Breast-conserving Therapy For Breast Cancer Research Articles

Impact of radiation therapy on breast-conserving therapy for breast cancer in Japanese women: A retrospective analyses of multi-institutional experience. Kansai Breast Cancer Radiation Therapy Study Group

Whole breast radiation therapy (RT) after breast-conserving surgery is sometimes omitted in Japan; however, its impact on the outcome has not been properly evaluated. A multi-institutional retrospective study was conducted to clarify the impact of RT on local control after breast-conserving therapy (BCT). Data were collected from 3576 patients from 37 participating hospitals, of whom 1763 were eligible for analyses. Five hundred and five patients had ipsilateral breast tumor recurrence (IBTR) and 1258 patients did not. Details of IBTR were available for 245 of 505 patients who had IBTR, the location of IBTR was within or adjacent to the original tumor bed in 168 patients (68.6%). IBTR was salvaged with partial mastectomy in 119 patients (48.6%). Second recurrence in the ipsilateral breast was observed in 27 patients (11.0%). Univariate analyses demonstrated that administration of RT, the resection margin status, hormone responsiveness, T stage, N stage and stage were significantly related to IBTR. Multivariate analysis demonstrated that administration of RT, T stage and N stage were significantly correlated to IBTR. Among them, administration of RT had the largest impact on RT and it decreased the risk of IBTR by 77.3%. Omission of RT had the most significant impact on IBTR. RT should be given as a standard component of BCT.

Intraoperative frozen section analysis for breast-conserving therapy in 1016 patients with breast cancer

Objective We evaluate the number of surgical two-stage procedures after FSA during breast-conserving therapy (clinical false negative result of FSA) and investigate the influence of microcalcifications, small tumour diameter, neoadjuvant therapy and preoperative biopsy on the clinical false negative rate of FSA. Subjects We retrospectively examined 1016 patients after intraoperative FSA during breast-conserving therapy for breast cancer operated between 1995 and 2001 at the Medical University Vienna. Results Only 9% of all patients had to undergo a two-stage operation due to a false negative intraoperative FSA result. The annual local recurrence rate was 1.2% in all patients with no difference between one- and two-stage operated patients. In situ and pT1 lesions were similarly distributed between one-stage and two-stage operated patients. The use of neoadjuvant therapy and stereotactic biopsy (reflecting non-palpable lesions and microcalcifications) were significantly predictive for a false negative FSA result. The use of a preoperative core biopsy, however, reduced the necessity of performing a two-stage operation. Conclusion Our study demonstrates that FSA leads to a low rate of two-stage operations. Small lesions and microcalcifications as well as the occurrence of intraductal cancer cells and neoadjuvant therapy increased while preoperative core biopsy reduced the false negative rate of FSA. Overall local recurrence rates after FSA were acceptable.

Rates of myocardial infarction and coronary artery disease and risk factors in patients treated with radiation therapy for early‐stage breast cancer

Radiation therapy (RT), a critical component of breast-conserving therapy for breast cancer, has been associated with coronary artery disease (CAD) in numerous older studies, but the risk may be lower with modern techniques. Observed rates of cardiac events in 828 patients treated with breast-conserving surgery and RT at the University of Michigan were compared with expected rates. Relations between potential risk factors and actuarial rates of first CAD event were analyzed. Observed risks of cardiac events were lower than expected. The standardized incidence ratio (SIR) of myocardial infarction (MI) was 0.44 (95% confidence interval [CI]: 0.21-0.70). The SIR of MI or CAD requiring intervention was 0.50 (95% CI: 0.27-0.68). With a median follow-up of 6.8 years, 12 (1.4%) patients had at least 1 MI on follow-up and 20 (2.4%) had at least 1 MI or CAD requiring intervention. Median age at first cardiac event was 75.9 years (range, 43.1-91.5). Median interval from RT to occurrence of the first cardiac event was 3.7 years (range, 13 days to 15.4 years). The 10-year cumulative incidence of MI was 1.2% and cumulative incidence of MI or CAD requiring intervention was 2.7%. On multivariate analysis, age, diabetes mellitus, active smoking, and laterality of RT were significant predictors of MI. Age and active smoking were significant predictors of MI or CAD requiring intervention. Patients in this series had lower risk of ischemic cardiac events than expected. Although small in absolute magnitude, patients radiated to the left side did have a statistically significant increased risk of MI. These findings support further investigation of techniques to minimize the long-term cardiac risks faced by breast cancer patients.

Timing of radiotherapy and survival benefit in breast cancer

To look at the optimum timing of radiotherapy in breast-conserving therapy (BCT) in relation to outcome in breast cancer. We analyzed 1473 BCT on 1446 breast cancer patients from our prospective cohort, stage I or II, node-negative, and without adjuvant systemic therapy. Timing was defined as time from lumpectomy till radiotherapy. Patients were categorized into three timing tertiles: 1-36 days, 37-53 days, and 54-112 days. The 10-year local relapse-free survival rates did not show significant differences between the three groups. The 10-year Distant Metastasis-Free Survival (DMFS) was 78.9% for the first tertile, versus 86.1% (HR 0.6; P = 0.009) for the second, and 90.7% (HR 0.3; P < 0.001) for the third. The 10-year Disease-specific Survival (DSS) was 83.8% for the first tertile, versus 90.6% (HR 0.5; P = 0.007) for the second, and 97.2% (HR 02; P < 0.001) for the third. Also in multivariate Cox regression analysis the second (HR 0.6; P = 0.053) and the third tertile (HR 0.3; P = 0.002) had significantly better DSS. Timing of radiotherapy in BCT for breast cancer seems to be highly important in relation to survival. This study shows a 40-70% relative survival benefit with timing after 36 days.

Lymphatic Mapping and Sentinel Lymph Node Biopsy for Patients With Local Recurrence After Breast-Conservation Therapy

Local recurrence (LR) after breast-conservation therapy for breast cancer occurs in 10% to 15% of cases. A subset of these represents biologically aggressive disease, yet prognostic features for identifying this high-risk category are lacking. We hypothesized that lymphatic mapping and sentinel lymph node biopsy would provide useful information regarding dominant lymphatic drainage patterns of patients with LR. Breast cancer case records involving surgery for LR at the University of Michigan from 2002 to 2004 were reviewed. The lymphatic drainage patterns were compared with those of 117 patients who underwent mapping for primary breast cancer. Fourteen LR cases were identified (10 with initial axillary lymph node dissection, 2 with initial sentinel lymph nodes, and 2 with no axillary surgery at the time of primary cancer treatment); lymphatic mapping was performed in 10. The sentinel lymph node identification rate was 90%, the median number of lymph nodes retrieved was 3, and no metastases were detected. Significantly more cases of nonipsilateral axillary sentinel node drainage were observed in mapping procedures performed for LR compared with those for primary breast cancer (67% vs. 15%; P = .001). Lymphatic mapping is feasible in patients undergoing mastectomy for LR and is likely to identify aberrantly located sentinel lymph nodes that would otherwise be overlooked with a conventional completion mastectomy.

Health-Related Quality of Life in Long Term Breast Cancer Survivors Treated with Breast Conserving Therapy: Impact of Age at Therapy

Aim was to compare the functional status in long-term breast cancer survivors related to age at diagnosis and to asses the effects of adjuvant therapy on health-related quality of life (HRQoL). Data were obtained from 370 patients after breast conserving therapy (BCT) at follow-up (F/U) visit. The self-administered EORTC QoL questionnaire (C30) and the breast module (QLQ-BR23) measuring global health, global QoL, physical, role, emotional, cognitive and social functioning, body image, sexual function, future perspective and arm/breast symptoms were used. Patients were grouped according to F/U (12 years, 7 years), age at therapy (< 50 years, 50-65 years, >65 years) and adjuvant treatment (none, chemotherapy, hormone replacement therapy). The global HRQoL was increased in patients with longer F/U (p < 0.01). Physical functioning, role functioning and sexual functioning were decreased in patients being older at therapy (> 65 years, p < 0.01). Increased arm symptoms were noticed in older women at longer follow-up. Younger women at therapy complained financial difficulties at follow-up (p < 0.006). Adjuvant chemotherapy and hormone replacement therapy did not affect physical and mental functioning. Women of different age treated with BCT for breast cancer should be considered at a different risk for HRQoL disturbance at long term F/U in both, physical and psychological dimensions. In clinical practice, specific identification of those women with negative impact of diagnosis and treatment on long term HRQoL would help for targeted interventions. In clinical studies focusing on HRQoL, the compared groups need to be age-adjusted.

Significance of margins of excision on breast cancer recurrence.

Randomized studies have established wide excision and radiation as an equal alternative to mastectomy in the treatment of breast cancer. The early studies mandated pathologically negative margins for those undergoing radiation. The absolute necessity of free margins is uncertain. We evaluated our experience and outcome with breast-conserving surgery and radiation in relation to margin status. Two hundred sixty patients underwent wide excision for breast-conserving therapy for breast cancer. Reexcision was performed in 149 patients. The initial margin status was correlated with the amount of residual found on reexcision and the effect on local failure. The incidence of residual disease on reexcision in patients with initial gross margin involvement, focal margin involvement, and free margins was 30%. Patients with multiple margin positivity had a 65% incidence of residual disease. Only 9% (14/149) of the reexcised patients had more than 3 mm of residual cancer. This was more likely, but not significant, in those with initial margin involvement (11/100 or 11%) than in those with free margins (3/49 or 6%, p= 0.49). The risk of subsequent local failure was 8% (12/143) in those with initial free margins and 5% (6/117) in those with initial margin involvement. Those who had any residual tumor on reexcision had a nonsignificant risk of local failure (13%) compared to those that had no residual on reexcision (4%). Positive margin on initial excision is only slightly more likely to predict for residual cancer than the finding of negative margins. Routine reexcision of patients with positive margins does not significantly increase the chance of local control in patients who receive breast irradiation.

Efficacy of MR Mammography (MRM) in Providing Preoperative Locoregional Information on Breast Cancer: Correlation between MRM and Histological Findings

To assess the efficacy of MRM in providing preoperative locoregional information on patients with breast cancer. MRI was performed on 62 female breast cancer patients. A 1.5T MR-system was used to acquire fat-suppressed T(1)WI, T(2)WI and dynamic-contrast-enhanced images with an SPGR pulse sequence. The extent of the cancer measured with MRM was confirmed histologically in all patients. The size obtained from MRM correlated well with the size obtained histologically, including intraductal spread of cancer (R: 0.853). As for shape, the round/oval type evident from MRM correlated more accurately (R: 0.934) than the ill-defined type associated with a linear and/or clumped enhanced area (R: 0.744). The difference between the size obtained from MRM and the size obtained histologically, including IDS, was less than 15 mm in the majority of patients (93.5%). MRM accurately reveals the extent of cancer, including IDS, and is effective at providing preoperative locoregional information for breast-conserving therapy for breast cancer.

Arm Morbidity after Breast-conserving Therapy for Breast Cancer

This study reports on 110 consecutive patients, mean age 59 years, operated on for partial mastectomy and axillary dissection. Radiotherapy of 50 Gy was administered to 75 of the patients. Most tumours were T1 tumours and all patients were N0. Lymphoedema is defined as an increase in arm volume >10% and impaired shoulder mobility as an impairment of 15 ° compared with the preoperative value. After operation, 21 patients developed lymphoedema, 17 in the radiotherapy group and 4 in the group without radiotherapy; 49% of the patients had reduced shoulder mobility, and of these, 57% were in the radiotherapy group and 30% in the group without radiotherapy. We found a good correlation between the number of patients stating arm swelling and patients with registered lymphoedema. There were fewer patients stating limitation of movement than patients with registered impaired mobility; 31% of patients were still perceiving some pain five years after the operation. We conclude, that breast-conserving therapy in breast cancer is afflicted with a significant arm morbidity that persists for several years after surgery.

Pilot study of high-frequency ultrasound to assess cutaneous oedema in the conservatively managed breast

Cutaneous oedema is a relatively frequent complication in patients treated conservatively for breast cancer. The factors that contribute to this complication have not been precisely determined. We performed a pilot study to assess the usefulness of high-frequency ultrasound as a quantitative measure of cutaneous oedema. Eleven patients undergoing breast-conserving therapy for breast cancer were studied. Both the treated and untreated breasts were examined. Total cutaneous thickness provided a useful measure of cutaneous oedema. The treated breast was significantly thicker than the untreated breast (P < 0.001). The medial aspect of the breast was thicker than the lateral aspect in both the treated and untreated breast (P < 0.001). The increase in cutaneous thickness predated radiotherapy in those patients who had undergone an axillary dissection. Intrapatient variation in skin thickness was much less than interpatient variation in skin thickness (coefficient of variation 6.4% vs. 18.2% for the untreated breast; coefficient of variation 13.9% vs. 30.9% for the treated breast). Increasing cutaneous thickness was associated with decreasing cutaneous echodensity. We were unable to derive quantitative estimates of echodensity. Cutaneous oedema is an important outcome variable following conservative treatment of breast cancer. High-frequency ultrasound is able to quantify this accurately. It can readily detect changes invisible to the naked eye. High-frequency ultrasound should enable the effects of different treatment options (e.g., extent of surgery, radiotherapy, and chemotherapy) on cutaneous oedema to be differentiated and for the time course of oedema to be accurately characterised.

Post-radiation fibrosarcoma of the breast

We report the first case of fibrosarcoma of stromal breast tissue occurring 11 years after breast-conserving therapy for breast cancer. A review of six cases of stromal malignant fibrous histiocytoma is presented, developing between 5 years and 11 years after breast radiation. Since all cases developed in the area of boost irradiation, abandoning the booster dose might reduce the incidence of secondary sarcomas. Treatment of radiation-induced sarcoma should be surgical, with wide excisional margins. A lifelong follow-up is recommended for patients treated with breast-conserving therapy for primary cancer.