Candidates For Breast-conserving Therapy Research Articles

Comparison of FDG PET and MRI for evaluating the tumor extent of breast cancer and the impact of FDG PET on the systemic staging and prognosis of patients who are candidates for breast-conserving therapy

FDG PET has not yet found a role in the clinical evaluation of the tumor extent of breast cancer. FDG PET has been reported to be useful for evaluating the prognoses of breast cancer patients with more accuracy than conventional imaging modalities. The purpose of this study was to compare the accuracy of FDG PET and MRI for the preoperative assessment of the tumor extent of breast cancer, for evaluating the impact of FDG PET on systemic staging, and also for predicting the prognosis of patients who are candidates for breast-conserving therapy. The study was a prospective series of 23 breasts with breast cancer that underwent both FDG PET and MRI before surgery. Systemic staging with FDG PET was also performed. The correlation between the results of these examinations and histological findings was thus examined. The maximum standardized uptake value (SUVmax) of the tumors was investigated in association with the patient prognoses. When evaluating the local tumor extent, the accuracy of FDG PET (43.5%) was significantly lower than that of MRI (91%) (P < 0.001). The sensitivity, specificity, and accuracy of FDG PET regarding the nodal status were 60, 94, and 87%, respectively. No patients demonstrated any distant metastasis, whereas FDG PET gave a false positive in one patient. The mean follow-up period was 61 months. The SUVmax value of the worse prognosis patient group was significantly higher than that of the good prognosis patient group (P = 0.032). FDG PET is not a breast imaging modality for evaluating the local tumor extent, but it is useful for predicting the prognoses of patients who are candidates for breast-conserving therapy.

Treatment of invasive lobular carcinoma with breast conserving therapy

11046 Background: Invasive lobular carcinoma (ILC) is the second most common histological type of breast carcinoma .There is still a persisting concern regarding the use of breast-conserving therapy(BCT) in patients with ILC.Difficulty to identify the exact size , location of ILC and multifocality and/or multicentricity are the reasons to suggest that patients with ILC might be poor candidates for BCT. The aim of our current study was to evaluate the possibilty of risk adapted BCT for patients with ILC with or without breast irradiation. Methods: 277 patients with ILC pure or mixed type between 1994 and 2006 were accrued for pospective risk adapted therapy. Contraindications for BCT are multicentricity , inability to obtain negative margins or poor cosmesis. Palpation, mammograpy,ultrasound were routinely done and preoperative MRI in cases with no sharp tumor image. Breast conserving surgery was standardised by performing a radial segmental resection. Inking margins,histological semiserial step sections and specimen radiography was done. Sharp dileneated ILC with a free margins of &gt;/= 1cm and no lymphvesel invasion(LVI) were treated by BCT without breast irradiation(Rx). Patients with ER + were treated with endocrine therapy.Mean follow-up time was 74 months. Results: Of the 277 ILC cases , 55(19,8%) were treated by mastectomy and five patients palliatively because of distant metastases. 217 ILC (79%) were treated with BCT (T1:108/48%;T2:45(21%);T3:67/31% ; NO:135/62%; ER+: 295/94%). 6 patients(2,8%) had local recurrence(LR). 161 ILC (T1 38%; T2 22%; T3 39%; N0 55%) were treated with BCT with Rx. Patients mean age was 57 years. 6(3,7%) of the patients had local recurrence (4 LR only, 2 LR and distant metastases). 56 ILC (T1 69%; T2 15% T3 22% ; NO 81%) were treated with BCT without Rx. Mean age 66 years. There were no LR , 2 patients had distant metastases. Conclusions: Using strict selecting criteria with a standardized breast conserving surgical procedure, thorough histological examination and using all breast imaging possibilities risk adapted BCT for ILC are not more likely to fail than BCT of other types of breast cancer. These results support the use of BCT for ILC patients. No significant financial relationships to disclose.

Selecting patients for breast‐conserving therapy

Concerns exist regarding the ability to select patients with lobular carcinoma for breast-conserving therapy (BCT) using mammography. The purpose of this study was to compare the conversion rate from BCT to mastectomy among patients with lobular (ILC) and ductal carcinoma (IDC), and to compare the number of resections needed to obtain negative margins. In all, 349 patients with pure or mixed ILC were identified from a database and 318 were successfully matched to 2 controls with IDC on the basis of year of diagnosis, menopausal status, and stage of disease. Conditional logistic regression was used to control for matching. Patients with ILC were older, had larger tumors (2.6 vs. 2.1 cm; P<.001), and were more likely to have contraindications to BCT (25% vs. 20%). In patients thought to be candidates for BCT, no difference in success rate was noted on the basis of histologic type after controlling for age and stage. In those undergoing BCT, no difference in the number of procedures was seen on the bases of histology after adjustment for age and stage. Patients with ILC are not more likely to fail BCT than those with IDC, nor do they require more operations to obtain negative margins. These results do not support the use of more extensive preoperative evaluation such as magnetic resonance imaging in patients with ILC.

Incidentally detected lesions on contrast‐enhanced MR imaging in candidates for breast‐conserving therapy: Correlation between MR findings and histological diagnosis

To investigate the correlation between MR findings and the histological diagnosis of incidentally detected lesions in candidates for breast-conserving therapy. MR images of 299 patients with breast cancer were reviewed. Incidentally detected lesions were noted in 59 of 299 (20%) patients, and a histological diagnosis was obtained in 48 of 59 (81%) patients. There were 25 benign and 23 malignant lesions. The number, size, location, morphologic character, and kinetic curve assessment of the MR findings were analyzed. Statistical analyses were performed to determine whether any differences could be observed between benign and malignant lesions. Lesions of over 10 mm tended to be malignant (11/16; 69%), whereas those equal or less than 5 mm tended to be benign (12/17; 71%; P < 0.05). Lesions in the same quadrant as the main lesion tended to be malignant (20/27.5; 73%), whereas those in a different quadrant tended to be benign (17.5/20.5; 85%; P < 0.001). Lesions with early peak of enhancement tended to be malignant (20/25; 80%), whereas those with persistent enhancement tended to be benign (20/23; 87%; P < 0.001). Incidentally detected lesions that are found in a different quadrant from the main lesion, are smaller than 10 mm in diameter, and show persistent enhancement on MR imaging suggest benign lesions. Therefore, patients with such lesions should avoid unnecessary surgical procedures unless lesions are proved to be malignant by cytology or biopsy.

Phase II study of dose-dense sequential doxorubicin and docetaxel for patients with advanced operable and inoperable breast cancer

Rapid sequential delivery of doxorubicin 75 mg/m2 q 2 weeksx3 cycles followed by docetaxel 100 mg/m2 q 2 weeksx3 cycles, with filgrastim support was evaluated in patients with inoperable and large operable breast cancers who were not initially candidates for breast conservation therapy. Postoperative CMF chemotherapy and/or radiation were administered based on surgical findings. Median age of the 39 enrolled patients was 47 (range 27-59), stage IIA (6 patients), IIB (14 patients), IIIA (10 patients), IIIB (9 patients), and 23 patients (59%) had clinical nodal involvement. The average bidimensional tumor size before treatment was 30 cm2. Clinical responses included 13 (33%) complete responses, 23 (59%) partial responses, 1 stable disease, and 2 progressive disease, for an overall response rate of 92%. Clinical response rate was 11/13(85%) in HER2/neu positive patients compared to 25/26 (96%) in tumors that did not express HER2/neu. Twenty patients (51%) underwent breast conservation surgery. Pathologic tumor response at the time of definitive surgery included 4 pathologic CR (pCR, 10%), 4 microscopic invasion (pINV), and 14 (36%) pathologically negative axillary nodes. pCR was not observed in any HER2/neu positive patients. 5/39 patients were unable to complete all cycles of docetaxel and 8 patients required dose reduction of docetaxel due to development of grade 3-4 mucositis and hand-foot syndrome. This observation prompted a protocol change requiring 3 weeks between doxorubicin and docetaxel. Primary chemotherapy with dose-dense doxorubicin and docetaxel given sequentially is well tolerated and allows a high rate of breast sparing in patients with large breast cancers.

Clinicopathologic features and long-term outcome of patients with medullary breast carcinoma managed with breast-conserving therapy (BCT)

The purpose of this study is to compare the clinical characteristics and outcome of medullary carcinoma to infiltrating ductal carcinoma of the breast in a large cohort of conservatively managed patients with long-term follow-up. Chart records of patients with invasive breast cancer managed with breast-conserving therapy (BCT) at the therapeutic radiology facilities of Yale University School of Medicine before 2001 were reviewed. Forty-six cases (1971-2001) were identified with medullary histology; 1,444 patients with infiltrating ductal carcinoma served as a control group. The medullary cohort presented at a younger age with a higher percentage of patients in the 35 years or younger age group (26.1% vs. 6.6%, p < 0.00001). Twelve patients with medullary histology underwent genetic screening, and 6 patients were identified with deleterious mutations. This group showed greater association with BRCA1/2 mutations compared with screened patients in the control group (50.0% vs. 15.8%, p = 0.0035). The medullary cohort was also significantly associated with greater T stage and tumor size (37.0% vs. 17.2% T2, mean size 3.2 vs. 2.5 cm, p = 0.00097) as well as negative ER (84.9% vs. 37.6%, p < 0.00001) and PR (87.5% vs. 48.1%, p = 0.00001) status. As of February 2003, median follow-up times for the medullary and control groups were 13.9 and 14.0 years, respectively. Although breast relapse-free rates were not significantly different (76.7% vs. 85.2%), 10-year distant relapse-free survival in the medullary cohort was significantly better than in the control group (94.9% vs. 77.5%, p = 0.028). Despite poor clinicopathologic features, patients with medullary histology demonstrate favorable long-term distant relapse-free survival. Local control rates of patients with medullary and infiltrating ductal carcinoma are comparable. These findings suggest that patients diagnosed with medullary carcinoma are appropriate candidates for BCT and are associated with favorable long-term prognosis.

Assessment of Suspected Breast Cancer by MRI: A Prospective Clinical Trial Using a Combined Kinetic and Morphologic Analysis

The objective of our study was to assess the incremental value of contrast-enhanced MRI in the diagnosis and treatment planning using both a three-time point kinetic and morphologic analysis in addition to mammography and sonography in patients thought to have early-stage breast cancer. Contrast-enhanced bilateral breast MRI was performed prospectively on 65 patients with highly suspicious imaging findings (BI-RADS category 4 or 5). All enrolled patients were believed to be candidates for breast conservation on the basis of clinical examination, mammography, and sonography. The primary index lesion's characteristics, size, and extent were assessed. Also, additional lesions detected by MRI that could represent potential malignancies in both the ipsilateral and contralateral breast were evaluated. Morphologic assessment and kinetic analysis were performed on each lesion using dedicated postprocessing and display software. The patients were reevaluated as to whether they were still candidates for breast-conservation therapy after the MRI examination and subsequent biopsies. There were 46 patients (71%) whose primary breast lesion (detected by mammography, sonography, or both) was found to be malignant (39 invasive breast cancers, five intraductal cancers, and two lymphomas). For the primary index lesions, the sensitivity for MRI was 100% (44/44) for predicting a breast malignancy and the specificity was 73.7% (14/19) for predicting benign lesions. MRI detected an additional 37 lesions, of which 23 were cancerous, beyond those suspected on mammography or sonography. One or more additional ipsilateral breast cancers were detected in 32% (14/44) of breast cancer patients and contralateral breast cancers in 9% (4/44) of the breast cancer patients. MRI also resulted in an incremental recommendation of mastectomy in 18% (8/44) of the pathologically confirmed breast cancer patients. MRI resulted in additional biopsy of only 14 benign lesions, six of which were shown to be atypical ductal hyperplasia. When added to the standard evaluation of clinical examination, mammography, and sonography in patients thought to have early-stage breast cancer, contrast-enhanced MRI using both a kinetic and morphologic analysis will often result in changes in recommended patient management and better treatment planning and will result in no significant increase in biopsies of benign lesions. In addition, there is a significant detection rate of occult contralateral breast cancers.

MRI before reexcision surgery in patients with breast cancer.

The aims of this study were to assess the diagnostic accuracy of MRI in evaluating patients for residual cancer, identify the prevalence of multicentric or multifocal disease, and evaluate the impact of MRI on surgical treatment planning. SUBJECTS AND METHODS. Of 101 potentially eligible patients, 80 candidates for breast conservation therapy who had primary breast cancer in 82 breasts diagnosed by excisional biopsy with close or positive margins were included in the study group. All patients underwent contrast-enhanced MRI before further surgery and subsequently underwent either reexcision lumpectomy or mastectomy with histopathologic correlation. Residual carcinoma, either invasive or in situ, was present in 59.8% of the breasts. The sensitivity and specificity of MRI for detecting residual disease were 61.2% and 69.7%, respectively. Twenty-three additional lesions distant from the biopsy site were identified in 19 breasts, and 18 suspicious lesions underwent biopsy. Histology results indicated that six lesions were malignant, so the overall prevalence was 7.3%. The positive predictive value of identifying an additional suspicious lesion was 33.3%. In 24 breasts, MRI changed which procedure would be performed next from reexcision lumpectomy to mastectomy (n = 9), biopsy of an additional lesion in the ipsilateral (n = 12) or contralateral (n = 2) breast, or neoadjuvant chemotherapy (n = 1). Approximately 25% of the breasts underwent mastectomy as definitive surgical treatment. Overlap in the appearances of benign and malignant lesions limits MRI evaluation for residual disease. MRI can show additional suspicious lesions that are likely to be multicentric or multifocal disease. These findings changed the original treatment plan for approximately 30% of breasts.

Breast-conserving therapy for ductal carcinoma in situ.

This retrospective analysis evaluates the treatment results and prognostic factors of 114 patients with ductal carcinoma in situ (DCIS) undergoing breast conserving therapy (BCT) at Keio University Hospital Department of Radiology, between 1988 and 1997. A total of 132 patients with DCIS of the breast came to our hospital between 1988 and 1997, and 114 cases were suitable candidates for BCT. All of the patients were female and ranged in age from 26 to 81 years (median 46). Ninety-one patients were premenopausal, and 23 were postmenopausal. Median clinical tumor size was 2.0 cm (0-8.0 cm). Postoperatively 48 cases received 50 Gy/25 fractions of external irradiation to the whole breast via tangential ports. The follow-up period after treatment ranged from 11 to 162 months (median 46.7). The local relapse-free rate and overall survival rate of the 114 patients were 89.5% and 100%, respectively. Local failure and regional nodal failure occurred in 12 and 1 patient, respectively. Radiotherapy was a significant risk factor for local failure (p=0.05). No postmenopausal patients developed local failure, but the difference did not reach statistical significance (p=0.103). The 12 recurrent cases underwent additional surgery and all remain alive without recurrence, to date, i.e., at least 16 months. Breast-conserving surgery plus irradiation is appropriate treatment for DCIS patients.

The unsatisfactory margin in breast cancer surgery

Background: Surgical margin involvement with breast cancer usually results in obligatory reexcision or mastectomy. While unalterable occult host and pathologic factors may interfere with margin clearance during the initial excision, it is possible that alterations in surgical technique might increase the likelihood of obtaining satisfactory margins. Methods: Two hundred and thirty-five patients who were candidates for breast conservation therapy were identified for 1991 and 1996 using the Tumor Registry. Margins were defined as “unsatisfactory” if there was microscopic involvement with tumor or the margin was close at initial excisional biopsy and the surgeon opted for reexcision. Multiple logistic regression analyses of factors associated with margin status were performed. Results: One hundred thirty-two (56%) patients had positive or close (unsatisfactory) margins; this rate increased from 51% in 1991 to 59% in 1996. Patients with unsatisfactory margins underwent more procedures (mean 2.0 versus 1.2; P <0.0001) than patients whose margins were satisfactory. The breast conservation rate for patients with unsatisfactory margins was 64% compared with 99% for patients with satisfactory margins. A multiple logistic regression demonstrated that patients with unsatisfactory margins were 67 times more likely to have a mastectomy than patients whose margins were satisfactory after adjusting for other significant factors ( P <0.0001). The practice of fine needle aspiration biopsy, orientation of specimen margins by the surgeon, and reexcision of tumor at the first operation were statistically significant technical factors in obtaining satisfactory margins. Significant pathology factors were extensive intraductal component (EIC), lobular or ductal extension, and tumor size. Conclusion: These data show that technical factors in the surgical management of breast cancer, as well as biological factors such as EIC, can influence the success of breast conservation.

Breast Conservation Therapy in Patients with Early-Stage Breast Cancer Who Have Undergone a Second Re-Excision of the Primary Tumor Bed: A Report of Four Cases

: For the women with early-stage breast cancer who are candidates for breast conservation therapy, re-excision of the primary tumor bed has commonly been used in patients for several indications. These indications include positive margin or uncertain margin status of the primary excision or residual microcalcifications on postbiopsy mammogram. If the pathology from the re-excision does not confirm negative margin status, mastectomy is generally recommended. This article examines patients who have undergone a second re-excision (i.e., a lumpectomy followed by two re-excisions) who have been treated with breast conservation therapy rather than a mastectomy. From September 1977 to November 1995, 1,562 patients underwent breast conserving therapy at this institution. Seven hundred forty of these patients underwent a re-excisional biopsy because of positive or uncertain margin status or residual microcalcifications after the first excision. Four patients (0.5%) underwent a second re-excision because of positive or uncertain margin status or residual microcalcifications on mammogram after the first re-excision. The final margin status after the second re-excision of all four patients was negative. The radiation dose was 4,600–5,000 cGy to the whole breast followed by a conedown to bring the total dose to 6,400–6,800 cGy to the primary tumor bed. Follow-up in the four patients was 13 years, 4 years, 14 months, and 8 months respectively. All four patients are clinically without disease and have not had a locoregional recurrence. Cosmesis was excellent in all four patients. One patient had an adriamycin-induced recall reaction causing a cellulitis, which resolved with antibiotics. There were no other complications. Highly selected patients may undergo breast-conserving therapy after a second re-excision. Good outcome and cosmesis can be achieved for this small subset of patients with avoidance of a mastectomy.

Nipple-areolar preservation during breast-conserving therapy for subareolar breast carcinomas.

To determine if women with subareolar breast carcinoma can be successfully treated by breast-conserving therapy consisting of segmental mastectomy that preserves the nipple-areolar complex, axillary lymph node dissection, and postoperative irradiation. Prospective study. Tertiary care cancer center. Twenty-five patients; median age, 56 years; median tumor diameter, 1.4 cm; and median follow-up, 48 months. Breast-conserving therapy for subareolar primary breast carcinoma. Two patients had positive surgical margins of resection, and another patient underwent simple mastectomy after developing a local recurrence. Nipple-areolar distortion was the most common cosmetic deformity after breast-conserving therapy, but overall cosmesis was good. At the most recent follow-up, all patients were free of disease. Patients who have small subareolar primary breast carcinomas without evidence of nipple involvement are candidates for breast-conserving therapy with nipple-areolar preservation.

Patient selection for breast conservation therapy with magnification mammography

Breast-conserving therapy (BCT) is an appropriate treatment for women with breast carcinoma of limited extent. This study was undertaken to determine the ability of microfocal spot magnification mammography to identify women with multifocal or multicentric breast carcinoma who were unlikely to have all gross carcinoma removed with a limited breast resection. Two hundred sixty-three women with mammographically visible ductal carcinoma in situ and stage 1 and 2 carcinoma who were clinical candidates for BCT were evaluated with magnification mammography before undergoing definitive local therapy. Biopsy specimens of additional abnormalities thought to have a greater than 2% risk of malignancy were obtained. Forty-seven women had other abnormalities in the index breast requiring intervention, and 216 had only the primary tumor identified. Mean age, cancer presentation, disease stage, and histologic tumor type did not differ between groups. BCT was successful in 97.2% of women without mammographic abnormalities versus 38% of women with abnormalities (p = 0.001). Clinical characteristics did not differ between patients undergoing successful BCT and those requiring mastectomy. Synchronous contralateral carcinoma was identified in 2.4% of women at risk. Magnification mammography allows accurate preoperative identification of patients requiring mastectomy or quadrantectomy and should be performed before diagnostic biopsy is done.

Low-grade adenosquamous carcinoma. A variant of metaplastic mammary carcinoma.

The prognostic significance of metaplasia in mammary carcinoma has not been well defined. Pseudosarcomatous metaplasia reportedly has an unfavorable impact on survival. Squamous metaplasia may have less effect on outcome except for the high-grade spindle cell form, which is particularly aggressive. This report describes 11 patients with a low-grade variant of adenosquamous metaplastic carcinoma which has a distinctive combination of glandular and squamous differentiation. The average age of the patients was 59 years (range 42-76). The tumors measured 1.5-3.4 cm (average 2.3) and were grossly hard, tan-yellow, and infiltrative. Follow-up in seven cases treated at least 1 year ago averages 3.5 years (range 1-6 years). Four of eight patients treated by local excision alone developed recurrence in the breast in 1-3.5 years. Negative lymph nodes were found in five axillary dissections. There have been no recurrences after mastectomy performed as primary therapy or for recurrence in seven cases. These findings suggest that patients with the low-grade adenosquamous variant of metaplastic carcinoma have a favorable prognosis. They may be good candidates for breast conservation therapy, but this will require adequate excision followed by primary radiotherapy.