Breast Neoplasms: Sener SF

Shyyan R, Sener SF, Anderson BO, Garrote LM, Hortobágyi GN, Ibarra JA, Ljung BM, Sancho-Garnier H, Stalsberg H, Anonymous00018. · Department of Surgery, Lviv Regional Cancer Center, Lviv, Ukraine. · Cancer. · Pubmed #18837018 No free full text.

Abstract: A key determinant of breast cancer outcome in any population is the degree to which newly detected cancers can be diagnosed correctly so that therapy can be selected properly and provided in a timely fashion. A multidisciplinary panel of experts reviewed diagnosis guideline tables and discussed core implementation issues and process indicators based on the resource stratification guidelines. Issues were then summarized in the context of 1) clinical assessment, 2) diagnostic breast imaging, 3) tissue sampling, 4) surgical pathology, 5) laboratory tests and metastatic imaging, and 6) the healthcare system. Patient history provides important information for the clinical assessment of breast and comorbid disease that may influence therapy choices. Focused clinical breast examination and complete physical examination provide guidance on the extent of disease, the presence of metastatic disease, and the ability to tolerate aggressive therapeutic regimens. Breast imaging improves preoperative diagnostic assessment and also permits image-guided needle sampling. Diagnostic mammography was not considered mandatory in low- and middle-income countries when resources are lacking. Needle biopsy is preferred to surgical excision for the initial diagnosis of suspicious breast lesions, unless resources are unavailable. Mastectomy should never be used as a method of tissue diagnosis. The availability of predictive tumor markers, especially estrogen receptor testing, is critical when endocrine therapies are available; quality assessment of immunohistochemistry testing is important to avoid false-negative results. Incremental allocation of resources can help address economic disparities and help ensure equity in access to timely diagnosis.

Sener SF, Winchester DJ, Brinkmann E, Winchester DP, Alwawi E, Nickolov A, Perlman RM, Bilimoria M, Barrera E, Bentrem DJ. · Department of Surgery, Evanston Northwestern Healthcare, 2650 Ridge, Burch #106, Evanston, IL 60201, USA. · J Am Coll Surg. · Pubmed #15110806 No free full text.

Abstract: BACKGROUND: Lymphatic mapping with sentinel lymphadenectomy (SL) has become more widely used as an alternative to axillary dissection for the staging of breast cancer. This study was conducted to evaluate the potential associations of patient and tumor characteristics with the lymphatic mapping failure rate. STUDY DESIGN: Between September 1996 and April 2003, 1,094 breast cancer patients participated in a single-institution prospective SL protocol, which was conducted using technetium 99 m sulfur colloid alone to identify sentinel lymph nodes. During the validation phase, consisting of the first 80 patients, all patients had SL followed by axillary dissection. Beginning with the 81st patient, the standard technique consisted of radiolabeled colloid injection in a peritumoral distribution 16 to 24 hours before the operation, followed by SL alone for node-negative patients. RESULTS: Of 1,094 consecutive patients, 62 (5.7%) did not map. Patients having more than 10 involved lymph nodes had a significantly higher incidence of mapping failure (40.9%) than those who were node-negative (5.3%) (odds ratio = 9.19, p = 0.002). Age was a factor predictive of mapping failure for node-negative patients 70+ years of age (odds ratio = 3.14, p = 0.018). Biopsy technique, tumor size, tumor location, cell type, and surgeon experience were not predictors of mapping failure, regardless of node status. CONCLUSIONS: The lymphatic mapping failure rate was associated with both anatomic and pathologic factors. Patients with extensive nodal involvement had a significantly greater chance of mapping failure. Among node-negative patients, those who were older were more likely to have mapping failure than those who were younger, suggesting that decreased breast density in postmenopausal women might provide an anatomic explanation for nonmapping.

Sener SF, Winchester DJ, Winchester DP, Du H, Barrera E, Bilimoria M, Krantz S, Rabbitt S. · Department of Surgery and the Center on Outcomes Research and Education, NorthShore University Health System, Evanston, and Northwestern University Feinberg School of Medicine, Chicago, IL, USA. · Am J Surg. · Pubmed #19245923 No free full text.

Abstract: BACKGROUND: The goal of this study was to compare the characteristics of breast cancers and survival rates in HRT users versus nonusers. METHODS: Data were analyzed for 1055 patients > or = 50 years of age who had definitive therapy for breast cancer from 1994 through 2002. RESULTS: There were 471 (45%) HRT users. The median age at diagnosis was 61.0 years for HRT users and 68.0 years for HRT nonusers (P < .001). HRT users more often had tumors that were <1 cm (P = .007), node negative (P = .033), and grade I (P = .016). HRT users had a decreased risk of death versus nonusers (hazard ratio = .438, 95% confidence limit = .263 to .729, P = .002). CONCLUSIONS: HRT users developed breast cancer at a younger age than nonusers; HRT use was associated with the development of biologically more favorable cancers than those that developed in nonusers; and overall and disease-free survival rates were higher in HRT users than nonusers.

Kennedy T, Stewart AK, Bilimoria KY, Patel-Parekh L, Sener SF, Winchester DP. · Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA. · Ann Surg Oncol. · Pubmed #17638060 No free full text.

Abstract: BACKGROUND: Breast conservation therapy (BCT) and adjuvant hormonal therapy for estrogen-receptor positive breast cancers have become standard of care. Our objectives were to evaluate trends in the surgical management and adjuvant therapy for early-stage breast cancer and to identify factors predicting survival. METHODS: Using the National Cancer Data Base (NCDB), patients with node-negative breast cancers less than 1 cm (T1aN0M0 and T1bN0M0) from 1993-2004 were identified. The time periods of 1993-1994, 1998-1999, and 2003-2004 were compared to analyze trends in surgical management and adjuvant therapy. Cox Proportional Hazards modeling was used to examine factors predicting survival. RESULTS: Overall, 123,212 cases of T1aN0M0 or T1bN0M0 breast cancer were identified. The use of breast conservation surgery increased from 61.3% in 1993/1994 to 78.3% in 2003/2004 with a concomitant decrease in the use of mastectomy. The use of radiation therapy also increased from 51.9% in 1993/1994 to 62.0% in 2003/2004. Adjuvant hormonal therapy administration rose sharply from 26.7% in 1993/1994 to 44.7% in 2003/2004. After adjusting for potential confounders, the difference in 5-year survival rates for T1a (94.3%) and T1b (93.1%) tumors was marginal (P = .04). Age, grade, size, and failure of BCS patients to receive radiation therapy and hormonal therapy were independent predictors of a higher likelihood of death. CONCLUSIONS: BCS utilization increased over time, but mastectomy rates may still be considered high given the small size of tumors in this cohort and the percent of patients eligible for BCT. The use of hormonal therapy increased significantly over the past decade. Further investigation into patient and physician factors affecting treatment choices is needed if BCT and hormonal therapy utilization is to increase.

Byers T, Barrera E, Fontham ET, Newman LA, Runowicz CD, Sener SF, Thun MJ, Winborn S, Wender RC, Anonymous00151. · University of Colorado School of Medicine, Denver, Colorado 80045, USA. · Cancer. · Pubmed #16770789 links to  free full text

Abstract: BACKGROUND: The American Cancer Society has challenged the U.S. to reduce cancer mortality rates 50% over the 25 years from 1990 to 2015. The current report is an analysis and commentary on progress toward that goal through 2002, the midpoint of the challenge period. METHODS: Cancer mortality rates were examined from 1990 through 2002, and projections to the Year 2015 were made. Cancer deaths that were prevented or deferred by the declining death rates were expressed as the difference between the observed and projected numbers of deaths and the numbers that would have been observed over that period had the 1990 death rates persisted. RESULTS: Since 1990, cancer mortality rates have been declining in the U.S. by approximately 1% per year. Trends especially have been favorable for cancers of the breast, prostate, and colorectum and for lung cancer among men. Should this rate of decline continue over the coming decade, death rates from cancer will be approximately 23% lower in the Year 2015 than they were in 1990, and approximately 1.8 million deaths from cancer will have been prevented or deferred. CONCLUSIONS: At this midpoint of the 25-year challenge period, it appears that fully reaching the goal will require substantial breakthroughs in cancer early detection and/or in cancer therapy. Between now and 2015, however, many more cancer deaths can be averted by concerted action to control tobacco and obesity, by redoubling efforts in mammography and colorectal screening, and by enacting policies to close gaps in access to cancer detection and treatment services.

Sener SF, Winchester DJ, Winchester DP, Barrera E, Bilimoria M, Brinkmann E, Alwawi E, Rabbitt S, Schermerhorn M, Du H. · Department of Surgery, Evanston Northwestern Healthcare and Northwestern University Feinberg School of Medicine, Evanston, IL 60201, USA. · Am J Surg. · Pubmed #16490556 No free full text.

Abstract: BACKGROUND: This single-institution long-term prospective study was performed in the setting of community service screening mammography to evaluate the association between the methods of breast cancer detection and survival rates. METHODS: From 1994 through 2001, data on 1237 patients with breast cancer were collected concurrent with definitive surgical treatment and entered into a comprehensive database. RESULTS: Mammography was the sole method of detection for 517 (44%) of 1179 Tis-T2 breast cancers. Fifty-seven percent of invasive cancers detectable by mammography alone were less than 1 cm in diameter. For 1049 patients with invasive cancers, the 5-year overall observed survival rates were 94% for 372 whose cancers were detectable by mammogram alone and 87% for 677 whose cancers were detectable by palpation (alone or in combination with mammography) (P = .0002). CONCLUSIONS: Most of the contribution to breast cancer mortality reduction is from the detection of small nonpalpable cancers, not from adjuvant therapy.

Jeruss JS, Winchester DJ, Sener SF, Brinkmann EM, Bilimoria MM, Barrera E, Alwawi E, Nickolov A, Schermerhorn GM, Winchester DJ. · Feinberg School of Medicine, Northwestern University, 303 E. Chicago Avenue, Chicago, Illinois 60611, USA. · Ann Surg Oncol. · Pubmed #15827776 No free full text.

Abstract: BACKGROUND: Sentinel node biopsy (SNB) has evolved as the standard of care in the surgical staging of breast cancer. This technique is accurate for surgical staging of axillary nodal disease. We hypothesized that axillary recurrence after SNB is rare and that SNB may provide regional control in patients with microscopic nodal involvement. METHODS: With institutional review board approval, SNB was performed with peritumoral injection of 99mTc-labeled sulfur colloid. From 1996 to 2003, 1167 patients were entered into a prospective cancer database after surgical therapy; 916 patients consented to long-term follow-up. Fifty-two patients (5.7%) did not map successfully and were excluded, leading to a study population of 864 patients. The median follow-up was 27.4 months (range, 1-98 months). RESULTS: The median number of sentinel nodes harvested was 2, and 633 (73%) patients had negative sentinel nodes. Thirty (4.7%) of those sentinel node-negative patients underwent completion axillary dissection, whereas 592 (94%) patients were followed up with observation. A total of 231 (27%) had positive sentinel nodes: 158 (68%) of these patients underwent completion axillary dissection, and 73 (32%) were managed with observation alone. Two (.32%) patients who were sentinel node negative had an axillary recurrence; one of these patients had undergone completion axillary dissection. No patient in the observed sentinel node-positive group had an axillary recurrence (odds ratio, .37; P = .725). CONCLUSIONS: On the basis of a median follow-up of 27.4 months, axillary recurrence after SNB is extraordinarily rare regardless of nodal involvement, thus indicating that this technique provides an accurate measure of axillary disease and may impart regional control for patients with node-positive disease.

Winchester DJ, Bernstein JR, Jeske JM, Nicholson MH, Hahn EA, Goldschmidt RA, Watkin WG, Sener SF, Bilimoria MB, Barrera E, Winchester DP. · Department of Surgery, Evanston Northwestern Healthcare, Evanston, Ill 60201, USA. · Arch Surg. · Pubmed #12799332 links to  free full text

Abstract: BACKGROUND: Nonpalpable mammographic abnormalities are frequently evaluated by means of a stereotactic core needle biopsy. This technique is a very sensitive indicator of invasive cancer, but is less reliable to discriminate between ductal carcinoma in situ and atypical ductal hyperplasia (ADH). The objective of this study was to determine the correlation of the 11-gauge vacuum-assisted core needle biopsy to open biopsy when a diagnosis of ADH is obtained. HYPOTHESIS: The use of 11-gauge vacuum-assisted stereotactic core needle biopsy does not conclusively diagnose ADH. DESIGN: Retrospective analysis. SETTING: University-affiliated teaching hospital. PATIENTS: Mammographic findings were evaluated with an 11-gauge vacuum-assisted stereotactic core biopsy in 1750 patients. Seventy-seven patients were diagnosed as having ADH; of these, 65 underwent excisional biopsy. MAIN OUTCOME MEASURES: Pathological upstaging rate. RESULTS: Of the 65 patients who underwent excisional breast biopsy, 11 (17%) had their condition upstaged to a breast cancer diagnosis. These patients had presented at a later age than those who retained a benign diagnosis after excisional biopsy. The number of cores taken did not correlate with diagnostic accuracy. CONCLUSIONS: Of the 65 patients who underwent open biopsy for ADH in this series, only 83% had an accurate diagnosis. A diagnosis of ADH by stereotactic core needle biopsy should be followed by an open excisional biopsy.

Sener SF. · Northwestern University Medical School, Chicago, Illinois, USA. · Cancer Pract. · Pubmed #11898259 No free full text.

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Sener SF, Cady B, Merkel D. · Northwestern University Medical School, Evanston, Illinois, USA. · Cancer Pract. · Pubmed #11866708 No free full text.

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Sener SF, Winchester DJ, Martz CH, Feldman JL, Cavanaugh JA, Winchester DP, Weigel B, Bonnefoi K, Kirby K, Morehead C. · Department of Surgery, Evanston Northwestern Healthcare, 2650 Ridge, Burch 106, Evanston, IL 60201, USA. · Cancer. · Pubmed #11550143 links to  free full text

Abstract: BACKGROUND: Initial studies of sentinel lymphadenectomy for patients with breast carcinoma confirmed that the status of the sentinel lymph nodes was an accurate predictor of the presence of metastatic disease in the axillary lymph nodes. Sentinel lymphadenectomy, as an axillary staging procedure, has risks of morbidity that have yet to be defined. METHODS: Patients were enrolled in a two-phase protocol that included concurrent data collection of patient characteristics and treatment variables. During the first (validation) phase, 72 patients underwent sentinel lymph node excision followed by a level I-II axillary dissection. After the technique had been established, the second phase commenced, during which only patients with positive sentinel lymph nodes underwent an axillary dissection. RESULTS: During the second phase, lymphedema was identified in 9 of 303 patients (3.0%) who underwent sentinel lymphadenectomy alone and in 20 of 117 patients (17.1%) who underwent sentinel lymphadenectomy combined with axillary dissection (P < 0.0001). Of 303 patients who underwent sentinel lymphadenectomy alone, 8 of 155 patients (5.1%) with tumors located in the upper outer quadrant and 1 of 148 patients (0.7%) with tumors in other locations developed lymphedema (P = 0.012). CONCLUSIONS: The risk of developing lymphedema after undergoing sentinel lymphadenectomy was measurable but significantly lower than after undergoing axillary dissection. Tumor location in the upper outer quadrant and postoperative trauma and/or infection were identifiable risk factors for lymphedema.

Sener SF, Milos S, Feldman JL, Martz CH, Winchester DJ, Dieterich M, Locker GY, Khandekar JD, Brockstein B, Haid M, Michel A. · Department of Surgery, Evanston Northwestern Healthcare, Evanston, IL 60201, USA. · J Am Coll Surg. · Pubmed #11442250 No free full text.

Abstract: BACKGROUND: With the general acceptance of lumpectomy, axillary staging, and radiotherapy as local treatment for infiltrating breast cancer, an appreciation is evolving for the spectrum of vascular lesions that occur in the mammary skin after this treatment. Most of these lesions develop within the prior radiation field after breast conservation treatment. STUDY DESIGN: A retrospective chart and slide review was conducted, consisting of five patients with cutaneous vascular lesions after breast conservation treatment for infiltrating breast cancer. RESULTS: The latent time interval from definitive treatment of breast cancer to the clinical recognition of vascular lesions ranged from 5 to 11 years. Two patients did not have either arm or breast edema, two patients had breast edema, and the fifth patient had arm edema. Lesions arising in the irradiated mammary skin included extensive lymphangiectasia (one), atypical vascular lesions (two), and cutaneous angiosarcoma (four). CONCLUSIONS: Atypical vascular lesions at the skin margins of mastectomy may be predictive of recurrence after resection of angiosarcoma. Excision of skin from the entire radiation field may be necessary to secure local control of the chest wall in patients with cutaneous angiosarcoma after therapeutic breast radiotherapy.

Sener SF, Winchester DJ, Winchester DP, Kurek R, Motykie G, Martz CH, Rabbitt S. · Department of Surgery, Evanston Northwestern Healthcare, Illinois, USA. · Am Surg. · Pubmed #10432082 No free full text.

Abstract: Mammographic screening of women at both ends of the age spectrum presents a number of challenges. The purpose of this study was to characterize experience with mammographic detection of breast cancer. The two goals were 1) to establish the cancer detection rate of screening mammography and 2) to compare the tumor size of cancers found by mammography, physical examination, or both modalities. From January 1994 through June 1997, data on 609 consecutive female primary breast cancer patients were collected concurrent with definitive surgical therapy. The method of detection was determined by the surgeon, after reviewing mammogram and physical examination. Screening ultrasound was not used. For the 184 patients under 50 years of age, 53 (29%) cancers were detected by mammography only and 48 (26%) by physical examination only. Women under 50 years of age had fewer cancers detected by mammography only (P < 0.001) and more cancers detected by physical examination only (P = 0.0014) than those over 50. With increasing age, the proportion of women with ductal carcinoma in situ decreased (P = 0.004), and the proportion with T1c or T2 tumors increased (P = 0.006). We conclude that 1) when examining women under 50 years of age, the surgeon must be clearly focused on the double-edged sword of screening mammography in this age group, and 2) community cancer programs should encourage annual screening of women over 40 years of age but focus on those over 70, without an arbitrary upper age limit.

Winchester DJ, Sener SF, Winchester DP, Perlman RM, Goldschmidt RA, Motykie G, Martz CH, Rabbitt SL, Brenin D, Stull MA, Moulthrop JM. · Department of Surgery, Evanston Northwestern Healthcare, IL 60201, USA. · J Am Coll Surg. · Pubmed #10359352 No free full text.

Abstract: BACKGROUND: Axillary node status remains the most important prognostic indicator of survival in breast cancer patients. Only 25% to 35% of patients having standard level I/II axillary dissection have involved nodes, yet all accept the potential for morbidity after the operation. This study was conducted to assess whether status of the sentinel node(s) was an accurate predictor of the presence of metastatic disease in axillary or internal mammary nodes. STUDY DESIGN: In 180 patients, technetium 99m sulphur colloid was injected in a 4-quadrant peritumoral distribution. During the first phase of the study, 72 patients had sentinel node excision followed by a level I/II axillary dissection. During the second phase of the study, 108 patients had sentinel node excision and only those with positive nodes had completion axillary dissection. Nodes were examined after formalin fixation by taking 10 sections at 20-microm intervals and staining with hematoxylin-eosin. RESULTS: Sentinel nodes were found in 162 (90%) of 180 patients. The mean number of sentinel nodes examined was 3.1. Of the 162 patients with successful lymphatic mapping, positive sentinel nodes were found in 44 (27%). In 23 (66%) of 35 patients with positive sentinel nodes who had a completion level I/II axillary dissection, the sentinel nodes were the only positive nodes. The concurrent negative predictive value was 4% in the first 72 patients who had completion axillary dissection after sentinel node excision, and 2% for the entire series. With evolution of technique, identification of sentinel nodes with radiolabeled colloid was successful in 97% of the last 100 patients. CONCLUSIONS: Because the concurrent negative predictive value was low, sentinel node excision appeared to accurately identify node status, potentially avoiding the need for standard level I/II axillary dissection in sentinel node-negative patients.

Bilimoria MM, Winchester DJ, Sener SF, Motykie G, Sehgal UL, Winchester DP. · Department of Surgery, Evanston Northwestern Healthcare, Northwestern University Medical School, Illinois, USA. · Ann Surg Oncol. · Pubmed #10082047 No free full text.

Abstract: BACKGROUND: The use of exogenous estrogen has been scrutinized as a risk factor for breast cancer formation. This prospective study addresses the relationship between the use of estrogen replacement therapy and the age of onset of breast cancer. In addition, an analysis of differences in pathological features of breast cancer between estrogen users and non-estrogen-users was evaluated. METHODS: A total of 425 women (age, > or = 50 years) were evaluated during a 4-year period (1994-1997). Data, including the age at diagnosis, method of detection, family history, use of estrogen therapy, and tumor ploidy, S-phase fraction, histological category, estrogen receptor positivity, and grade, were prospectively collected. Data from a control group of 657 women without a diagnosis of breast cancer were obtained from the Evanston Northwestern division of the Women's Health Initiative. Significant associations between the use of estrogen and pathological parameters were determined using the chi2 test and t-test (P < .05). RESULTS: At the time of breast cancer diagnosis, 140 patients were currently receiving estrogen and 202 patients had no history of estrogen use. Eighty-three patients were excluded from analysis (76 patients had a history of previous but not current use of estrogen therapy, four women used only progesterone, and three patients provided incomplete information). There was no difference between patients with breast cancer using estrogen at the time of diagnosis and those with no history of estrogen use with respect to tumor size, age of menopause, family history, mammographic sensitivity, axillary lymph node status, and histological features. Women using estrogen at the time of diagnosis were younger at the time of breast cancer diagnosis, by an average of 5.1 years (61.3 years vs. 66.4 years, P < .001). Women without a history of breast cancer who were receiving estrogen therapy were an average of 2.4 years younger (63.3 years vs. 65.7 years, P < .001) than women without a history of breast cancer who were not receiving estrogen therapy. Patients with breast cancer receiving estrogen also tended to have more grade II tumors (45.9% vs. 36.5%, P = .045) and fewer grade III tumors (25.6% vs. 37.0%, P = .015), compared with women not receiving estrogen therapy at the time of their diagnoses. Estrogen receptor positivity was noted to be more frequent for estrogen users presenting with lobular carcinoma (85% vs. 76%, P = .042) and less frequent for estrogen users presenting with ductal carcinoma (72% vs. 85%, P = .003). CONCLUSIONS: A significantly earlier age of diagnosis for women receiving estrogen therapy suggests that exogenous estrogen may accelerate the pathogenesis of postmenopausal breast cancer. Estrogen therapy may also play a role in altering the grade and estrogen receptor positivity for certain histological types of breast cancer.

Anderson BO, Yip CH, Smith RA, Shyyan R, Sener SF, Eniu A, Carlson RW, Azavedo E, Harford J. · Department of Surgery, University of Washington, Seattle, Washington 98195, USA. · Cancer. · Pubmed #18816619 No free full text.

Abstract: Breast cancer outcomes in low- and middle-income countries (LMCs) correlate with the degree to which 1) cancers are detected at early stages, 2) newly detected cancers can be diagnosed correctly, and 3) appropriately selected multimodality treatment can be provided properly in a timely fashion. The Breast Health Global Initiative (BHGI) invited international experts to review and revise previously developed BHGI resource-stratified guideline tables for early detection, diagnosis, treatment, and healthcare systems. Focus groups addressed specific issues in breast pathology, radiation therapy, and management of locally advanced disease. Process metrics were developed based on the priorities established in the guideline stratification. The groups indicated that cancer prevention through health behavior modification could influence breast cancer incidence in LMCs. Diagnosing breast cancer at earlier stages will reduce breast cancer mortality. Programs to promote breast self-awareness and clinical breast examination and resource-adapted mammographic screening are important early detection steps. Breast imaging, initially with ultrasound and, at higher resource levels with diagnostic mammography, improves preoperative diagnostic assessment and permits image-guided needle sampling. Multimodality therapy includes surgery, radiation, and systemic therapies. Government intervention is needed to address drug-delivery problems relating to high cost and poor access. Guideline dissemination and implementation research plays a crucial role in improving care. Adaptation of technology is needed in LMCs, especially for breast imaging, pathology, radiation therapy, and systemic treatment. Curricula for education and training in LMCs should be developed, applied, and studied in LMC-based learning laboratories to aid information transfer of evidence-based BHGI guidelines.