Management Of Breast Carcinoma Research Articles

Recent Progress with Breast-Conserving Volume Replacement Using Latissimus Dorsi Miniflaps in UK Patients.

Significant volume loss during breast conserving surgery(BCS)can be anticipated in patients with small breast: tumor ratios, limiting the use of BCS in womenwith smaller breasts or larger tumors. Early experience with autogenous immediate volume replacement(IVR)at the time of BCS led to refinements in the technique, extending its role in clinical practice. The evolution of the technique has been examined, with particular reference to tumor selection, technique and modifications, histopathological findings, and cosmetic, radiological and psychologicalsequelae. Between 1991-1997, 62 patients underwent BCS and IVR using a latissimus dorsi(LD)miniflap. Tumors(diameter 22[ 5-40 ] mm)were located in the upper outer quadrant(29)center(15)upper inner quadrant(17)and lower outer quadrant(1)of the breast. Operations lasted 129(80-245)min, resecting specimens of 144(37-345)g. Margins were positive in 8/62 specimens(13%)and local recurrence was recorded in 5/62(8%), 4 of whom had not received radiotherapy. One local recurrence was treatedby mastectomy(1.8% of whole group)and 4 were treated by re-excision and delayedradiotherapy. The cosmetic, radiological and psychological outcomes of the procedure compared favorably with BCS alone. Breast-conserving volume replacement with LD miniflaps extends the role of BCS without compromising resection, cosmesis or surveillance, and provides a furtheroption in the surgical management of breast carcinoma.

0-36. An assessment of tissue polypeptide specific antigen (TPS) in the management of breast carcinoma

0-36. An assessment of tissue polypeptide specific antigen (TPS) in the management of breast carcinoma

Analysis of Adjuvant Treatment in Postmenopausal Patients with Stage II Invasive Breast Carcinoma: A Pattern of Care Study and Quality Assurance of 431 Consecutive Patients in Oslo 1980–1989

A retrospective study of consecutive radically operated stage II postmenopausal breast carcinoma patients diagnosed in Oslo 1980–1989 is presented. The primary aim was to analyse to which extent the increasing knowledge of the new life-prolonging treatment with adjuvant tamoxifen influenced the clinical routine, and how the national recommendations were followed up. Secondary, the concomitant use of estrogen receptor (ER) analysis during the decade was to be assessed. Eligible were 150 patients without adjuvant treatment, 123 patients with radiotherapy alone, and 158 patients who had received systemic adjuvant hormone therapy. The percentage of patients without any adjuvant treatment decreased from 43% (1980–1983) to 29% (1987–1989) together with decreasing use of radiotherapy. Adjuvant tamoxifen treatment increased from 18% to 51%. In 1989, the year after publication of national recommendations of adjuvant tamoxifen treatment in stage II patients, 43% of the patients who were candidates for adjuvant tamoxifen failed to receive the therapy. Only 58% of all stage II patients had an ER analysis in the study period. The low compliance to a scientifically proven and publicly recommended adjuvant treatment of patients with stage II breast carcinoma is disappointing, as is the low performance of ER determination. To reduce the delay of implementation of new treatment modalities in the management of breast carcinoma a strict quality assurance program is needed.

Flow cytometric analysis of apoptosis and BCL‐2 in primary breast carcinomas: Clinical and biological implications

Analysis of programmed cell death (apoptosis), of bcl-2, a critical regulator of this process, and of the proliferative fraction may provide detailed information on the biologic characteristics of tumor cell populations. To investigate the potential role of these parameters in assessing mammary carcinoma, we adapted flow cytometric procedures for concurrent measurement of apoptosis, bcl-2 expression, and cell proliferation in 54 primary breast carcinomas and correlated the findings with traditional clinicopathologic information. Overall, a significant inverse relationship between apoptosis levels and bcl-2 expression was observed (P = 0.005). Apoptosis levels correlated significantly with DNA aneuploidy (P = 0.03) and S + G2M fractions (P = 0.005) of these tumors. A significant correlation between bcl-2 expression and estrogen receptor positivity (P = 0.05) and DNA diploidy (P = 0.02) was noted. Bcl-2 expression, however, was inversely correlated with S + G2M fractions (P = 0.001). We conclude that analysis of apoptosis and bcl-2 by flow cytometry allows further characterization of tumor cell populations that may be useful for prognostic and therapeutic management of breast carcinoma. © 1996 Wiley-Liss, Inc.

Flow cytometric analysis of apoptosis and BCL-2 in primary breast carcinomas: Clinical and biological implications

Analysis of programmed cell death (apoptosis), of bcl-2, a critical regulator of this process, and of the proliferative fraction may provide detailed information on the biologic characteristics of tumor cell populations. To investigate the potential role of these parameters in assessing mammary carcinoma, we adapted flow cytometric procedures for concurrent measurement of apoptosis, bcl-2 expression, and cell proliferation in 54 primary breast carcinomas and correlated the findings with traditional clinicopathologic information. Overall, a significant inverse relationship between apoptosis levels and bcl-2 expression was observed (P = 0.005). Apoptosis levels correlated significantly with DNA aneuploidy (P = 0.03) and S + G2M fractions (P = 0.005) of these tumors. A significant correlation between bcl-2 expression and estrogen receptor positivity (P = 0.05) and DNA diploidy (P = 0.02) was noted. Bcl-2 expression, however, was inversely correlated with S + G2M fractions (P = 0.001). We conclude that analysis of apoptosis and bcl-2 by flow cytometry allows further characterization of tumor cell populations that may be useful for prognostic and therapeutic management of breast carcinoma.

Ambulatory Surgical Management of Breast Carcinoma Using Paravertebral Block

The authors describe an initial experience using paravertebral block for ambulatory or short-stay operations for breast cancer. Rising hospital costs have focused attention on limiting the length of stay for patients undergoing surgical treatment of breast cancer. Thus far, ambulatory surgery has been limited by side effects and complications of general anesthesia. Paravertebral block offers the potential benefit of effective analgesia, with limited postoperative nausea and vomiting. The medical records of the first 15 patients with breast cancer who underwent 16 major operations for the treatment of breast cancer using paravertebral block were reviewed. Patients were either discharged directly from the recovery room or after overnight hospital admission. The effectiveness of anesthesia, surgical outcome, patient satisfaction, and hospital costs are reviewed. Paravertebral block achieved effective anesthesia for cancer operations of the breast and axilla; conversion to general anesthesia or supplementation with local anesthesia was not required. There was one postoperative hemorrhage, there were two seromas, and there was one superficial wound infection. Sensory block persisted for an average of 23 hours. Postoperative pain was effectively controlled, in fact, nine patients required no postoperative narcotic for pain control. Nausea and vomiting transiently afflicted three patients and prompted overnight observation in one patient originally scheduled for immediate discharge. Fourteen patients (93%) rated their experience as "very satisfactory." Breast operations for the surgical management of breast cancer using paravertebral block can be performed safely, with great patient satisfaction, and with potential for significant cost savings.

Controversies in the Surgical Management of Operable Breast Cancer.

The literature is reviewed regarding the surgical management of breast carcinoma, and controversies are discussed. Several unresolved issues remain in the surgical management of breast carcinoma. First, the optimal surgical treatment of patients who are at increased risk for having internal mammary lymph node metastases remains unknown. Second, it remains controversial whether axillary dissection is therapeutic or merely represents a staging procedure. Third, there is no consensus regarding the optimal extent of resection prior to irradiation in breast-conserving treatment. Nevertheless, breast conservation is generally accepted as a preferable therapy in patients with operable breast carcinoma, while modified radical mastectomy, with or without breast reconstruction offers an acceptable alternative for these patients.

In Vivo Dosimetry with TLD in Conservative Treatment of Breast Cancer Patients Treated with the EORTC Protocol 22881

Two anthropomorphic phantom breasts and six patients with breast carcinoma were irradiated according the prescriptions of the EORTC protocol 22881 on the conservative management of breast carcinoma by tumorectomy and radiotherapy. During the implantation procedure for an iridium-192 boost, three tubes were implanted, enabling the measurement with TLD rods of the dose within the breasts of the phantom and the patients during one fraction of the external x-ray therapy and during the interstitial therapy. Measured doses were compared with calculated values from a 2-D dose planning system. In general a fair agreement was found between the measured and calculated doses in points within the breast for the external beam therapy as well as for the interstitial treatment.

Estrogen receptor imaging with 17α-[ 123I]iodovinyl-11β-methoxyestradiol (MIVE 2)—part I. Radiotracer preparation and characterization

It is important to know the estrogen receptor rate in breast carcinoma management. Thus, an in vivo and atraumatic method would be very useful. Different ligands have been proposed for this. We present here the specific synthesis of 20E- and 20Z-17α-iodovinyl-11β-methoxyestradiols and their biological characterization as estrogen receptor ligands. The two isomers were analysed by current chemical methods (NMR) and purified by HPLC. We carried out an in vivo study with 21-day-old Swiss mice to compare properties of the two ligands. The 20E-MIVE 2 showed the best affinity for estrogen receptors, the uterus-to-blood ratio was 15-fold higher for the trans derivative. We enhanced the in vivo and in vitro properties of the 20E-MIVE 2: the affinity constant was determined by Scatchard analysis, K d = 16 × 10 −10M, and biodistributions were performed with unlabelled estradiol pre-injection. We concluded that 20E-MIVE 2 can be used for a feasibility study in patients with breast carcinoma.

The conservative management of breast carcinoma by tumourectomy and radiotherapy: an EORTC phase III study (22881/10882)

The conservative management of breast carcinoma by tumourectomy and radiotherapy: an EORTC phase III study (22881/10882)

Entrance and exit TL-dosimetry in the conservative treatment of breast cancer: a pilot study for the EORTC-radiotherapy cooperative group

Mailed dosimetry, using thermoluminescent dosimeters, can play an important role in quality assurance procedures in radiotherapy. In 1989, a pilot study was started with the main aim to show the feasibility of this method for the multicentre EORTC trial 22881 on the conservative management of breast carcinoma. Two anthropomorphic breast phantoms and six patients with breast carcinoma were irradiated according the prescriptions of the protocol. TLD measurements of the entrance and exit dose were performed in 6 MV tangential X-ray beams. It proved to be possible to correlate the dose measured in the entrance and exit points of the beams to the calculated dose closely under the surface. A thickness of at least 5 mm bolus material must be applied over the, dosimeters and a distance of at least 3 cm from the lateral and medial field borders must be maintained in order to reach a clinically acceptable accuracy in the measurements.

Rationale for a quality assurance programme in clinical trials of conservative management of breast carcinoma

The EORTC Consensus Meeting held at Tübingen on 13–14 December, 1990 reviewed the treatment sequence in conservative management of early breast cancer from the standpoint of quality assurance. These reports considered the most relevant criteria for evaluating pathology, surgery and radiotherapy techniques, not only for selected institutions participating in prospective randomised trials but also aiming at developing quality control procedures that could be used anywhere for routine standard treatment. This paper lists the various steps justifying quality control procedures in radiotherapy of the breast and actions to be taken according to the score of observed deviations. At last, it includes a discussion of the justification of quality control and of its potential consequences on the results of trial in the EORTC trial 22881/10882 (boost treatment versus no boost in conservative management of early breast cancer) in which the accrual of 1500 patients is planned.

An Overview of Contemporary Management of Breast Carcinoma

Breast cancer mortality has shown little decline over the past several decades. Yet, of all solid tumors, breast cancer remains one of the most responsive tumors to hormonal therapy, radiotherapy, and chemotherapy. Adjuvant chemotherapy, endocrine therapy, or both is effective in stage II patients, but not all patients benefit. Breast cancer is a heterogeneous disease whose biologic behavior is reflected by a variety of prognostic variables. The treatment of advanced breast cancer is still palliative; however, worthwhile complete and partial responses are obtained by using the multimodal therapeutic approach.

The pattern of metastases in Nigerian breast cancer patients

The management of breast carcinoma in Nigeria poses a big challenge as a large proportion of the patients present at an advanced stage. The records of 214 patients with carcinoma of the breast seen at the Lagos University Teaching Hospital between 1971 and 1981 were studied. Of these, 128 developed metastases within 2 years of follow-up. The pattern of metastases and local factors which influenced the results of treatment are discussed.

Internal mammary lymphoscintigraphy in the conservative management of breast carcinoma: An update and recommendations for a new TNM staging

The results of internal mammary lymphoscintigraphy (IML) in 524 patients with breast carcinoma who underwent partial mastectomy, with or without axillary dissection, demonstrate the predictive value of an abnormal lymphoscintigram. There was a significant difference (P less than 0.0005) in actuarial survival between patients with normal and abnormal IML. In view of the increased mortality associated with metastases to both internal mammary and axillary lymphatics compared with involvement of either site alone, and the most favourable outcome in patients with involvement of neither site, it is proposed that the current TNM staging for breast carcinoma should henceforth include the status of internal mammary lymph nodes determined by radiocolloid lymphoscintigraphy. Further refinement of the N status into NA (axilla) and N1 (internal mammary nodes) is suggested. Stages I, II, and III should designate, respectively, patients with no evidence of involvement of either lymphatic site, patients with involvement of one or the other site and patients with involvement of both sites. This would constitute a more rational approach to the staging and management of the patient with breast carcinoma and would also provide a more accurate means of evaluating the true efficacy of current strategies in comparable groups of patients. Unrecognised internal mammary lymphatic metastases have probably confounded the results of past prospective trials.

The relevance of internal mammary lymphoscintigraphy in the management of breast carcinoma.

The incidence, implications, and significance of an abnormal internal mammary lymphoscintigram (IML) in 981 breast carcinoma patients without histologic or clinical evidence of axillary metastases is reported. A 13%-16% incidence of parasternal abnormality in patients with early, operable disease correlates well with clinical data. The statistically significant increase, with P consistently less than or equal to 0.005, in incidence of local or distant relapse associated with an abnormal IML when compared to the normal IML emphasizes the value of the procedure as a marker. These results indicate that patients with negative axillae but an abnormal IML should be considered to have stage II disease and should be offered adjuvant therapy. The significance of the IML in determining the true extent of disease in patients with apparent local relapse as well as the prognostic implications of an abnormal IML in 311 patients seen initially with recurrent breast carcinoma is also reported.

Internal mammary lymphoscintigraphy: Current status in the treatment of breast cancer

In the management of breast carcinomas, the internal mammary lymphoscintigraphy represents a simple, nontraumatic and reproducible technique to visualize and investigate the internal mammary nodes. As suggested by the total absence of visualization of nodes on the operated side in all or in the two upper intercostal spaces, internal mammary chain invasion concerns 30% of the population. This frequency increases with the clinical staging of the tumor, its size, and the extent of the disease in the axilla. It is higher for tumors of inner rather than of outer quadrants. When internal mammary lymphoscintigrams are compared in frontal view to the limits of the usual irradiation fields, parasternal nodes outside these limits or in borderline position are observed in 15 to 34% of the population according to the X-ray technique used. Furthermore, 40% of the tangential irradiation fields does not give an adequate irradiation dose to the internal mammary nodes. In one case out of four, IMLSc allows the reduction of useless heart- and lung-irradiated volumes. Internal mammary node invasion as demonstrated by lymphoscintigraphy has been demonstrated to have a prognostic value as the anatomopathological axillary node status, concerning both survival and disease evolution rates. IMLSc, when compared to the other possible investigation techniques of these nodes (X-ray computed tomography, echography or surgery, etc.), represents at the present time the investigation method of choice with the widest implications (diagnostic, therapeutic, and prognostic).

Conservative management of breast carcinoma. The Créteil experience.

The results of conservative management of breast carcinoma are presented. The disease free survival for patients with T1 lesions was 84 per cent at 5 years, 76 per cent at 7 years and 65 per cent at 10 years, for T2 75, 71 and 64 per cent, and for T3 65, 51 and 45 per cent. The proportion of breast conserved amongst the patients free of disease at 10 years was 94 per cent for T1, 93 per cent for T2 and 80 per cent for patients with T3 lesions. The cosmetic results were very good for T1 lesions, good for T2 and quite good for T3 lesions. Up to 1981 a simple tumorectomy was carried out in most of the T1 lesions and some of the T2 lesions, followed by radical irradiation. Most of the T2 and T3 lesions were exclusively treated with radical irradiation. In an attempt to improve the cosmetic results, since 1981, the indications for tumorectomy were extended to include some of the T2 lesions, and when possible also some of the T3 lesions, where a tumorectomy is performed before or after irradiation, together with a limited axillary dissection.

The management of breast carcinoma by primary radiotherapy at Mount Sinai Hospital from 1962–1979

The management of breast carcinoma by primary radiotherapy at Mount Sinai Hospital from 1962–1979

The management of breast carcinoma in pregnancy and lactation.

Until recent years, the prognosis for breast cancer in pregnancy and lactation was regarded as grave. The current new data suggest that pregnant women with early breast carcinoma may be treated in the same way as nonpregnant women without affecting pregnancy. However, women with breast cancer in their first trimester of pregnancy and in whom axillary lymph nodes are involved, should receive chemotherapy and have their pregnancy terminated. Toward the end of pregnancy, adjuvant therapy, when needed, can be delayed until after delivery. In patients with advanced disease pregnancy should be terminated and subsequent treatment initiated. During lactation, diagnosis of breast carcinoma requires suppression of lactation by means other than estrogens. The carcinoma will be treated by standard methods. After radical mastectomy for breast cancer, subsequent pregnancies are allowed but should be delayed until the period of greatest risk has passed.