5-year Locoregional Recurrence Research Articles

The Ratio of Positive to Excised Nodes Identifies High-risk Subsets and Reduces Inter-Institutional Differences in Locoregional Recurrence Risk Estimates in Breast Cancer Patients With 1–3 Positive Nodes: An Analysis of Prospective Data From British Columbia and the M. D. Anderson Cancer Center

To examine the power of the nodal ratio (NR) of positive/excised nodes in predicting postmastectomy locoregional recurrence (LRR) in patients with 1-3 positive nodes (N+) and in identifying cohorts at similar risk across independent data sets. Data from 82 patients with 1-3 N+ treated without postmastectomy radiotherapy (PMRT) in the British Columbia (BC) randomized trial were compared with data from 462 patients treated without PMRT in prospective chemotherapy trials at the M. D. Anderson Cancer Center (MDACC). Kaplan-Meier LRR curves were compared between centers using the absolute number of N+ and nodal ratios. The median number of excised nodes was 10 in BC and 16 in MDACC (p < 0.001). Examining LRR by number of N+, the 10-year LRR rate for patients with 1-3 N+ was higher in BC compared with MDACC (21.5% vs. 12.6%; p = 0.02). However, when examining LRR using NR, no differences were found between institutions. In patients with NR < or = 0.20, the 10-year LRR rate was 17.7% BC vs. 10.9% MDACC (p = 0.27). In patients with NR > or = 0.20, the 10-year LRR rate was 28.7% BC vs. 22.7% MDACC (p = 0.32). On Cox regression analysis, NR was a stronger prognostic factor compared with number of N +. In patients with 1-3 N+, evaluating nodal positivity using NR reduced inter-institutional differences in LRR estimates that may exist due to variations in numbers of nodes excised. Nodal ratio >0.20 was associated with LRR >20%, warranting PMRT consideration. Nodal ratio may be useful for extrapolating data from prospective trials to clinical practices in which axillary staging extent vary.

259 ORAL Standardisation of HER2 testing: results of an international proficiency testing ring study

To evaluate locoregional control and survival after mastectomy, as well as toxicity, in patients irradiated by a previously described postmastectomy highly conformal electron beam radiation therapy technique (PMERT).We included all women irradiated by postmastectomy electron beam radiation therapy for nonmetastatic breast cancer between 2007 and 2011 in our department. Acute and late toxicities were retrospectively assessed using Common Terminology Criteria for Adverse Events version 3.0 criteria.Among the 796 women included, 10.1% were triple-negative, 18.8% HER2-positive, and 24.6% received neoadjuvant chemotherapy (CT). Multifocal lesions were observed in 51.3% of women, and 64.6% had at least 1 involved lymph node (LN). Internal mammary chain, supraclavicular, infraclavicular, and axillary LNs were treated in 85.6%, 88.3%, 77.9%, and 14.9% of cases, respectively. With a median follow-up of 64 months (range, 6-102 months), 5-year locoregional recurrence–free survival and overall survival were 90% (95% confidence interval 88.1%-92.4%) and 90.9% (95% confidence interval 88.9%-93%), respectively. Early skin toxicity was scored as grade 1 in 58.5% of patients, grade 2 in 35.9%, and grade 3 in 4.5%. Concomitant CT was associated with increased grade 3 toxicity (P<.001). At long-term follow-up, 29.8% of patients presented temporary or permanent hyperpigmentation or telangiectasia or fibrosis (grade 1: 23.6%; grade 2: 5.2%; grade 3: 1%), with higher rates among smokers (P=.06); 274 patients (34.4%) underwent breast reconstruction. Only 24 patients (3%) had early esophagitis of grade 1. Only 3 patients developed ischemic heart disease: all had been treated by anthracycline-based CT with or without trastuzumab, all had been irradiated to the left chest wall and LN, and all presented numerous cardiovascular risk factors (2-4 factors).This study demonstrated the good efficacy of this technique in terms of locoregional control and survival, and good short-term and long-term safety. Longer follow-up is required to analyze chronic cardiac events.

Postoperative radiotherapy for Stage 1 endometrial carcinoma: Long-term outcome of the randomized PORTEC trial with central pathology review

In 2000, the results of the multicenter Post Operative Radiation Therapy in Endometrial Carcinoma (PORTEC) trial were published. This trial included 714 Stage I endometrial carcinoma patients randomly assigned to postoperative pelvic radiotherapy (RT) or no further treatment, excluding those with Stage IC, Grade 3, or Stage IB, Grade 1 lesions. Radiotherapy significantly decreased the risk of locoregional recurrence (4% vs. 14%), without affecting overall survival. In this report the long-term outcome and results with central pathology review are presented. The slides of 569 patients (80%) could be obtained for pathology review. Median follow-up for patients alive was 97 months. Analysis was done according to the intention-to-treat principle. The primary study endpoints were locoregional recurrence and death. Ten-year locoregional relapse rates were 5% (RT) and 14% (controls; p < 0.0001), and 10-year overall survival was 66% and 73%, respectively (p = 0.09). Endometrial cancer related death rates were 11% (RT) and 9% (controls; p = 0.47). Pathology review showed a substantial shift from Grade 2 to Grade 1, but no significant difference for Grade 3. When cases diagnosed at review as Grade 1 with superficial myometrial invasion were excluded from the analysis, the results remained essentially the same, with 10-year locoregional recurrence rates of 5% (RT) and 17% (controls; p < 0.0001). In view of the significant locoregional control benefit, radiotherapy remains indicated in Stage I endometrial carcinoma patients with high-risk features for locoregional relapse.

The prognostic significance of the percentage of positive/dissected axillary lymph nodes in breast cancer recurrence and survival in patients with one to three positive axillary lymph nodes

Adjuvant therapy for women with T1-T2 breast carcinoma and 1-3 positive lymph nodes is controversial due to discrepancies in reported baseline locoregional recurrence (LRR) risks. This inconsistency has been attributed to variations in lymph node staging techniques, which have yielded different numbers of dissected lymph nodes. The current study evaluated the prognostic impact of the percentage of positive/dissected lymph nodes on recurrence and survival in women with one to three positive lymph nodes. The study cohort was comprised of 542 women with pathologic T1-T2 breast carcinoma who had 1-3 positive lymph nodes and who had undergone mastectomy and received adjuvant systemic therapy without radiotherapy. Ten-year Kaplan-Meier (KM) LRR, distant recurrence (DR), and overall survival (OS) rates stratified by the number of positive lymph nodes, the number of dissected lymph nodes, and the percentage of positive lymph nodes were examined using different cut-off levels. Multivariate analysis was performed to evaluate the prognostic significance of the percentage of positive lymph nodes in disease recurrence and survival. The median follow-up was 7.5 years. LRR, DR, and OS rates correlated significantly with the number of positive lymph nodes and the percentage of positive lymph nodes, but not with the number of dissected lymph nodes. The cut-off level at which the most significant difference in LRR was observed was 25% positive lymph nodes (the 10-year KM LRR rates were 13.9% and 36.7% in women with < or = 25% and > 25% positive lymph nodes, respectively; P < 0.0001). Higher DR rates and lower OS rates were observed among patients who had > 25% positive lymph nodes compared with patients who had < or = 25% positive lymph nodes (DR: 53.0% vs. 30.3%, respectively; P < 0.0001; OS: 43.4% vs. 62.6%, respectively; P < 0.0001). In the multivariate analysis, the percentage of positive lymph nodes and the histologic grade were significant, independent factors associated with LRR, DR, and OS. The presence of > 25% positive lymph nodes was an adverse prognostic factor in patients with 1-3 positive nodes and may be used to identify patients at high risks of postmastectomy locoregional and distant recurrence who may benefit with adjuvant radiotherapy and more aggressive systemic therapy regimens.

Patient subsets with T1-T2, node-negative breast cancer at high locoregional recurrence risk after mastectomy

To identify patient subsets with T1-T2N0 breast cancer at high risk of locoregional recurrence (LRR) who may warrant consideration for postmastectomy radiotherapy. Data were analyzed for 1505 women referred between 1989 and 1999 with pathologic T1-T2N0M0 breast cancer treated with mastectomy with clear margins and no adjuvant radiotherapy. Logistic regression analysis was performed to identify statistically significant factors associated with LRR. Recursive partitioning was used to develop a classification tree model for LRR given the prognostic variables. The median follow-up was 7.0 years. The 10-year Kaplan-Meier LRR rate was 7.8%. On logistic regression analysis, the statistically significant factors predicting LRR were histologic grade (p <0.0001), lymphovascular invasion (LVI) (p <0.0001), T stage (p = 0.05), and systemic therapy use (p = 0.01). In the recursive partitioning model, the first split in the classification tree was histologic grade. For 972 patients without high-grade histologic features, the 10-year Kaplan-Meier LRR rate was 5.5%. For 533 patients with Grade 3 disease (LRR rate 12.1%), the concomitant presence of LVI was associated with a LRR rate of 21.2% (n = 126). In patients with Grade 3 disease without LVI, T2 tumors conferred a LRR rate of 13.4% (n = 194), which increased to 23.2% for patients who did not receive systemic therapy (n = 63). Women with pT1-T2N0 breast cancer experienced a LRR risk of approximately 20% in the presence of Grade 3 disease with LVI or Grade 3 disease, T2 tumors, and no systemic therapy. These subsets of node-negative patients warrant consideration of for postmastectomy radiotherapy.

Selecting breast cancer patients with T1-T2 tumors and one to three positive axillary nodes at high postmastectomy locoregional recurrence risk for adjuvant radiotherapy

To define the individual factors and combinations of factors associated with increased risk of locoregional recurrence (LRR) that may justify postmastectomy radiotherapy (PMRT) in patients with T1-T2 breast cancer and one to three positive nodes. The study cohort comprised 821 women referred to the British Columbia Cancer Agency between 1989 and 1997 with pathologic T1-T2 breast cancer and one to three positive nodes treated with mastectomy without adjuvant RT. The 10-year Kaplan-Meier estimates of isolated LRR and LRR with or without simultaneous distant recurrence (LRR +/- SDR) were analyzed according to age, histologic findings, tumor location, size, and grade, lymphovascular invasion status, estrogen receptor (ER) status, margin status, number of positive nodes, number of nodes removed, percentage of positive nodes, and systemic therapy use. Multivariate analyses were performed using Cox proportional hazards modeling. A risk classification model was developed using combinations of the statistically significant factors identified on multivariate analysis. The median follow-up was 7.7 years. Systemic therapy was used in 94% of patients. Overall, the 10-year Kaplan-Meier isolated LRR and LRR +/- SDR rate was 12.7% and 15.9%, respectively. Without PMRT, a 10-year LRR risk of >20% was identified in women with one to three positive nodes plus at least one of the following factors: age <45 years, Stage T2, histologic Grade 3, ER-negative disease, medial location, more than one positive node, or >25% of nodes positive (all p < 0.05 on univariate analysis). On multivariate analysis, age <45 years, >25% of nodes positive, medial tumor location, and ER-negative status were statistically significant predictors of isolated LRR and LRR +/- SDR. In the classification model, the first split was according to age (<45 years vs. >/=45 years), with 29.3% vs. 13.7% developing LRR +/- SDR (p < 0.0001). Of 123 women <45 years, the presence of >25% of nodes positive was associated with a risk of LRR +/- SDR of 58.0% compared with 23.8% for those with </=25% of nodes positive (p = 0.01). Of 698 women >45 years, the presence of >25% of nodes positive also conferred a greater LRR +/- SDR risk (26.7%) compared with women with </=25% of nodes positive (10.8%; p < 0.0001). In women >45 years with </=25% of nodes positive, tumor location and ER status were factors that could be used to further distinguish low-risk from higher risk subsets. Clinical and pathologic factors can identify women with T1-T2 breast cancer and one to three positive nodes at high LRR risk after mastectomy. Age <45 years, >25% of nodes positive, a medial tumor location, and ER-negative status were statistically significant independent factors associated with greater LRR, meriting consideration and discussion of PMRT. Combinations of these factors further augmented the LRR risk, warranting recommendation of PMRT to optimize locoregional control and potentially improve survival. The absence of high-risk factors identifies women who may reasonably be spared the morbidity of PMRT.

Predictors of locoregional recurrence in patients with locally advanced breast cancer treated with neoadjuvant chemotherapy, mastectomy, and radiotherapy

To identify the clinical and pathologic factors predictive of locoregional recurrence (LRR) after neoadjuvant chemotherapy, mastectomy, and radiotherapy. We retrospectively reviewed the hospital records of 542 patients treated on six consecutive institutional prospective trials using neoadjuvant chemotherapy and postmastectomy radiotherapy. The clinical stage (American Joint Committee on Cancer, 1988) was Stage II in 17%, Stage IIIA in 30%, Stage IIIB in 43%, and Stage IV (ipsilateral supraclavicular disease) in 10%. All LRRs were considered events, irrespective of the timing to distant metastases. The median follow-up was 70 months. The 5-year and 10-year actuarial LRR rate was 9% and 11%, respectively. The clinical factors associated with LRR included combined clinical stage, clinical T stage, ipsilateral supraclavicular nodal disease, chemotherapy response, physical examination size after chemotherapy, and no tamoxifen use (p < or = 0.04 for all factors). The pathologic predictors of LRR included the number of positive nodes, dissection of <10 nodes, multifocal/multicentric disease, lymphovascular space invasion, extracapsular extension, skin/nipple involvement, and estrogen receptor-negative disease (p <or = 0.05 for all factors). Multivariate Cox regression analysis revealed that five factors independently predicted for LRR: skin/nipple involvement, supraclavicular nodal disease, no tamoxifen use, extracapsular extension, and estrogen receptor-negative disease (hazard ratio, 2.1-2.8; p < or = 0.02 for all factors). The 10-year LRR rate was only 4% for patients with one or none of these five independent factors, 8% for those with two factors, and 28% for those with three or more factors (p < 0.0001). Although the long-term rate of LRR after neoadjuvant chemotherapy, mastectomy, and radiotherapy is low, we identified a number of factors that correlated independently with greater rates of LRR. Patients with three or more of these factors may benefit from research protocols investigating alternative treatment strategies.

Sentinel lymphadenectomy guided complete lymph node dissection improves loco-regional disease control in early-stage head and neck melanoma

7552 Introduction: The utility of lymphatic mapping (LM) and sentinel lymphadenectomy (SL) in head and neck (H&N) melanoma is still debated. The purpose of this study is to determine the therapeutic efficacy of LM/SL-directed surgical clearance of tumor-involved lymph node (LN) basins in early-stage cutaneous H&N melanoma. Methods: Database query identified all cutaneous H&N melanoma patients who were seen at our institution within first 3 months of diagnosis and underwent surgery between 1974 - 2002. Inclusion criteria were stage I - III, wide local excision (WLE) only, WLE/SL ± complete lymph node dissection (CLND), and at least 1-year of follow-up. Exclusion criteria were mucosal melanoma and stage III with palpable LNs. Group 1 underwent WLE only, whereas Group 2 underwent WLE/SL + CLND if sentinel node contained metastatic tumor. Patients from each group were matched for Breslow thickness (0 - 1 mm, 1.01 - 2 mm, 2.01 - 3 mm, 3.01 - 4 mm, > 4 mm), primary site (face/nose, scalp, ear, neck), and gender. 5-year disease free survival (DFS), loco-regional recurrence (LRR), and times to LRR were measured. χ2 and log-rank tests were used to determine statistical significance. Results: Of 604 eligible patients, 176 patients from each group (total of 352) were matched for above prognostic factors. Distribution of Clark level (p = 0.16) and % of patients with ulceration (p = 0.63) were not different. 5-year DFS rates were not statistically different (65 ± 4% for Group 1 vs. 71 ± 4 for Group 2; p = 0.287). However, the difference in LRR was statistically significant (Group 1: 20% vs. Group 2: 6.3%; p = 0.0001). Despite differences in median follow-up times (99 vs. 51 months), the median/mean times to LRR were not different (Group 1: 12/26 months vs. Group 2: 13/36 months; p = 0.56). Conclusions: Our data indicate that LM/SL-directed surgical clearance of melanoma-involved LN basins decreases the incidence of LRR for early-stage cutaneous H&N melanoma. Its therapeutic superiority in controlling loco-regional disease, when compared to WLE alone, provides a de-facto evidence of validity for application of LM/SL in early-stage cutaneous H&N melanoma. No significant financial relationships to disclose.

T3 disease at presentation or pathologic involvement of four or more lymph nodes predict for locoregional recurrence in stage II breast cancer treated with neoadjuvant chemotherapy and mastectomy without radiotherapy

Purpose: To help define the clinical and pathologic predictors of locoregional recurrence (LRR) in breast cancer patients treated with neoadjuvant chemotherapy and mastectomy without radiotherapy for early-stage disease. Methods and Materials: We retrospectively reviewed the outcomes of all 132 patients with Stage I or II breast cancer treated in prospective institutional trials with neoadjuvant chemotherapy and mastectomy without radiotherapy between 1974 and 2001. The clinical stage (American Joint Committee on Cancer 1988) at diagnosis was I in 5%, IIA in 46%, and IIB in 49% of patients. The median age at diagnosis was 49 years. All patients were treated with either a doxorubicin-based neoadjuvant regimen or single-agent paclitaxel. The total LRR rates were calculated by the Kaplan-Meier method, and comparisons were made with two-sided log–rank tests. The median follow-up was 46 months. Results: The actuarial LRR rate at both 5 and 10 years was 10%. Factors that correlated positively with LRR included clinical Stage T3N0 ( p = 0.0057), four or more positive lymph nodes at surgery ( p = 0.0001), age ≤40 years at diagnosis ( p = 0.0001), and no use of tamoxifen. In the patients who did not receive tamoxifen, estrogen receptor-positive disease correlated positively with LRR ( p = 0.0067). The 5-year LRR rate for the 42 patients with clinical Stage T1 or T2 disease and one to three positive lymph nodes at surgery was 5% (only two events). Conclusion: For patients with clinical Stage II breast cancer, T3 primary disease, four or more positive lymph nodes after chemotherapy, and age ≤40 years old predicted for LRR. For most patients with clinical T1 or T2 disease and one to three positive lymph nodes, the 5-year risk for LRR was low, and the routine inclusion of postmastectomy radiotherapy does not appear to be justified.

Using loco-regional recurrence as an indicator of the quality of breast cancer treatment

The aim of our study was to compare the loco-regional recurrence (LRR) rates after breast-conserving surgery and mastectomy between the time periods of 1985–1992 and 1993–1999. The first period reflects the early experiences with breast conservation. The second period covers the years when a mammographical screening programme was introduced for women 50–69 years of age. We collected data on 1212 patients with 1264 resectable breast cancers (i.e. stage I, IIA, IIB and IIIA), of which 385 were removed by breast conserving surgery and 879 by mastectomy. During follow-up, 47 loco-regional recurrences developed after breast conservation, and 67 after mastectomy. The 5- and 10-year loco-regional recurrence rates were 5.7% (95% Confidence Interval (CI) 4.0–7.4) and 11.0% (95% CI 8.0–14.0), respectively, after mastectomy and 7.3% (95% CI 4.5–10.1) and 15.8% (95% CI 11.2–20.4), respectively, after breast conservation. The 8-year loco-regional recurrence rate after breast conservation decreased from 20.1% (95% CI 14.7–26.5) in the period of 1985–1992 to 5.4% (95% CI 1.8–9.0) in the period of 1993–1999 (P=0.0018). Despite the more favourable stage distribution of the patients undergoing mastectomy, no significant decrease was observed in the LRR risk in the latter period (P=0.18). Improvements in patient selection and treatment techniques are the most likely explanations of the decreasing LRR rate after breast conservation in our teaching hospital.

Locoregional recurrence after doxorubicin-based chemotherapy and postmastectomy: Implications for breast cancer patients with early-stage disease and predictors for recurrence after postmastectomy radiation

Purpose To compare rates of locoregional recurrence (LRR) after mastectomy, doxorubicin-based chemotherapy, and radiation with those of patients receiving mastectomy and doxorubicin-based chemotherapy without radiation and to determine predictors of LRR after postmastectomy radiation. Methods Kaplan-Meier freedom-from-LRR rates were calculated for 470 patients treated with mastectomy, doxorubicin-based chemotherapy, and postmastectomy radiation in five single-institution clinical trials. The LRR rates in these patients were compared to previously reported rates in 1031 patients treated without radiation in the same trials. Results Median follow-up was 14 years. Irradiated patients had significantly less favorable prognostic factors for LRR than did unirradiated patients. Despite this, in all subsets of node-positive patients, postmastectomy radiation led to lower rates of LRR. This included patients with T1 or T2 tumors and one to three positive nodes (10-year LRR rates of 3% vs. 13%, p = 0.003). Multivariate analysis of LRR for patients with this stage of disease revealed that no radiation, close/positive margins, gross extracapsular extension, and dissection of <10 nodes predicted for increased LRR (hazard ratios 6.25, 4.61, 3.27, and 2.66, respectively). Significant predictors of LRR for patients treated with postmastectomy radiation were higher number and ≥20% positive nodes, larger tumor size, lymphovascular space invasion, and estrogen receptor (ER)-negative disease. Recursive partitioning analysis revealed ER-negative status to be the most powerful discriminator of LRR in irradiated patients. Conclusions Postmastectomy radiation decreases LRR for patients with breast cancer, including those with Stage II breast cancer and one to three positive lymph nodes.

Treatment of squamous cell carcinoma of the anterior faucial pillar–retromolar trigone

Cancer of the anterior faucial pillar–retromolar trigone is an uncommon head and neck tumor, which has historically been shown to be associated with poor prognosis. In this retrospective study, we reviewed our experience with primary surgery followed by postoperative radiation therapy in order to determine the impact of our treatment protocols on patients’ outcome. Between January 1994 and December 1998, 31 patients with histologically proven squamous cell carcinoma (SCC) of the anterior faucial pillar–retromolar trigone were treated in our department. Surgical excision of the primary lesion and ipsilateral neck dissection were performed in all patients. Reconstruction was accomplished using masseter muscle flap or tongue flap. Postoperatively, most patients (90%) received radiation therapy (51–58 Gy) to the primary side and neck. Adjuvant chemotherapy was offered if histologic signs of aggressive behavior were identified. Four out of 31 patients were initially seen at stage I or II and 27 patients at stage III or IV of the disease. Metastatic disease was demonstrated in 78% of ipsilateral neck nodes. Occult metastases were found in 64% of clinically N0 necks. The 3-year loco-regional recurrence rates were 44.8%. SCC of retromolar trigone is considered as an aggressive and insidious tumor. The reconstruction of the deficit of the anterior faucial pillar–retromolar area with masseter muscle flap is a reliable, safe and absolutely functional method.

Impact of radiotherapy for high-risk neuroblastoma: a Children’s Cancer Group study

Purpose To assess the effect of local radiation administered to primary disease sites in children with high-risk neuroblastoma. Methods and materials A total of 539 eligible patients were entered on protocol CCG-3891, consisting of chemotherapy, primary surgery, and 10 Gy of external beam radiation therapy (EBRT) to gross residual disease, followed by randomized assignment to continuation chemotherapy (CC) or autologous bone marrow transplantation (ABMT). ABMT patients received total body irradiation (TBI). Results Estimated event-free survival and overall survival at 5 years were 25% ± 2% and 35% ± 2%, respectively. Estimated 5-year locoregional recurrence rates were 51% ± 5% and 33% ± 7% for CC and ABMT patients ( p = 0.004). For patients who received 10 Gy of EBRT to the primary, the addition of 10 Gy of TBI and ABMT decreased local recurrence compared with CC (22% ± 12% and 52% ± 8%, p = 0.022). EBRT did not increase acute toxicity, except for increased total parenteral nutrition administration. Conclusions In combination with EBRT to the primary tumor site, the addition of 10 Gy of TBI as a component of high-dose chemotherapy with ABMT improved local control compared with CC without TBI. Results suggest a dose–response relationship for local EBRT. Short-term toxicity of local EBRT is limited.

Late locoregional recurrence in rectal carcinoma

Aims: Locoregional recurrence in rectal carcinoma usually occurs within the first five years of treatment. In recent years we have increasingly diagnosed patients with late locoregional recurrence more than 5 years after primary treatment.Methods: The data of 978 patients with invasive stage I–III rectal carcinoma who underwent curative resection (R0) between 1978 and 1990 were analysed retrospectively. The median follow-up time was 10 years.Results: The earliest locoregional recurrence was observed at 2 months, the latest at 148 months (extramural locoregional recurrence) after primary treatment. Within 1, 2 and 5 years 34, 64 and 91 per cent of all locoregional recurrences had been diagnosed. The 2-, 5- and 10-year locoregional recurrence rates of all patients increased from 11.3 to 16.7 to 18.8 per cent. The time lapse to diagnosis of locoregional recurrence was significantly influenced by the pN category (pN0: later), grading (low grade: later) and tumour cell dissemination (present: earlier). Locoregional recurrence was also diagnosed significantly earlier in patients undergoing regular follow-up. The curative reoperation rate was 22 per cent (n=37), being higher in patients with intramural locoregional recurrence (49 per cent), after primary anterior resection (32 per cent) and in the absence of distant metastases (29 per cent).Conclusion: Long-term follow-up beyond five years demonstrates increasing numbers of late locoregional recurrences.

Role of conservation therapy for invasive lobular carcinoma of the breast.

Invasive lobular carcinoma (ILC) accounts for 5% to 10% of all invasive breast cancers. Although breast conservation therapy using local excision and postoperative irradiation is a standard therapy for early invasive ductal breast cancer, the result of this strategy in ILC is not well documented. We sought to determine the rate of locoregional recurrence after breast conservation therapy in patients with ILC. A retrospective review of 74 patients with ILC treated with breast conservation therapy at The University of Texas M. D. Anderson Cancer Center (n = 43) or The John Wayne Cancer Institute (n = 31) between 1977 and 1993 was performed. The median age of patients was 60 years, and median follow-up was 56 months (range 1 to 207 months). Thirty-nine patients had American Joint Committee on Cancer stage I disease, 30 had stage IIa disease, and five had stage IIb disease. All patients underwent surgical resection and postoperative radiation therapy. Twelve patients received postoperative adjuvant chemotherapy, and 27 patients were treated with adjuvant hormonal therapy. The 5-year actuarial locoregional recurrence rate was 9.8%, and the median time to recurrence was 77 months (range 41 to 113 months). Patients with positive or close (< or = 1 mm) surgical margins were at increased risk for local recurrence on univariate analysis (p = 0.034). Of the nine patients with breast recurrence, six underwent salvage therapy with total mastectomy and are disease free at the time of this writing, two patients died of distant disease, and one is alive with local disease at the time of this report. The 5-year disease-specific survival rate was 93.7%. Breast conservation therapy for ILC achieves locoregional control in the majority of patients. However, long-term follow-up of patients is important because many local recurrences following breast conservation therapy are late events.