Radiotherapy For Breast Carcinoma Research Articles

Surgical solution of the extensive post-radiation defect developped 33 years after radiotherapy for breast carcinoma − case report

Introduction: Damage of the skin and its underlying structures is a common side effect of radiotherapy. These conditions limit further treatment and dealing with these complications is a routine practice of clinical oncologist. The majority of the complications are immediate, with a perspective of healing ad integrum within a few weeks. Less frequently, but sometimes with severe manifestations, chronic toxicity occurs belatedly after months, or even many years after irradiation, in form of post-radiation ulcer, for instance with potential of secondary malignant transformation. Regarding surgery, it might be one of the most challenging chronic wounds to treat. In extreme cases, extensive resection of the entire affected area is needed, inevitably ending with demanding reconstruction of the resulting defect. Case report: This case report presents a female patient with rapidly progressive post-radiation chest wall defect 33 years after the irradiation, when relatively insignificant skin injury occured. Prior to this sudden deterioration, only long-term, non-progressive changes, without a cutaneous defect, were described during the dispensarisation. After a protracted outpatient treatment with unsatisfactory results, when the patient repeatedly refused mastectomy, the condition inevitably led to the complex surgical procedure with necessary cooperation of breast, plastic and thoracic surgeons. Conclusion: Although changes of the similar severity rarely occur even after many years following the treatment, we haven‘t found such a dramatic change of the patient’s condition three decades after the therapy with urgency of this type of complex, surgical intervention in current literature.

Effect of Graded Thera-Band Exercises on Shoulder Muscle Strength and Activities of Daily Life in Modified Radical Mastectomy Subjects

Modified radical mastectomy leads to dissection of muscles and soft tissue structures and chemotherapy causes weakness of the muscles involved resulting in functional limitations that affects the activities of daily life. Graded resistance exercise is effective in improving muscle strength, functional capacity and activities of daily life. To find the effect of graded thera-band exercises on shoulder muscle strength and activities of daily life in modified radical mastectomy patients. A total of 40 females who underwent mastectomy procedure along with chemotherapy or radiotherapy for breast carcinoma were included based on inclusion criteria. Group A received conventional strengthening program with weights and group B received thera-band exercises for five days per week for eight weeks and pre and post assessment was done with Disabilities of Arm, Shoulder and Hand(DASH) Questionnaire and Manual Muscle Testing(MMT). Statistical results within group values for Conventional strengthening program for DASH (p = <0.0001) and mean difference(MD) was 2.58, MMT for Shoulder flexion (p=0.867),MD= -0.15 and extension(p=0.046),MD= -2, abduction (p=0.775),MD= -0.3, internal rotation (p=0.701),MD= -0.35 and external rotation (p=0.039),MD= -1.65. The within group statistical results for experimental group for DASH (p=<0.0001),MD=4.98 , MMT for Shoulder flexion (p=0.012),MD= -2.05, extension (p=0.0007),MD= -2.1 and external rotation(p=0.036),MD= -2.2, abduction (p=0.055),MD= -1.65 and internal rotation (p=0.051),MD= -1.4 . The results conclude that strengthening with thera-band showed more better effect compared to conventional strengthening program. Strengthening exercise program with thera-band showed significant improvement in the outcome variables on strength and activities of daily life involving shoulder, arm and hand.

18F-FDG PET/CT in Patients with Parenchymal Changes Attributed to Radiation Pneumonitis

Objectives:Radiation pneumonitis (RP) can be an adverse complication of radiotherapy (RT) and can limit the application of the already planned radiation dose. It is often associated with RT of lung carcinoma and is occasionally caused by radiation therapy of breast carcinoma and lymphomas located in the mediastinum. Positron emission tomography/computed tomography (PET/CT) emerges lately as a prospective modality for early diagnostics of RP. The aim of this study was to summarize the initial data from diagnostic application of PET/CT in patients suspicious of RP and to derive criteria, which can help differentiate RP from early recurrence of the disease and/or residual tumor.Methods:The current study included 23 patients who had metabolic (PET) and anatomical (CT) changes consistent with RP. We additionally defined metabolic activity (SUVmax) in the lung parenchyma of 20 patients without RT.Results:All patients had increased metabolic activity in the lung parenchyma involved in the irradiated area with a mean SUVmax 3.45 (ranging between 1 and 7.1). The control group had a physiological background metabolic activity-SUVmax 0.61 +/- 0.11.Conclusion:Metabolic changes in patients suspicious of RP involved diffusely increased metabolic activity coinciding with the anatomical changes in the irradiated area. Three out of 23 patients had a proven recurrence of the primary neoplastic process in the irradiated area. The metabolic changes in those patients involved an increase in metabolic activity at follow-up or lack of tendency towards normalization after chemotherapy, which implied the existence of viable tumor cells. Our initial experience in the diagnostic application of 18F-FDG PET/CT in patients suspicious of RP allows us to summarize the following: PET/CT is a reliable imaging modality in the diagnostics of RP. Through its sequential use, we can differentiate inflammatory changes related to RP from early recurrence of the primary neoplastic process.

Retrospective Analysis of Efficacy and Toxicity of Hypo-fractionated Radiotherapy in Breast Carcinoma

The conventional dose fractionation of adjuvant radiotherapy (RT) to whole breast is 45-50 Gy in 25 fractions as 1.8-2.0-Gy per fraction. Lumpectomy cavity with a 1.5-2-cm margin receieves additional 10- 16 Gy doseas boost. Alternative dose fraction schedules used in various randomised trials have established the role of hypofractionated radiotherapy (HRT) in early breast cancer. HRT allows time and cost saving thus better patient compliance. However the efficacy and toxicity of HRT in locally advanced breast cancer is still under evaluation. To study the toxicity and efficacy of Hypofractionated Radiotherapy (HRT) as compared to Conventional Radiotherapy (CRT) in breast cancer at our centre. A retrospective analysis of breast cancer patients treated between October 2012- September 2014 with adjuvant radiation therapy as CRT or HRT. The data of these patients was retrieved and analysed regarding demographic profile, stage at presentation, pathological type, extent of surgery, chemotherapy, efficacy and toxicity of HRT. The toxicity assessment was done as per RTOG toxicity criteria. The data were analysed using SPSS software version 20.0. A total of 100 patients with carcinoma breast who received radiotherapy over two years were analysed. Age ranged from 18-90 years, mean 49.15 ± 12.7 years. Fifty-five patients were post-menopausal, predominant clinical feature was painless lump in the breast (98%). Early stage (Stage I and II) constituted 41%, locally advanced disease in 59%. Modified radical mastectomy was done in 75%, breast conserving surgery in 25%. A 56 patients received HRT and 44 were treated with CRT. The most common acute toxicity was skin grade I. An 18% patients in HRT arm and 30% patients in conventional arm developed grade II skin toxicity (p=0.23). Dysphagia grade I was seen in 10% cases in CRT arm and 12% in HRT arm. The median follow-up period was 11.3 months with 2 loco-regional failures in each arm. HRT seems to be equally efficacious and no more toxic than CRT in carcinoma breast even in unselected sub-group of patients.

Molecular Profiling of Angiosarcomas of the Breast

ABSTRACT Aim: Angiosarcoma of the breast is a rare, aggressive soft tissue neoplasm occurring as either a primary or secondary malignancy due to previous radiotherapy for breast carcinoma. There is an unmet medical need for targeted therapies for angiosarcoma. Methods: Seventeen patients with angiosarcoma of the breast were identified (Caris Life Sciences) and profiled for biomarkers of drug response using multiplatform methodologies (Tumor DNA sequencing, gene copy number alterations, RNA/microarray and protein/IHC expression). Results: Eight primary, 5 post-radiation and 4 mammary angiosarcomas of unknown etiology were identified in women (age 31-85 years), all exhibiting multiple biomarker alterations. Eight out of 17 cases (47%) harbored overexpression (mRNA and/or protein) of the genes [VEGFR2 (5/17), PDGFRA/PDGFRB (3/17), c-KIT (2/17)] that can be targeted by multikinase inhibitor Sunitinib. Based on the VEGFR2 overexpression, one patient with recurrent, refractory angiosarcoma was treated with Sunitinib resulting in a complete remission and is disease free at 14 months. Also, multiplatform molecular profiling revealed useful predictors of various other treatment modalities including anthracyclines (overexpression of topoisomerase 2a in 69%), topo 1 inhibitors (topoisomerase 1 overexpression in 44%), and fluoropyrimidines (low levels of thymidylate synthase in 29%). One case devoid of the Sunitinib-associated genetic alterations harbored a KRAS mutation indicating a potential benefit of MEK inhibitors. Conclusions: A comprehensive molecular profiling of breast angiosarcomas enables identification of various molecular alterations that can be treated by both targeted and conventional treatment modalities. Disclosure: All authors have declared no conflicts of interest.

Clinicopathological and immunohistochemical study of 30 cases of post-radiation atypical vascular lesion of the breast

Atypical vascular lesions (AVL) that occur in the field of prior radiation therapy for breast carcinoma are placed within the differential diagnosis with low grade angiosarcoma and other benign vascular lesions. Although considered a benign entity, the exact biological behavior of AVLs is not fully established because of the small number of cases reported in the literature. We aim to further characterize these lesions clinically and histopathologically, and to study their behavior. We report a series of 30 patients with AVL of the breast occurring after radiation exposure, diagnosed and treated at the European Institute of Oncology, Italy. Immunohistochemical study was performed in all cases, using CD31, D2-40, CD105, and Ki-67 antibodies. Twenty-seven patients were treated with standard doses of conventional adjuvant radiation therapy for the prior breast carcinoma. Three patients were treated with intraoperative radiotherapy with electrons. The post-radiation latency interval from breast carcinoma to AVL was 48.5 months (ranged from 1 to 146 months). Most of the lesions were classified as lymphatic type (78.6 %) based on D2-40 positivity. No extension into subcutaneous tissue or significant atypia was noted in all cases. Despite the fact that the AVL of our series have shown benign behavior in 93.3 %, one patient developed local recurrence of AVL, and two cases progressed to angiosarcoma at the previous AVL site. Further studies should be conducted to better understand the clinical behavior and to propose additional histopathologic diagnostic criteria to distinguish AVL from low grade angiosarcoma and those AVL with increased risk for malignant progression. Concerning current treatments of AVL, we recommend complete excision with free surgical margins and close follow up.

Sarcoma of the Breast: Outcome and Reconstructive Options

IntroductionSurgery is the mainstay of treatment for all breast sarcomas. The role of adjuvant chemotherapy and radiation therapy has not been clearly defined. The aim of this single-center retrospective study was to analyze prognostic factors, outcome, and recent advances. Materials and MethodsData from 203 patients with all breast sarcomas treated in a single center were collected from 1996 to 2010. Phyllodes tumors and metastatic disease at presentation were excluded from the population. Thirty-six women and 1 man were included in the analysis. Local recurrence, metastatic disease, survival, and reconstructive outcome were evaluated. ResultsThirty-four patients out of 37 (91.9%) had an angiosarcoma and 3 had a stromal sarcoma (8.1%). Twenty-one patients (56.8%) had previously undergone breast radiation therapy for breast carcinoma or lymphoma. Twenty-six patients (70.3%) underwent mastectomy, 14 of whom (53.8%) with breast reconstruction. Thirty-six patients (97.3%) had free margins, 1 (2.7%) had a microscopically focally involved margin after surgery. Five patients received adjuvant chemotherapy and 6 received adjuvant radiation therapy. Median follow-up was 58 months (range, 4-146 months). Twelve sarcoma-related deaths were observed with a 5-year cumulative incidence of 43.4%. Twenty-four sarcoma-related events were observed with a 5-year cumulative incidence of 70.8%. The same figure was 49.7% in patients affected by primary sarcoma and 85.7% in patients with secondary sarcoma (P = .06). ConclusionSecondary sarcomas were associated with a higher risk of events. Patients undergoing breast conservative surgery or reconstruction after mastectomy did not show a worse prognosis compared with patients undergoing mastectomy.

Atypical Vascular Lesions of the Breast: Clinicopathological and Immunohistochemical Study of 24 Cases from a Single Institution

INTRODUCTION: Atypical Vascular Lesions (AVL) of the breast after radiation exposure show heterogeneous clinical and histopathologic features. Most data on outcomes reported previously favored a benign process, but some studies have challenged this concept, suggesting that AVL and post-radiation angiosarcoma represent a morphologic continuum, implying AVL as a precursor to angiosarcoma. However, the risk of malignancy is still undefined due to small number of reported cases with follow-up information. OBJECTIVES: To characterize AVL of the breast clinically and histopathologically, and to study their behavior, trying to establish whether they are a true benign process or a risk factor for developing angiosarcoma. MATERIAL AND METHODS: All cases of AVL of the breast diagnosed at the Department of Anatomic Pathology at the European Institute of Oncology (EIO), Milan, from 1999 to 2009 were selected. Histo-pathologic review and immunohistochemical studies for podoplanin (D2-40), CD31, Ki67 and endoglin (CD105) were performed. RESULTS: Twenty-four female patients treated at the EIO were diagnosed with AVL of the breast after radiotherapy for breast carcinoma. The median age was 58 years old (range: 36-81 years), and AVL size ranged from 0.3cm to 1.1cm (median, 0.5cm). The latency interval between radiotherapy and AVL diagnosis was 49 months (range: 17-124 months). The most common clinical presentation of AVL was an erythematous or violet unique papule in the irradiation field (62.5% of the cases). Microscopically, AVL did not infiltrate the subcutaneous tissue and did not have endothelial multilayering, prominent nucleoli, mitoses or lakes of blood. A patchy chronic inflammatory infiltrate accompanied all AVL to varying degrees. Thirteen cases were classified as lymphatic type (LT) AVL and 11 cases as vascular type (VT) AVL, according to positive staining for D2-40. The endothelial cells stained for CD31 (18 cases), Ki-67 (5 cases), and CD105 (12 cases). One patient with VT-AVL with positive margin developed local recurrence. Two patients, one with VT-AVL, and the other with LT-AVL with compromised margin, developed high grade angiosarcoma in the previous biopsy site, 19 and 89 months later, respectively. Both cases showed overexpression of Ki-67 in the endothelial cells of the AVL. Margin involvement was associated to unfavorable outcome. DISCUSSION: Our data indicate that post-radiation angiosarcoma and AVL may represent a morphologic continuum. AVL cases of both types, VT and LT-AVL, showed similar risk of progressing to angiosarcoma, as well as AVL with high Ki-67 expression. CONCLUSION: Although our data are not conclusive, the development of local recurrence and subsequent angiosarcoma indicate that AVL must be completely excised, with free surgical margins, and patients must be accompanied by clinical exams and imaging until the natural history of the AVL is better explained.

Lésions vasculaires atypiques et angiosarcomes post-radiothérapie : 11 cas

Post-radiation atypical vascular lesions of the skin display clinical and morphological overlap with well-differentiated angiosarcomas, and correct diagnosis may be difficult. We studied clinical, histological and immuno-histochemical aspects (CD31, CD34, D2-40 and VEGFR-3) of eight post-radiation atypical vascular lesions comparatively with three post-radiation angiosarcomas. All patients were female and received radiation therapy for breast carcinoma. On average, atypical vascular lesions occurred 4.3 years after radiation therapy and presented as small papulonodules or erythematous plaques. The clinical course after simple excision was benign. Histologically, they were relatively circumscribed lesions and showed slit-like vessels dissecting dermal collagen in all cases. On average, angiosarcomas occurred 5 years after radiation therapy and presented as more extensive lesions with a more aggressive clinical course. The lesions showed histological overlap with atypical vascular lesions, but were poorly circumscribed, with deeper invasion, cytological atypia and mitosis. Although the immuno-histochemical profiles were similar, expression of VEGFR-3 was greater in two cases of angiosarcoma. Post-radiation atypical vascular lesions are benign lesions that display clinical, histological and immuno-phenotypic overlap with well-differentiated angiosarcoma, and diagnosis requires good clinicopathological correlation. VEGFR-3 may be useful for differential diagnosis, as well as amplification of the MYC gene.

Synchronous Angiosarcoma, Melanoma and Morphea of the Breast Skin 14 years After Radiotherapy for Mammary Carcinoma

With the improvement in survival after breast cancer there has been increasing interest in the long-term effects of radiotherapy, including the development of tumours. Compared with the general population, breast cancer survivors have a 10-50% higher risk of developing a second cancer. Radiotherapy may play a role in the onset of such lesions. We describe here the case of a 68-year-old woman who developed synchronous cutaneous angiosarcoma, melanoma and morphea of the breast skin and the local area, 14 years after radiotherapy for breast carcinoma. Given the risk of post-radiation secondary primaries in breast cancer patients, long-term surveillance is necessary, with particular attention being paid to skin changes in the irradiation field. Radiation-induced morphea is a rare complication in which immunological abnormalities may stimulate malignant transformation. Long-term studies are required to clarify the pathogenesis of these rare associations.

MRI of angiosarcoma associated with chronic lymphoedema: Stewart–Treves syndrome

Cutaneous angiosarcoma is a rare complication of a chronic lymphedematous extremity (Stewart-Treves syndrome). Early recognition of these aggressive tumours is important, as they have a high incidence of local recurrence and metastasis. This report describes the MRI appearance of Stewart-Treves syndrome in a patient with a background of lumpectomy, axillary node dissection and radiotherapy for breast carcinoma. MRI revealed a lobulated cutaneous mass of intermediate signal on T(1) weighted imaging, and low signal on T(2) weighted imaging, with diffuse enhancement following contrast.

Translocation (4;11)(p12;q23) with rearrangement of FRYL and MLL in therapy-related acute myeloid leukemia

Reciprocal chromosomal translocations involving the MLL gene at chromosome region 11q23 are recurring cytogenetic abnormalities in both de novo and therapy-related acute myeloid leukemia (AML) and in acute lymphoblastic leukemia. We report a t(4;11)(p12;q23) with rearrangement of MLL and FRYL (also known as AF4p12), a human homolog to the furry gene of Drosophila, in an adult patient with therapy-related AML after fludarabine and rituximab therapy for small lymphocytic lymphoma and radiation therapy for breast carcinoma. To our knowledge, t(4;11)(p12;q23) has been reported in two previous patients, and MLL and FRYL rearrangement was demonstrated in one of them. Both of the previous patients had therapy-related leukemias after exposure to topoisomerase II inhibitors, whereas our patient had received cytotoxic therapy that did not include a topoisomerase II inhibitor. Thus, t(4;11)(p12;q23) with MLL and FRYL involvement represents a new recurring 11q23 translocation, to date seen only in therapy-related acute leukemias.

Angiosarcoma arising in the breast following breast-conserving surgery with radiation for breast carcinoma

We report a case of angiosarcoma arising in the breast following breast-conserving surgery with radiation therapy for breast carcinoma. The patient, a 49-year-old postmenopausal woman, had undergone breast-conserving surgery for invasive ductal carcinoma of the left breast (pT2 pN0 M0 Stage IIA). Adjuvant radiotherapy (50 Gy with a booster dose to the tumor bed of 10 Gy) was then performed for the residual breast tissue and the patient was treated with hormone therapy (tamoxifen, 20 mg daily) for 5 years. She presented with skin erosion with bleeding 10 years after the initial operation. Incisional biopsy revealed angiosarcoma of the breast, and total mastectomy was subsequently performed. The patient was the treated with chemotherapy (weekly paclitaxel, 80 mg/m2 x cycles) and has remained well without evidence of local or distant recurrence.

Postirradiation Morphea in a Breast Cancer Patient

We present the case of a 52-year-old woman who underwent lumpectomy and radiation therapy for breast carcinoma and 2 years later presented with changes limited to the breast radiation field including hyperpigmentation, retraction, and skin thickening. These clinical features, along with pathologic findings, were diagnostic of postirradiation morphea. It is important to be aware of this rare complication of radiation therapy because it clinically presents with symptoms mimicking malignancy and may be misinterpreted as recurrent carcinoma or even angiosarcoma.

P53 and bcl-xl-apoptotic markers predicting axillary recurrence following axillary radiotherapy in carcinoma of breast

p53 and bcl-xl-apoptotic markers predicting axillary recurrence following axillary radiotherapy in carcinoma of breast

Sarcomes radio-induits après cancer du sein : expérience de l'institut Curie et revue de la littérature

Adjuvant radiotherapy to the breast plays a significant role in preventing local failure in women treated for early stage breast cancer. This fact is supported by multiple clinical trials demonstrating that adjuvant radiotherapy decreases the risk of local recurrence and increases the rate of breast preservation, and actually the rules of adjuvant breast irradiation are clearly established. Sarcomas are a rare but recognized complication of radiation therapy for breast carcinoma, and are associated with poor prognosis. The first case of a bone sarcoma after radiation therapy of breast cancer was described by Beck in 1922. In 1948, Cahan et al. defined the criteria for diagnosis of radiation-induced sarcoma. Since then, some studies have reported the incidence of radiation-induced sarcoma after radiotherapy for different cancers. This article reports and discusses the incidence, management and treatment outcome of radiation-induced sarcomas occurring after radiotherapy for breast cancer in our institute. The incidence, histology, latency of appearance, genesis, their treatment and the prognostic factors of these rare tumors are discussed and the literature is reviewed.

The Capillary Lobule: A Deceptively Benign Feature of Post-Radiation Angiosarcoma of the Skin

Three cases are presented of a proliferative vascular lesion of the skin developing in the chest wall of women who had received radiation therapy for breast carcinoma. All 3 lesions were characterized microscopically by the presence of the so-called capillary lobule, a formation generally regarded as a sign of benignancy but that in this setting proved to be a forerunner or indicator of angiosarcoma (malignant hemangioendothelioma). Therefore, the detection of capillary lobules in irradiated skin ought to be regarded with great suspicion, and other morphologic signs suggestive of angiosarcoma should be sought in the specimen.

Post‐Irradiation Vascular Proliferations: Potential Mimic of Kaposi’s Sarcoma

A variety of benign and malignant cutaneous vascular lesions occur in irradiated skin. We report two cases of vascular lesions that developed on the breast within a year after radiation therapy for breast carcinoma. Both cases mimicked Kaposi’s sarcoma (KS) histologically. We compare these with one case of post‐irradiation angiosarcoma and 3 cases of acquired progressive lymphangioma (APL) unrelated to radiation therapy. The post‐irradiation vascular lesions showed slit‐like vessels dissecting through superficial dermal collagen, leading to an initial diagnosis of KS by one contributing pathologist. Immunohistochemically, the vessels in both cases expressed CD31 and CD34, stained only partially for actin, and had a low Ki67 proliferation index. Neither case expressed HHV8. The post‐irradiation angiosarcoma occurred three years after radiation, and also exhibited a focal slit‐like growth pattern resembling KS. However, there was marked cytologic atypia, a high proliferation rate, and negative staining for HHV8. The APL were characterized by more ectactic vascular spaces and deeper involvement of the dermis than was present in the post‐irradiation lesions. These cases also failed to stain for HHV8. Recognition of the phenomenon of post‐irradiation vascular proliferations is important, especially because such lesions may resemble KS, yet invariably follow a benign clinical course.

Radiotherapy for breast carcinoma: an evaluation of the relationship between the central lung depth and respiratory symptoms

Purpose Treatment for early breast cancer is multimodal with radiotherapy playing a fundamental role. This study investigated the relationship between the depth of lung incorporated in the tangential chest wall fields and self-reported respiratory symptoms. Method A randomised trial was conducted with 350 patients from one radiotherapy centre, randomised to one of two lung depth categories (0–2 cm or 0–2.5 cm). The primary outcome measure was the self-reported incidence of dry unproductive cough (DUC) post-treatment. Results On an intention to treat basis no difference in post-treatment symptoms for DUC could be identified between the two lung depth categories. A logistic regression analysis identified patient age, the use of nodal irradiation, and symptoms of DUC pre-treatment as significant in determining the risk of patients developing symptoms post-treatment. Conclusion These results confirm the importance of considering total volume of lung incorporated in the radiotherapy portals (identified by the relationship between reported symptoms and the use of nodal irradiation). The results of this study serve to further emphasise the need for evidence-based study into the radiotherapy policies employed in the UK.

Early versus late local recurrences after conservative treatment of breast carcinoma. Are there differences in primary tumor characteristics

To investigate whether some aspects of patient or tumor characteristics influence the timing of local recurrence in breast cancer treated conservatively. A retrospective analysis was conducted on patients treated with conservative breast surgery followed by radiotherapy for breast carcinoma, and who developed local recurrence. Out of 2037 cases treated in our Institute, 59 local recurrences were observed within 36 months after treatment, called early local recurrence (ELR), and 87 local recurrences occurred after 60 months, called late local recurrence (LLR). Patient and tumor characteristics were analyzed in the 2 groups and compared. In patients with ELR, the mean age was 53, versus 54 in patients with LLR (ns). Likewise, the menopausal status was evenly distributed in the 2 groups. Primary tumors greater than 20 mm were more frequently found in patients with ELR: 35% vs. 19% in patients with LLR (p = 0.03). Grade 3 tumors were more encountered in patients with ELR: 35% vs. 8% in patients with LLR (p < 0.0001). Tumor ploidy was evenly distributed within the 2 groups. Patients with ELR had tumors with negative estrogen receptors more frequently than patients with LLR: 42% vs. 19% (p = 0.006), and negative progesterone receptors more frequently than patients with LLR: 54% vs. 22% (p = 0.0003). There was no statistically significant difference in the axillary lymph node (LN) status between patients with ELR and those with LLR: respectively 37% and 27% of positive LN (p = 0.18). The specific mortality was higher in patients with ELR: 63% vs. 24% for patients with LLR (p < 0.0001). Unfavorable tumor characteristics as big size, high grade, lack of hormone receptors, but not lymph node status were associated with ELR. The first 3 factors are often linked to tumor cell kinetics. These findings suggest that patients with such aggressive tumor characteristics who do not recur early will have a lower risk of LLR than patients with more favorable factors