · 2.78 Impact Factor
