Patients Undergoing Radical Mastectomy Research Articles

CEA as a prognostic factor in locally advanced breast cancer patients undergoing neoadjuvant chemotherapy

10705 Background: CEA and CA 15.3 are most commonly used to evaluate disease progression in metastatic and recurrent breast cancer. Only few significant studies showed a potential predictive role of CEA and CA 15.3 in adjuvant or neoadjuvant setting. We evaluated the correlation between tumour markers level at diagnosis and outcome in locally advanced breast cancer patients treated with neoadjuvant chemotherapy. Methods: Patients with locally advanced breast cancer (T > 3.5 cm and T4) at diagnosis entered the study. All patients had to have initial negative staging (chest X-ray, abdominal ultrasonography, bone scintigraphy and CT scan), whereas all patients who developed metastatic disease in sites which were uncertain during initial staging were excluded. Tumour markers at diagnosis were considered negative if CEA was inferior to 5 ng/ml and CA 15.3 inferior to 35 U/ml. All patients received neoadjuvant chemotherapy (4–6 cycles with regimens containing Anthracyclines and Taxanes or FEC). Most of patients underwent radical mastectomy followed by sequential radiation therapy and adjuvant chemotherapy and/or hormonotherapy in hormonal responsive patients. Results: Fifty-three patients entered the study. At a median follow up of 73 months, 35 patients were disease free after adjuvant treatment (group A), whereas 18 patients developed metastatic disease during follow-up (group B). At diagnosis 14 patients had CA 15.3 greater than 34 U/ml (7 in group A and 7 in group B), 6 patients had CEA greater than 5 ng/ml (1 in group A and 5 in group B) and 18 patients had CEA or CA 15.3 greater than normal values (7 in group A and 11 in group B).We analyzed DFS and OS in patients with normal (CEA < 5 ng/ml, CA15.3 < 35 U/ml) and elevated (CEA ≥ 5 ng/ml, CA 15.3 ≥ 35 U/ml) tumour markers at diagnosis; DFS (p = 0.001) and OS (p = 0.03) were significantly reduced in patients with elevated CEA at diagnosis; differences were not statistically significant for CA 15.3 (p > 0.05). Conclusions: CEA levels before neoadjuvant treatment could represent an important prognostic factor and may influence the choice of treatment in locally advanced breast cancer patients . No significant financial relationships to disclose.

Radiotherapy following mastectomy: indication and contraindication of chest wall irradiation

Purpose: To determine in which cases radiotherapy of the chest wall following mastectomy is indicated, based on the local recurrent rate in patients with locally advanced breast cancer. Methods and Materials: From 1984 until 1994, 105 patients who had four or more histopathologically confirmed axillary nodes metastases, or T3-4Nany, were subjected to mastectomy and were administered radiotherapy postoperatively using the hockey-stick field, which included the ipsilateral supraclavicular fossa and internal mammary nodes, except the chest wall. Median age was 51 years old (range, 23 to 82 years old). Eighty-five patients underwent radical mastectomy, 18 modified radical mastectomy, and 2 extended radical mastectomy. Fraction size was 2 Gy/day, the weekly fraction size was 10 Gy and the total dose ranged from 44 Gy to 54 Gy (median 50 Gy). Seventy-four patients were administered adjuvant chemotherapy, and 61 patients were administered hormone therapy. Results: The 5-year disease-free survival rates of the whole study population were 66%. The 5-year chest wall recurrence rates were 10%. The 5-year chest wall recurrence rates of the patients who had no vascular invasion ( n = 19) and the patients who had definite vascular invasion ( n = 38) were 0% and 24%, respectively ( p = 0.036). All the patients who presented chest wall recurrence had four or more axillary nodes metastases. Nine of the 10 patients who presented chest wall recurrence had definite vascular invasion, while there was no information about vascular invasion for the remaining patient. Factors such as age, pathological subtypes, tumor location, estrogen receptors, extent of resection, chemotherapy, and hormone therapy did not influence the development of chest wall recurrence. Conclusion: Among patients with breast cancer who have four or more positive axillary nodes or T3-4Nany, those who have no vascular invasion or less than 4 axillary nodes metastases do not need to be subjected to chest wall irradiation after radical mastectomy.

Malignant hematopoietic breast tumors.

Hematopoietic neoplasms involving the breast, although less common than breast carcinoma, are often clinically indistinguishable from other breast tumors. Microscopically, these tumors can mimic primary carcinoma of the breast, especially in limited material such as needle biopsy specimens. Forty-five hematopoietic breast neoplasms including 21 primary non-Hodgkin's lymphomas (NHLs), 19 secondary NHLs, 1 undetermined NHL, 1 lesion secondary to Hodgkin's disease, and 3 granulocytic sarcomas were reviewed with regard to histologic subtype, morphologic features, and immunophenotype. The median age of patients at presentation was 67 years for those with primary NHLs and 61 years for those with secondary NHLs. The majority of lymphomas were intermediate or high grade. Diffuse large cell type was by far the most common histologic subtype. No lymphomas resembling lymphomas of mucosa-associated lymphoid tissue were identified in this series, suggesting that such lymphomas are rare in breast compared with other sites such as the gastrointestinal tract and lung. Four primary NHLs, 2 secondary NHLs, and 1 granulocytic sarcoma were initially misdiagnosed as carcinomas; three patients underwent radical mastectomy, and at least three other patients nearly received surgical treatment. One primary anaplastic large cell lymphoma of B-cell origin was identified that closely resembled poorly differentiated ductal carcinoma. "Single file" or targetoid patterns with extensive sclerosis mimicking invasive lobular carcinoma was common in lymphomas and was seen in one of the granulocytic sarcomas. In addition, two breast lymphomas, one of B-cell phenotype and the other of T-cell phenotype, showed frequent signet ring cells, which potentially could be confused with lobular carcinoma. Despite a number of recent articles on lymphomas of the breast, it appears that these tumors continue to be confused with carcinomas. Histologic features suggestive of lymphomatous involvement include absence of in situ carcinoma, frequent individual karyorrhectic cells, lymphoepithelial lesions, and cellular discohesiveness.

A century of breast cancer surgery.

Presented are three consecutive breast cancer series totaling 1912 women, treated by three generations of surgeons. All operations were done in one institution over the last 100 years. Most of the early patients underwent radical mastectomy. The 673 patients in the last series were treated by an assortment of different modalities, reflecting the changing therapeutic concepts of the past 25 years. This report is primarily an historical account showing the improvement in operating conditions and survival figures. Of greater scientific significance is the collection of 50 patients with late-appearing metastases (more than 10 years postoperatively) as well as a group of long-surviving patients with advanced stage II disease.

Treatment results in males with breast cancer

Because cancer of the male breast is rare knowledge about its biology and behavior is essentially due to a compilation of pooled experiences. Hence, a continued report of cases appears to be important. Therefore a retrospective review of patients suffering from male breast cancer was carried out. Twenty-four evaluable cases were analyzed. Eight patients (1 patient with bilateral Stage I carcinoma was included) were in Stage I, 7 in Stage II, 2 in Stage IIIa, 4 in Stage IIIb, and 3 in Stage IV. Of 23 patients who were treated with mastectomy, 22 had modified radical mastectomy and postoperative irradiation to the chest wall as well as to the peripheral lymphatic areas in most cases. One patient underwent radical mastectomy. Another patient had an excision biopsy only, followed by irradiation. One of 24 patients received tamoxifen; another received cyclophosphamide, methotrexate, 5-fluorouracil, predisone (CMF) regimen in an adjuvant setting. Local recurrence developed in one of 23 (4%) patients treated with mastectomy and radiation therapy to the chest wall and peripheral lymphatics. Four (17%) patients developed distant metastases. The 5-year overall survival (Kaplan-Maier) was 90% for the entire group, 100% for patients in Stage I–III disease, and 60% in Stage IV disease (P = <0.005). As observed in former reports the stage of disease at initial presentation seems to be a parameter that significantly contributes to survival in male breast cancer patients. To what extent improved local control by adequate local therapy, such as surgery and postoperative radiotherapy, may improve overall survival remains to be discussed.

Long-term risk of sarcoma following radiation treatment for breast cancer

Between 1954 and 1983, 7620 patients were treated for breast carcinoma at Institut Gustave Roussy (France). Of these patients, 6919 were followed for at least 1 year. Out of these, 11 presented with sarcomas thought to be induced by irradiation, 2 of which were Steward-Treves Syndrome, and 9 of which were sarcomas within the irradiated fields. All histological slides were reviewed and a comparison with those of breast cancer was done. The sites of these sarcomas were: parietalwall, 1 case; second costal cartilage, 1 case; infraclavicular region, 1 case; supraclavicular region, 2 cases; internal third of the clavicle, 2 cases; axillary region 2 cases; and the internal side of the upper arm (Stewart-Treves syndrome), 2 cases. The median age of these 11 patients at the diagnosis of sarcomas was 65.8 (49–83). The mean latent period was 9.5 years (4–24). Three patients underwent radical mastectomy and nine modified radical mastectomy. Only one patient received chemotherapy. The radiation doses received at the site of the sarcoma were 45 Gy/18 fr. for 10 cases and 90–100 Gy for 1 case (due to overlapping between two fields). The histology was as follows: malignant fibrous histiocytoma, 5 cases; fibrosarcoma, 3 cases; lymphangiosarcoma, 2 cases; and osteochondrosarcoma, 1 case. The median survival following diagnosis of sarcoma was 2.4 years (4 months– 9 years). Two patients are still alive: one with recurrence of her breast cancer, the other in complete remission, with 7 and 3 years follow-up, respectively. All other patients died from their sarcomas. The cumulative incidence of sarcoma following irradiation of breast cancer was 0.2% (0.09–0.47) at 10 years. The standardized incidence ratio (SIR) of sarcoma (observed n# of cases (Obs)/expected n# of cases (Exp) computed from the Danish Cancer Registry for the same period) was 1.81 (CI 0.91-3.23). This is significantly higher than one, with a p = 0.03 (One Tailed Exact Test). The mean annual excess (Obs-Exp)/100.000 person-years at risk during the same period/(100 000) was 9.92. This study suggests that patients treated by radiation for breast cancer have a risk of subsequent sarcomas that is higher than the general population. However, the benefit from adjuvant radiation therapy in the treatment of breast cancer exceeds the risk of second cancer; therefore, the potential of radiation-induced sarcomas should not be a factor in the selection of treatment for patients with breast cancer.

BREAST CANCER ASSOCIATED WITH PREGNANCY

Three cases of breast cancer associated with pregnancy were reported. Two of the patients died of stage IV disease, 2 months and 17 days after delivery respectively. A third patient underwent radical mastectomy for stage I disease and the pregnancy was terminated by D & C. Then she gave birth to a child 16 months later and is well now, 5 years after surgery. It is said that breast cancer detected during pregnancy or lactation accounts for only 0.4-3.8% of this malignancy and its incidence is 1 per 3000 pregnancies. If it is reviewed for women of childbearing age, the incidence naturally increases to be as large as about 5 to 8 times the figure for entire breast cancers. Correct diagnosis of breast cancer occurring during pregnancy or lactation is often difficult to make owing to hormonal breast changes and tends to be deferred until advanced stages of the disease. However, we can find a lot of reports describing that no significant difference in disease course has been found between pregnant patients and non-pregnant ones, if the both patients groups were compared in the same stage. Accordingly, the more active diagnostic and therapeutic approach is strongly recommended for a breast mass which is formed during pregnancy or lactation.

NINE CASES OF MALE BREAST CANCER WITH REFERENCE TO LITERATURE

Male breast cancer is an uncommon disease and its prognosis is reported to be worse than that of the females. Male breast cancer is an uncommon disease and its prognosis is reported to be worse than that of the females. age was 63.3±15.0 years and the duration between first symptom and treatment was 3.8±4.6 months. The most presenting symptom was a breast lump. Preoperatively, all cases were classified into stage I or II and 8 patients underwent radical mastectomy (standard radical mastectomy in 4 cases, Patey's operation in 2 and Auchincloss' operation in 2) and only lumpectomy was performed in one. Histopathologically, 4 of 7 patients had axillary lymph nodes with positive metastasis. Adjuvant chemotherapy was performed in 6 cases and no adjuvant endocrinotherapy was performed. Consequently, there were 4 cases with recurrence, two of which had local recurrence and the remainings had pulmonary metastasis. As the therapy for pulmonary metastasis, although a variety of chemotherapy and endocrinotherapy was performed, they did not yield complete remission. However, endocrinotherapy such as orchiectomy or tamoxifen regimen seemed to be effective, compared with chemotherapy, because they had minimal responses. Therefore in male breast cancer, endocrinotherapy, especially tamoxifen, should be recommended in the treatment of metastatic disease, as well as for an adjuvant use.

Primary radiation therapy and breast cancer.

Twenty years ago the management of early carcinoma of the breast in the US was routine. Patients underwent radical mastectomy, and, usually, nothing further was done. Since then, various new concepts and approaches have been introduced, and there is now considerable controversy and uncer­ tainty regarding the optimal treatment of this disease. Two major areas of discussion have emerged. The first concerns the limitations of local treatment. Even when breast cancer is apparently local­ ized, a significant proportion of patients manifest distant metastases in the years following local treatment, i.e. breast cancer is a systemic disease in many patients and no local treatment by itself can cure it. It is now clear that some form of systemic therapy, such as chemotherapy or hormonal therapy, will be required to improve the cure rate in this disease. The second major area of discussion concerns the extent of local treat­ ment required. In part, this reflects a recognition of the importance of body image, particularly the loss of a breast, for women in this culture. As a result of these cosmetic as well as functional concerns, surgeons have, for the most part, adopted some form of a modified radical mastectomy with preserva­ tion of one or both pectoral muscles as the standard surgical treatment for early breast cancer. There is increasing evidence that primary radiation therapy without mastectomy is an effective alternative to mastectomy as local treatment. This article reviews the historical background and current status of primary radiation therapy as local treatment for early carcinoma of the breast.

Intraductal "Noninfiltrating" Carcinoma of the Breast

We are reviewing 40 patients with noninvasive intraductal carcients; 10% developed oppostie breast cancer of the invasive variety. Twenty-one patients underwent radical mastectomy in which one patient was found to have a positive axillary node. The 19 remaining patients had total mastectomy alone. No recurrence of death attributed to intraductal carcinoma was found in 39 patients available for follow-up.

Immunologic competence of regional lymph nodes in patients with breast cancer.

In 24 patients undergoing radical mastectomy, the degree of sensitization to breast cancer was compared between lymphocytes obtained from regional lymph nodes and circulating lymphocytes. Using the direct lymphocyte migration inhibition assay a greater immunologic response was observed in regional lymph node lymphocytes as compared to circulating lymphocytes when challenged with breast cancer antigen in vitro. In the breast cancer group, migration inhibition (M.I.) was 21% plus or minus 3% in the regional lymph node (R.L.N.) lymphocytes, as compared to 7% plus or minus 3% in the peripheral blood (P.B.) lymphocytes (p smaller than .01). In the control group M.I. was - 10% plus or minus 2% in the R.L.N. lymphocytes, as compared to - 2% plus or minus 3% in the P.B. lymphocytes (p equal to n.s.) indicating no immunologic response to the breast cancer antigen. A significant delayed hypersensitivity response (M.I.greater 20%) was found in 17/24 regional lymph nodes of the radical mastectomy graoup, as compared to 7/24 in the peripheral blood samples tested in the same group, indicating a superior immune response in the regional lymph node lymphocyte population. These data support the concept that regional lymph nodes in breast cancer patients are immunologically competent, and that the lymphocytes in these nodes are more reactive with a tumor antigen than are the circulating lymphocytes.

Surface immunoglobulin positive lymphocytes in human breast cancer tissue and homolateral axillary lymph nodes.

Surface immunoglobulins were determined on human lymph node lymphocytes by the use of immunofluorescence technique in 59 breast cancer patients undergoing radical mastectomy. In 10 of these cases, lymphocyte surface immunoglobulins were also studied on lymphocytes infiltrating the primary cancer mass. The most outstanding finding was a difference between the IgM lymphocyte populations in the lymph nodes of patients with and without lymph node metastases. When cancer tissue was present in one or more lymph nodes, the tumor-free as well as the tumor-positive nodes showed a higher percentage of IgM positive lymphocytes than did lymph nodes from patients without nodal metastases. The greatest difference was found when IgM lymphocytes from tumor-bearing lymph nodes were compared with those from the lymph nodes of patients without nodal metastases (p is less than .005). The lymphocyte populations infiltrating 5 of the 10 primary cancer masses studied showed no surface immunoglobulins; in the remainder, both IgG and IgM positive lymphocytes were found but in variable proportions. While the findings are not definitive, this is the first study dealing with the quantitation of immunoglobulin specific lymphocytes in the lymph nodes and tumor tissue of patients with breast cancer.

Carcinoma of the breast: Thirty years' experience with radical mastectomy

Seven hundred fifty-seven cases of carcinoma of the breast in women seen on the ward service of The Mount Sinai Hospital from 1933 to 1965 are reported. Five hundred forty-two of these patients underwent radical mastectomy and the long-term follow-up study of these patients is presented. The over-all five and ten year survival rates were 51 and 41.7 per cent, respectively. The five and ten year survival rates for stage I carcinoma was 64.4 and 54.1 per cent, for stage II carcinoma 49.6 and 27.9 per cent, and for stage III carcinoma 15 and 12 per cent. These results indicate that radical mastectomy is effective in treating patients with stage I and II carcinoma of the breast but is of no value in patients with stage III carcinoma in whom survival after radical mastectomy does not differ from that in untreated patients with carcinoma of the breast.

Histologic Malignancy Grading of the Primary Tumour as a Prognostic Factor in Breast Cancer

The prognostic value of the histologic malignancy grading system of Eker et al. (1) has been analysed in a prospective clinical study of 864 female breast cancer patients undergoing radical mastectomy. The percentage of patients with tumour infiltration of the axillary nodes was found to increase with increasing malignancy grade of the primary tumour (9% in grade I, 80% in grade IV). When the axillary nodes were not infiltrated, the recurrence rate was low, regardless of the malignancy grade. When the axillary nodes were infiltrated, the recurrence rate increased with increasing malignancy grade, from 34% in grades I and II up to 67% in grade IV. If the infiltration of the axillary nodes had not been known, the histologic grading of the primary tumour alone would have divided the case material into four prognostic groups with a recurrence rate increasing from 12.5% to 53.3%. In those cases where recurrences developed, however, the speed of progression of the disease did not seem to be related to the malig...

Excision of the internal mammary lymph nodes in the treatment of breast cancer

From 1948 to May 1961, 304 patients underwent radical mastectomy with dissection of the internal mammary lymph node chain at the Cancer Institute of Milan. Out of these, 199 were submitted to extrapleural removal of internal mammary lymph nodes, and 105 to an «en bloc » removal, with sterno-costal toracectomy. Of the 305 cases operated upon by the two different techniques, 72 (23.7 %) had internal mammary metastases. The internal mammary involvement was found to be frequent also in tumours of the lateral quadrants (20%). In addition, it could be demonstrated that a relation exists between size of the mammary tumour and frequency of internal mammary metastases. The latter were present in the 15 per cent of tumours less than 3 cm in diameter and in the 61 per cent of tumours 8 cm or more in diameter. Out of the 156 cases with axillary invasion, 54 (41 %) had also internal mammary metastases. Out of the 148 cases without axillary invasion, 7 (4.7 %) had internal mammary metastases. Of the 165 patients operated upon until 1956 (by extrapleural exeresis not «en bloc » with the primary tumour), 91 (55.5 %) were alive after 5 years. The 5-year survival of cases with axillary metastases only was demonstated to be of the 52.4 per cent, whereas it drops to 13.2 per cent in cases with axillary and internal mammary metastases.