Severe hyponatraemia in two patients with breast cancer caused by low-dose cyclophosphamide and precipitated by aprepitant (2022)

Type of publication:
Journal article

Author(s):
*Parikh S; *Pettit L; *AbdelGadir H

Citation:
BMJ Case Reports, 2022 Mar 22; Vol. 15

Abstract:
Two postmenopausal women with breast cancer developed acute confusion and seizures, less than 24 hours after the first cycle of neoadjuvant chemotherapy with fluorouracil, epirubicin and low-dose cyclophosphamide. They were found to have severe, life-threatening hyponatraemia with sodium levels of 113 and 115 mEq/L, respectively. Both women made a full recovery within 24 hours of admission with slow correction of sodium levels. Following investigational workup, the most likely diagnosis was cyclophosphamide-associated syndrome of inappropriate antidiuretic hormone secretion (SIADH). Aprepitant – a commonly used antiemetic and moderate cytochromeP450 3A4 inhibitor was identified as the precipitating factor. Aprepitant was discontinued and both women were successfully re-challenged with full dose cyclophosphamide in an outpatient setting with no subsequent adverse events. This is a typical case of a rare cause of a common medical problem. A systematic approach to diagnosis and treatment of hyponatraemia in an oncology patient requires awareness of toxicities of systemic anticancer agents.

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Rare histological subtypes of breast cancer: A study of 10 years' experience at (SATH) UK District General Hospital (2022)

Type of publication:Conference abstract

Author(s):*Mansour A.; *Pettit L.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: Breast cancer is a heterogeneous disease with different histologic subtypes, molecular characteristics, oestrogen receptors (ER) and HER2 status. Common subtype include lobular and ductal cancers. The rare subtypes are a heterogeneous group with differing behaviour specific for each subtype. This study aims to determine the clinicopathological features, management pathway and survival outcome of rare subtypes of invasive breast cancer (IBC) at a single U.K. hospital.Material(s) and Method(s): Data was obtained from the department of Cellular Pathology at The Shrewsbury and Telford Hospital (SATH) NHS Trust. All patients diagnosed with a rare subtype of breast cancer from January 2005 to December 2014 were identified. The histology diagnosis of a rare subtype of breast cancer was reviewed. Biological behaviour, management, follow up and prognosis were obtained from surgical and oncology clinic letters. Also, survival data and cause of death when applicable is reviewed from Clinical Portal (our hospital digital documentation system). Patients with imaging, after the introduction of the digital format to the system in 2012, were also reviewed.
Result(s): Total number of patients diagnosed with IBC was 3049. 201 patients (6.59%) were identified to have a rare subtype of IBC. Patients were divided into subgroups according to their specific rare subtype and included mucinous, tubular, medullary, metaplastic, papillary, neuroendocrine, cribriform, apocrine, malignant phyllodes, angiosarcoma, lymphoma and metastatic from non-breast primary. Some cancers had good prognosis with 100% 5 years overall survival like tubular carcinoma and some have poor prognosis like metaplastic and angiosarcoma.Conclusion(s): Our experience with these heterogeneous groups of rare subtypes of breast cancer identified the clinical behaviour and prognosis of each type. This could be the basis to improve the management of these subtypes and for further studies to improve the outcome for patients with identified breast cancer known to have poorer prognosis.

Her-2 expression pattern evaluation in breast invasive lobular carcinoma and its association to the clinicopathomorphological characteristics and female sex hormones expression in 71 cases (2022)

Type of publication:Conference abstract

Author(s):Barron M.; Asaad A.; Ali S.; Chicken W.; Elamass M.; Alkistawi F.; Abdalla Al-Zawi A.S.; *Khan K.A.; Idaewor P.; Osayi K.

Citation:European Journal of Surgical Oncology; Feb 2022; vol. 48 (no. 2)

Abstract:Background: HER2 status is considered as an important prognostic and predictive factor in breast cancer treatment The cellular E-cadherin protein (encoded by the CDH1 gene) is expressed in the breast epithelial cells. Its function is functions is epithelial-to epithelial cell adhesion and epithelial-to-mesenchymal transition. Invasive lobular carcinoma (ILC) is characterised by the absence of E-cadherin expression, usually its oestrogen /progesterone positive however lack Her-2 amplification. Approximately, about 20% of breast cancers are Her2 +ve. The evidence revealed that, HER2 amplification or overexpression is encountered predominantly in invasive ductal carcinomas (NST) of high nuclear grade and infrequently in pleomorphic lobular carcinomas. The aim is to analyse the Her-2 expression pattern in breast invasive lobular carcinoma.Material(s) and Method(s): The clinical records of 71 patients diagnosed in the period between 2014 -2019,with ILC has been analysed. The lobular phenotype was confirmed by the absence of E-cadherin expression. We have evaluated the following criteria: clinico-pathologic variables, female sex hormone receptor status as well as Her-2 expression status.Result(s): ILC cases has been identified in 71 cases, the age ranges between 39-85 yrs, with mean of 68.In 22.% of cases, the phenotype was mixed ILC& invasive ductal carcinoma. Her-2 overexpression detected in 13% cases, 89% of Her2+ve group are above 65 years of age. Her2 overexpression was more associated with ER+ve group (13%), where 60% were ER+ve,PR+ve and Her2-ve, also 23% noticed to have PR-ve status. Triple negative status was seen only in two cases(2.8%), one of them was pleomorphic lobular carcinoma, both cases age was > 80 yrs.Ki-67 was tested in 58 patients, it was low or moderate in 66%, 7% was Her2 +ve with high Ki-67.Her2+ve status was associated with tumour grade 2 in 7% of cases, grade 3(1.4%) and grade 1 (4%).Conclusion(s): ER expression is noticed to in HER2+ classical ILCs, in spite of the fact that the level of expression is significantly low, compared with the Her2ve- disease.

Effective implementation of an advanced clinical practitioner role in breast imaging (2021)

Type of publication:
Conference abstract

Author(s):
*Deane L.; *Williams S.; *Cielecki L.; *Burley S.

Citation:
Breast Cancer Research 2021, 23(Suppl 1):P57

Abstract:
Background: Due to the immense pressure to provide capacity for women with breast symptoms, to be seen  within two weeks, a new innovative role has been created to provide increased capacity. Introduction: The breast services see many women with conditions that are benign and easily identified upon ultrasound. The majority of these conditions occur in women under the age of 40years. The role of an advanced clinical practitioner was created to answer a service need. This role requires a highly specialised cohort of skills combining breast image interpretation, breast ultrasound and breast biopsying alongside a range of clinical competences enabling autonomous practice within clear governance.
Method(s): A new clinic was created for under 40 aged women only requiring only a breast clinical specialist and an advanced clinical practitioner, using ultrasound for assessment. Unexpected findings suspicious upon ultrasound-would be redirected to the next consultant led clinic for full imaging assessment and biopsy.
Result(s): Increased capacity was achieved, without increased costs. Anxiety levels were reduced due to these patients seen within these clinics and more specialist skills could be directed to more complex cases in the traditional cancer clinics.
Conclusion(s): The use of this specialist role has proven to be innovative and specialised in answering capacity issues within the workforce. The ACP role is utilised as a support to all clinics working alongside consultant radiographers as well as in an autonomous role, thereby freeing up the consultants for cases requiring specialist skills. The stability of the breast service has been ensured

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Male breast ultrasound: 2019 audit results (2021)

Type of publication:
Conference abstract

Author(s):
*Ozcan U.A.; *Williams S.; *Metelko M

Citation:
Breast Cancer Research 2021, 23(Suppl 1):O3.3

Abstract:
Background and Purpose: Male breast cancer is rare whereas gynaecomastia is very common. Only asymmetrical gynaecomastia require breast imaging and focal lumps are amenable to clinical core biopsy. So the use of ultrasound in the assessment of male breast should be limited. The aim of this study is to audit the referral indications and ultrasound outcomes in male breast US (MBUS) patients against local guidelines.
Method(s): In the last 5 years, 968 patients were referred for MBUS in our Trust. This audit includes the patients between 02/01/2019-04/12/2019. The duplicate patients and follow-ups were excluded from the study. In total, 197 patients were analysed (mean age: 58 (8-90) retrospectively. Referral diagnosis, age, US grading and clinical outcomes were noted.
Result(s): Of the 197 patients, 79% were gynecomastia (133), lipoma (21) or fat necrosis (2), and 15% (30) were normal. There was 1 chest wall lymphoma and 1 DCIS, and 9 (5%) patients had benign breast disease (fibroepithelial lesions, abscess, papilloma, sebaceous cysts, haematoma). In 122 patients (62%) clinical grade was not given, 66 had P2, 8 had P3, 1 had P5. 2 patients were scored as U4 and 4 patients as U3.
Conclusion(s): These results clearly show that 99% of the patients referred to MBUS were benign. And also 95% of the patients were clinically benign or not assessed. The excessive use of MBUS without a clinical indication leads to patient anxiety, increased waiting times and might delay the proper imaging to the patients who should have the priority in terms of clinical indication. Careful clinical assessment before ultrasound referral is mandatory for better care.

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Does arbitration work? (2021)

Type of publication:
Conference abstract

Author(s):
*Williams S.; *Deane L.; *Burley S.; *Cielecki L.; *Aksoy U.; *Metelko M.

Citation:
Breast Cancer Research 2021, 23(Suppl 1):P63

Abstract:
Introduction: To improve cancer detection rates, personal performance and as part of our routine service improvement programme, an audit was undertaken of discordant cases returned directly to routine recall between 1/4/15 and 31/3/17 inclusive. These were reviewed against the results of the subsequent screening round to determine if the correct judgement had been made at the previous screening round or if there were any opportunities to learn from misinterpretation.
Method(s): All cases arbitrated and directly returned to routine screening between 2015/16 and 2016/17 were identified and crossreferenced with the results for the subsequent screening episode. All screen detected cancers previously arbitrated on the same side were reviewed by the same routine method and criteria as all interval cancers within our unit and each was given an 'interval' category. All of the screen detected cancers previously arbitrated on the same side were included in the annual interval cancer review session to discuss learn opportunities and improved outcomes.
Result(s): There were 829 cases arbitrated and returned to routine screening at the original screening episode 2015/16 or 2016/17. 11 cases were diagnosed with a same side screen detected cancer at the subsequent screening round and 2 cases presented as a same side interval cancer. Neither interval cancers detected at the case review. 1 of the 11 same side screen detected cancers classified as minimal signs.
Conclusion(s): In our unit arbitration cases returned to routine recall is the correct decision in the vast majority.

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Impact of COVID-19 pandemic on the 2WW breast referrals to a district general hospital (2021)

Type of publication:
Conference abstract

Author(s):
*Tokode O.; *Rastall S.; *Wilson M.

Citation:
European Journal of Surgical Oncology; May 2021; vol. 47 (no. 5)

Abstract:
Introduction: Recommendations were issued to the hospital Trusts to configure service delivery to balance cancer care with the safety of the patient and the hospital staff during the COVID-19 pandemic. The public felt the service restrictions might lead to delays in diagnosis and treatment of cancer patients. We compared the management of 2ww breast referrals in our centre between May to July 2019 and 2020. Method(s): We triaged all referrals to face-face consultation or initial telephone consultation during the pandemic. Patients with suspicious symptoms were offered face-face consultation after the telephone triage. Result(s): Overall, breast patients' referrals fell by 28.3% during the pandemic. 10.2% reduction was noted in May (95% CI 6.73 – 13.59, p<0.001) but a non-significant increase was recorded in June and July. Waiting time reduced by 8.43 days (95% CI -8.88 to -7.98, p< 0.0001). Breast cancer suspicion increased across all age groups in 2020 (+10.4% to + 16.2%). Breast cancer diagnosis rose by 2.0% in 2020 (95% CI 0.19 – 3.92, p=0.030). No cancer was diagnosed among under 29 years. 29.1% of the 522 patients triaged to telephone consultation were discharged, and 70.9% needed face-to-face follow-up. One patient discharged after telephone consultation was later diagnosed with breast cancer. Conclusion(s): COVID-19 pandemic did not lead to a prolonged waiting time or reduced breast cancer diagnosis, but there was an overall reduction in referrals to our breast service.

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Systematic review and metanalyses of prognostic value of circulating tumour cells in early breast cancer (2021)

Type of publication:
Conference abstract

Author(s):
*Mahmood N.

Citation:
European Journal of Surgical Oncology; May 2021; vol. 47 (no. 5)

Abstract:
Background: Prognostic value of circulating tumour cells (CTC) in breast cancer is currently under investigation. This systematic review with Meta-analysis measures the evidence on prognostic relevance of CTC in early breast cancer presented in recent published studies. Method(s): A detailed search was made for published primary studies, those assessed prognostic value of CTC in early breast cancer. Review and quality assessment of 22 included studies were performed and data on CTC status and disease recurrence and death were extracted. Primary outcomes analysed were hazard ratios for disease-free survival (DFS) and overall survival (OS) between the patient groups with positive and negative detection of CTC. Meta-analysis calculated the pooled hazard ratio (HR) with 95% confidence intervals (CIs) as the overall effect measure on DFS and OS using the fixed and random effects models. Result(s): 22 studies enrolling total of 5724 patients were eligible for the systematic review and meta-analysis. Pooled HR for DFS: 2.81 (CI: 2.20-3, 61) and for OS: 2.74 (CI: 2.20-3.41) was found with CTC positive status. Conclusion(s): This systematic review and meta-analysis finds that positive detection of CTC in early breast cancer is a poor prognostic index for disease recurrence and mortality by nearly 3 times.

Triple Negative Male Breast Cancer (2021)

Type of publication:
Conference abstract

Author(s):
Qavi Q.; Alkistawi F.; Lesi O.; Asaad A.; Abdalla Al-Zawi A.S.; Abraham B.; Kumar S.; Ahmed R.; Barron M.; Arooj *Khan K.; Syed A.; Deniz E.; Abduljawad N.H.; Idaewor P.; Aladili Z.; Rasheed N.; Eldruki S.; Uddin A.

Citation:
European Journal of Surgical Oncology; Feb 2021; vol. 47 (no. 2)

Abstract:
Background: Male breast cancer (MBC) is a rare malignancy, may present at advanced disease stage. Triple negative breast cancer (TNBC) known to have the poorest prognosis of all other histological types of breast cancer. This paper presents a case of 71 years old gentleman diagnosed with TNBC. Material(s) and Method(s): A 71 years old male patient, presented with a right breast lump of a recent history also has chronic kidney disease, gastroesophageal reflux,, and excision of basal cell carcinoma of abdominal wall. Clinically he had a skin dent and apalpable 3cm lump underneath in the right breast axillary tail. Mammogramand breast US showed suspicious lesion in right breast axillary tail in additionto a suspicious lymph node in right axilla. Imaging guided core biopsies weretaken from the breast and axillary abnormalities. The histology revealed grade1 invasive ductal carcinoma NST, ER 0 and PR 0 and HER 2 negative. The Breast Multidisciplinary Team meeting advised for mastectomy and axillary clearance, this has been performed. The postoperative Pathomorphology report revealed 23 mm triple negative invasive ductal carcinoma NST, grade 1with Ki67 10%, T2N1M0. The postoperative MDT recommended annual surveillance with mammogram for 5 years. Result(s): MBC is very rare, it is the cause of 1% of all malignant diseases in men, andcauses < 1% of all breast cancers in both males and females.MBC is diagnosed at an average of 10 years later than the age at which breast cancer is diagnosed in females at 65 years of age.There are some reported risk factors associated with MBC as, cryptorchidism, family history, Klinefelter's syndrome, infertility and smoking. Also it has been reported that Only 1/3 of male patients who have BRCA1/2 mutation maydevelop malignancy of breast, pancreas and prostate. Similar to female breast cancer, the most histological type of male breast cancer is invasive ductalcarcinoma NST, and the oestrogen hormone receptors expression is greaterthan in females (up to 95%).Male triple negative breast cancer (MTNBC) is associated with aggressivedisease course, late stage of diagnosis, large size of the tumour size, hightumor histological grade, and high rate nodal disease, also is reported more in a younger patients.Mastectomy is the mainstay of surgical treatment and the triple-negative breast cancer generally has a better to chemotherapy than tumours with oestrogen hormone-receptor positive expression. Adjuvant radiotherapy is recommended, however it doesn't effect the cause-specific survival rate. Conclusion(s): MBC is uncommon entity, accounting for < 1% of all breast cancer diagnosed in both genders and the MTNBC still is rarer, and mastectomy is the mainstay of surgical treatment. in addition to chemotherapy and radiotherapy, however the later doesn't effect the cause-specific survival rate.

Epidemiology, Incidence and Outcomes from Male breast cancer in Mid and South Essex (2021)

Type of publication:
Conference abstract

Author(s):
Alkistawi F.E.; Qavi Q.; Omotara L.; Asaad A.; Salih A.; Chicken W.; Elamass M.; Cathcart P.; Venkat S.E.; Syed A.; Barron M.; *Khan K.; Deniz E.; Abduljawad N.; Aladili Z.; Ozua P.; Idaewor P.; Uddin A.; Rasheed N.; Abdalla Al-Zawi A.S.

Citation:
European Journal of Surgical Oncology; Feb 2021; vol. 47 (no. 2)

Abstract:
Background: Breast Cancer is the most common cancer in the United Kingdom and the second most common cancer in the world. Male breast cancer (MBC) is rare, but reported to account for <1 % of all breast cancer cases and 1% of all male malignancies. The management protocols for male breast cancer are largely derived from the evidence in female breast cancer management.In this study we analysed all MBC within our region presenting over a 6 year period. We are reporting the incidence, clinico-pathological features, management and outcomes of MBC patient treated in 3 breast centres serving the Mid and South Essex region of England. Material(s) and Method(s): Retrospective multicentre review of all the male breast cancer patients presented between 2014 and 2019, in Basildon Hospital, Broomfield Hospital & Southend Hospital. We identified 44 patients and collected data from their clinical records. Data related to patients' age, risk factors, histopathology,surgical treatment, adjuvant treatment and survival were analysed. Result(s): Out of 6952 cases of breast cancer diagnosed between 2014 and 2019, 44 cases of male breast cancer were identified which represents 0.63% of all cases. This lies within the international figures of incidence of male breast cancer. The age group ranged between 43 &96 years with higher incidence on the 9th decade of life. Family history was significantly linked to MBC,in our study and it was observed in 31% of cases.Smoking association with male breast cancer needs to be further assessed in a larger study as in our study group only 3 patients were actively smoking, though another 9 were ex-smokers, this gives a total of 25% of cases associated with smoking history.As for female breast cancer, Invasive ductal carcinoma (IDC) is the most common encountered histological subtype (77%), though other histopathologic subtypes were recorded including invasive lobular carcinoma (4.5%), tubular (4.5%), papillary carcinoma (4.5%) Combined IDC & ILC (2.5%) and DCIS (7%).The receptor status is comparable to the reported figures except for the triple negative cancers which showed a higher rate 6.5% compared to less than 1% rate in documented literature. Mastectomy and sentinel node biopsy remains the main line of treatment, though management with hormonal manipulation only was undertaken in 20% of patients due to frailty or metastatic disease. At a median follow-up of 3 years, 11 patients had died, but only 3 deaths were caused by breast cancer, the mortality rate in our cohort was 25%; however the MBC specific mortality in the cohort was only 6.8%. Conclusion(s): Male breast cancer is rare. It maybe associated with late presentation and less favorable outcomes. Public and health professional education is recommended to enable early disease detection. Multi-centre collaboration is suggested to allow access to a larger database for research to determine the risk factors, optimum treatment and outcomes.