Receiving Breast Conservation Therapy Research Articles

Neighborhood socioeconomic status and low-value breast cancer care.

BackgroundThe objective of this study is to examine the association between neighborhood socioeconomic status (nSES) and receipt of low‐value breast cancer procedures.MethodsPatients with breast cancer diagnosed between 2010 and 2016 were identified in the Surveillance, Epidemiology, and End Results (SEER) Program. Low value procedures included: (1) axillary lymph node dissection (ALND) for patients with limited nodal disease receiving breast conservation therapy (BCT); (2) contralateral prophylactic mastectomies (CPM); and (3) sentinel lymph node biopsies (SLNB) in patients ≥70 years old with clinically node negative early‐stage hormone‐positive breast cancer. The cohort was divided by nSES. Univariable and multivariable logistic regression analysis compared the groups.ResultsThe study included 412 959 patients. Compared to patients in high nSES areas, residing in neighborhoods with low nSES (odd ratio [OR] 2.20, 95% confidence interval [CI] 2.0−2.42) and middle nSES (OR 1.42, 95% CI 1.20−1.56) was associated with a higher probability of undergoing low value ALND. Conversely, patients in low SES neighborhoods were less likely to receive low value SLNB (OR 0.89, 95% CI 0.85−0.94) or CPM than (low nSES OR 0.75, 95% CI 0.73−0.77); middle nSES OR 0.91 (0.89−0.92) those in high SES neighborhoods.ConclusionIn the SEER Program, low nSES was associated with a lower probability of low value procedures except for ALND utilization.

Quality of Life in Patients with Breast Cancer following Breast Conservation Surgery: A Systematic Review and Meta-Analysis.

To evaluate the health-related quality-of-life (QOL) outcomes in surgical breast cancer survivors who received breast conservation therapy (BCT) compared to mastectomy, we utilized a systematic review to conduct observational studies of QOL in patients with breast cancer following breast conservation therapy from their inception until October 2021. The PubMed, the Cochrane Library, and the Web of Science databases were systematically searched to retrieve the observational studies. The pooled odds ratios (ORs) with 95% confidence intervals (CIs) were applied as an effect estimate and calculated using Stata 15 software. Nine studies comprising 2301 patients were included. The results showed that no significant differences compared to mastectomy were detected for global health status (P=0.971 and P=0.613), physical function (P=0.099), emotional function (P=0.096), cognitive function (P=0.377), social function (P=0.602), sexual functioning (P=0.072), and sexual enjoyment (P=0.142), while role function (P=0.036), body image (P=0.000), and future perspective (P=0.012) showed a significant difference for BCT when compared to mastectomy. When compared to breast reconstruction (BR), the BCT group was inferior at physical function (P=0.002) and cognitive function (P=0.040) but superior at body image (P=0.001). When used the Functional Assessment of Cancer Therapy (FACT) tool, BCT has better results in physical function (P=0.000), emotional function (P=0.000), and social function (P=0.000) than mastectomy. QOL outcomes after BCT were better than mastectomy in body image, future perspective, and role function. BCT may be an acceptable option in the study setting for breast cancer patients who pursue high QOL.

Idiopathic mast cell activation syndrome and radiation therapy: a case study, literature review, and discussion of mast cell disorders and radiotherapy

BackgroundMast Cell Activation Syndrome (MCAS) is classified as an idiopathic mast cell disorder where inconsistent or unknown triggers release inflammatory mediators and cause a constellation of symptoms. Studies demonstrate mast cells increase histamine, tryptase, and inflammatory cytokine expression following ionizing radiation. Additionally, there are cases of cutaneous mastocytosis developing within the initial radiation field suggesting mast cells play a role in local tissue reactions. Literature is sparse on radiation induced toxicity in patients with mast cell disorders.Case presentationA 62 year old female patient with a history of MCAS received breast conservation therapy for invasive lobular carcinoma of the left breast initially AJCC 7th Stage IIB, pT3 pN0 M0. The patient underwent external beam radiotherapy (EBRT) and received 4500 cGy to the left whole breast, followed by a 1000 cGy boost to the lumpectomy cavity. She developed grade 1 radiation dermatitis. Two years later she progressed distantly and received stereotactic body radiation therapy to a lumbar vertebrae lesion to a dose of 2400 cGy in a single fraction. She developed no in-field dermatologic or systemic flare in her MCAS symptoms during radiation therapy.ConclusionsTo our knowledge there are no reported cases in the literature of patients diagnosed with MCAS or other idiopathic mast cell disorders undergoing radiation therapy. Idiopathic mast cell disorders such as MCAS and primary mast cell disorders alike should not be considered a contraindication to treatment with EBRT. This patient population appears to tolerate treatment without systemic flares in symptoms.

Anti-Müllerian hormone as a new marker of the ovarian reserve function preservation by goserelin during (neo)adjuvant chemotherapy for young breast cancer patients

To observe the dynamic change of anti-Müllerian hormone (AMH) in 1 year after chemotherapy which is the best biochemical marker of ovarian reserve in reproductive medicine setting and to evaluate the effect of gonadotropin-releasing hormone agonist (GnRHa)goserelin to prevent ovarian reserve function during (neo)adjuvant chemotherapy for young breast cancer patients. Between December 2015 and June 2017, 101 breast cancer patients of age ≤ 45 years with stages I to III had been enrolled. The patients were assigned without interference to receive either (neo) adjuvant chemotherapy with goserelin (goserelin group) or without goserelin (chemotherapy group) as their own selection. AMH and menstrual status were evaluated before, during and 0.5 year, 1 year after chemotherapy. Primary end point was the incidence of low AMH value (<0.4 μg/L) at the end of 1 year. Secondary end point was the incidence of amenorrhea (the absence of menses in the preceding 12 months after assignment). In the study, 51 patients chose to join the chemotherapy group, while the other 50 patients selected goserelin to preserve their ovarian reserve function. More unmarried or childless, hormone receptors negative,receiving breast conservation therapy patients with earlier stage selected goserelin before chemotherapy. The incidence of low AMH value was significantly higher in chemotherapy group than in goserelin group (74.5% vs. 38.0%, P<0.001) in 1 year after chemotherapy. The incidence of amenorrhea was consistent with AMH (56.9% vs. 24.0%, P=0.001). And more patients' menstruation (78.9% vs. 54.5%) and AMH value (71.0% vs. 53.8%) recovered in goserelin group within 6 months after chemotherapy. In subgroup analysis, AMH and menstruation seemingly recovered more in goserelin group independent of age, chemotherapy regimen and use of tamoxifen. Especially, AMH value of 36.4% (8/22) patients in chemotherapy group and 18.4% (7/38) patients in goserelin group still maintained low level (<0.4 μg /L) although their menstruation had recovered 1 year after chemotherapy. In addition, 41 patients (20 patients in chemotherapy group, 21 patients in goserelin group) could be evaluated for the dynamic change of AMH and menstrual status during chemotherapy. The mean level of AMH in chemotherapy group declined rapidly to very low level before the 3rd cycle, while 70% of the patients kept presence of menstruation. At the same time, the mean level of AMH in goserelin group was still above 0.4 μg /L, but all of the patients had menopause. Our study has offered evidence that Goserelin with chemotherapy could protect against ovarian reserve failure for young breast cancer patients, now that more patients' AMH value recovered earlier who had selected co-treatment. AMH may be a more precise marker than menstrual status to clinically evaluate ovarian reserve function pre-, during and post- chemotherapy.

Patient-reported Quality of Life and Satisfaction With Cosmetic Outcomes After Breast Conservation and Mastectomy With and Without Reconstruction: Results of a Survey of Breast Cancer Survivors.

Although breast conservation is therapeutically equivalent to mastectomy for most patients with early-stage breast cancer, an increasing number of patients are pursuing mastectomy, which may be followed by breast reconstruction. We sought to evaluate long-term quality of life and cosmetic outcomes after different locoregional management approaches, as perceived by patients themselves. We surveyed women with a diagnosis of nonmetastatic breast cancer from 2005 to 2007, as reported to the Los Angeles and Detroit population-based Surveillance, Epidemiology, and End Results registries. We received responses from 2290 women approximately 9 months after diagnosis (73% response rate) and from 1536 of these 4 years later. We evaluated quality of life and patterns and correlates of satisfaction with cosmetic outcomes overall and, more specifically, within the subgroup undergoing mastectomy with reconstruction, using multivariable linear regression. Of the 1450 patients who responded to both surveys and experienced no recurrence, 963 underwent breast-conserving surgery, 263 mastectomy without reconstruction, and 222 mastectomy with reconstruction. Cosmetic satisfaction was similar between those receiving breast conservation therapy and those receiving mastectomy with reconstruction. Among patients receiving mastectomy with reconstruction, reconstruction type and radiation receipt were associated with satisfaction (P < 0.001), with an adjusted scaled satisfaction score of 4.7 for patients receiving autologous reconstruction without radiation, 4.4 for patients receiving autologous reconstruction and radiation therapy, 4.1 for patients receiving implant reconstruction without radiation therapy, and 2.8 for patients receiving implant reconstruction and radiation therapy. Patient-reported cosmetic satisfaction was similar after breast conservation and after mastectomy with reconstruction. In patients undergoing postmastectomy radiation, the use of autologous reconstruction may mitigate the deleterious impact of radiation on cosmetic outcomes.

Application of ACOSOG Z0011 Criteria Reduces Perioperative Costs

The ACOSOG Z0011 (Z0011) trial concluded that sentinel lymph node biopsy (SLNB) without completion axillary lymph node dissection (ALND) provides excellent regional control in women with T1-T2 sentinel lymph node (SLN) positive breast cancers receiving breast conservation therapy. We determined whether application of Z0011 guidelines would reduce costs. A retrospective chart review of patients with invasive breast cancer treated with lumpectomy and SLNB at our institution during 2009 was performed. We determined the number of overnight hospital admissions following ALND and estimated costs pertaining to the perioperative surgical management of the axilla patients actually received, and compared those to the estimated number of inpatient days and perioperative costs if Z0011 guidelines had been followed for eligible patients. The 2011 Medicare Fee Schedule was used to estimate costs for procedures, and costs for OR time were estimated using procedure length and cost of OR time per minute. A total of 71 patients underwent lumpectomy with SLNB and had at least 1 positive SLN. Estimated costs related to perioperative surgical management of the axilla were $322,775, and there were 36 overnight admissions. Applying Z0011 criteria, 51 patients (72%) would have been eligible to forego completion ALND. Estimated costs would have been $264,513 with 13 overnight admissions, translating into a cost savings of $58,262 and 23 fewer overnight admissions. Application of Z0011 guidelines resulted in cost savings, with a 64% reduction in inpatient hospital days and an 18% reduction in early perioperative costs.

Time-Course of Arm Lymphedema and Potential Risk Factors for Progression of Lymphedema After Breast Conservation Treatment for Early Stage Breast Cancer

The objective of this study was to describe the progression of arm lymphedema (ALE) after the initial presentation among patients receiving breast conservation therapy for early stage breast cancer and to identify potential risk factors contributing to ALE progression. The study sample was the 266 stage I or II breast cancer patients with documented ALE who underwent breast conservation therapy that included lumpectomy, axillary staging followed by radiation therapy. ALE were graded according to a difference of 0.5-2 cm (mild), 2.1-3 cm (moderate), and >3 cm (severe) in the circumference between the upper extremities for the treated and untreated sides. ALE at presentation was scored as mild, moderate, and severe in 109 (41%), 125 (47%), and 32 (12%) patients, respectively. One third of patients with ALE progressed to a more severe grade of lymphedema at 5 years of follow-up. Age older than 65 years at the time of breast cancer treatment was associated with higher risk of ALE progression when compared 65 year age or younger (p = 0.04). The patients who had regional lymph node irradiation including posterior axillary boost were at higher risk of lymphedema progression than the patients treated with whole breast irradiation only (p = 0.001). Progression of ALE is a common occurrence. The current study provides support for the utility of routine arm measurements after breast cancer treatment to facilitate timely diagnosis and treatment of ALE.

Adjuvant trastuzumab reduces locoregional recurrence in women who receive breast‐conservation therapy for lymph node‐negative, human epidermal growth factor receptor 2‐positive breast cancer

Patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer have a higher risk of locoregional recurrence (LRR), even in the setting of early stage, lymph node-negative disease. In this sequential, retrospective study, the authors evaluated whether adjuvant trastuzumab was associated with reduced LRR in women with lymph node-negative, HER2-positive disease who received breast-conservation therapy (BCT). By using an institutional database, 197 women were identified who had lymph node-negative, HER2-positive breast cancer measuring ≤5 cm diagnosed between 2002 and 2008 and who received BCT, including whole-breast irradiation. Two cohorts were compared: 70 women who did not receive trastuzumab (the no-trastuzumab cohort) and 102 women who did receive trastuzumab (the trastuzumab cohort). Kaplan-Meier methods were used to estimate LRR-free survival. The 2 cohorts were similar in age, tumor size, histology, and hormone receptor status. Chemotherapy was received by 73% of the no-trastuzumab cohort and by 100% of the trastuzumab cohort. In both groups, 99% of patients completed radiotherapy with a median dose of 60 Gray. The median recurrence-free follow-up was 86 months for the no-trastuzumab cohort and 47 months for the trastuzumab cohort. The 3-year LRR-free survival rate was 90% (95% confidence interval, 83%-97%) for the no-trastuzumab cohort and 99% (95% confidence interval, 97%-100%) for the trastuzumab cohort. In the no-trastuzumab cohort, LRR occurred in 7 patients (median time to LRR, 14 months). In the trastuzumab cohort, there was 1 LRR at 14 months. Even among women with lower risk breast cancer, the relatively high locoregional failure rates associated with positive HER2 status could be reduced markedly with adjuvant trastuzumab chemotherapy. Within 3 years, a 10% LRR rate without trastuzumab and a 1% LRR rate with trastuzumab were observed in women with lymph node-negative disease who received BCT.

Long-term results of breast-conservation therapy for Japanese women classified according to intrinsic subtype

e11578 Background: Microarray analysis has identified breast cancer subtypes with distinct gene expression profiles according to the estrogen receptor (ER) and the human epidermal growth factor 2 (HER2) expression. The luminal subtypes (ER-positive) appear to be associated with the better prognosis, whereas the basal and HER2 subgroups tend to have worse recurrence rates. The impact of intrinsic subtype for Japanese women with early-stage invasive breast cancer on prognosis is unknown. The purpose of this study is to address whether breast cancer subtype is associated with recurrence among Japanese women who receive breast-conservation therapy (BCT). Methods: The study cohort included 770 consecutive women with invasive breast cancer who received BCT at University of Tokyo Hospital from 1994 through 2007. Among them, 285 women had complete information on the ER and HER2 status of their primary tumors. The number of patients according to luminal A (ER+HER2- ), luminal B (ER+ HER2+), basal (ER-HER2-) and HER2 (ER-HER2+) subtype was 162, 66, 40 and 17, respectively. All patients received external-beam radiation therapy to the whole breast. The most common doses were 50 Gy in 25 fractions to the whole breast plus a tumor-bed boost to 60 Gy. Results: Median follow-up time was 55 months (range, 6 to 144 months). No significant difference was observed between 5-year disease control and four major subtypes. The 5-year relapse free survival rate of HER2-positive and -negative patients was 77% vs. 95%, which was of statistically significance (p = 0.001). Multivariate analysis showed that T stage, N stage, HER2 status and lymphatic vessel invasion correlated significantly with shorter relapse free survival. Multivariate analysis showed that only N stage was associated with decreased overall survival (p = 0.017). Conclusions: Overall, the 5-year relapse free survival rate after BCT was high, and no significant difference was found in four major subtypes as approximated using ER and HER2 status in Japanese women who receive BCT. Only HER2 status was a statistically significant risk factor after BCT. Although further follow-up is needed, BCT may still be optimal option in Japanese women with early-stage invasive breast cancer to whichever intrinsic subtype their tumors belong. No significant financial relationships to disclose.

The survival impact of the choice of surgical procedure after ipsilateral breast cancer recurrence

Background Many women with breast cancer recurrence previously treated with breast-conservation therapy desire repeat lumpectomies. We hypothesized that women undergoing mastectomy for breast cancer recurrence would show superior survival. Methods Patients who previously received breast-conservation therapy diagnosed with an ipsilateral breast cancer recurrence between 1988 and 2004 were identified using the Surveillance, Epidemiology, and End Results database. Univariate survival analysis was performed using the Kaplan-Meier method. Cox regression was used for multivariate analysis. Results Criteria for analysis were met in 747 patients. Of those, 24% underwent lumpectomy. On univariate analysis, patients undergoing lumpectomy had worse overall survival ( P = .03). Five-year survival was 67% versus 78% for the lumpectomy and mastectomy groups, respectively. On multivariate analysis, mastectomy remained significantly associated with better survival with a hazard ratio of .5 ( P = .003). Conclusions The use of lumpectomy for ipsilateral breast cancer recurrence previously treated with breast-conservation therapy should generally be discouraged.

Considerations of Previous Augmentation in Subsequent Breast Reconstruction

The number of patients receiving augmentation mammaplasty is rapidly growing. Breast cancer will develop in a significant number of these women. The authors report on a series (expanding the size of a previous study by the senior author, S.L.S.), encompassing one surgeon's experience performing breast reconstruction in women who had undergone previous augmentation. They compare the stage and detection method in this series with other published studies and also review their experience with regard to the benefit of subpectoral versus subglandular implant placement. A retrospective review of the senior author's reconstructive practice was performed, including the period from July 1983 to July 2007. Thirty-two consecutive women were identified who had previously received augmentation mammaplasty, were subsequently diagnosed with cancer, and then underwent breast reconstruction. Types of reconstructive procedures and outcomes were evaluated. A statistical analysis of the results was performed with a standard 2-tailed t test and chi(2) analysis. The occurrence of breast cancer diagnosis after augmentation ranged from 1 to 25 years (mean, 15 years). No implants were ruptured at the time of mastectomy. Of the 16 patients with previous subpectoral augmentation, cancer was detected mammographically in 12 (75%). Of the 16 patients with previous subglandular augmentation, cancer was detected mammographically in 7 (44%). This difference was not statistically significant, but that may be related to the insufficient population size (P = .15). Twenty-two (69%) of the patients underwent a purely prosthetic reconstruction. Flaps were used in the other 10 (31%), including 5 (16%) latissimus dorsi flaps and 5 (16%) transverse rectus abdominis flaps. Nine (90%) of those 10 flaps were used in patients undergoing radiation therapy. There were 9 stage 0 (28.1%), 9 stage I (28.1%), 12 stage II (37.5%), and 2 stage III (6.3%) patients. Among the subglandular group, there were 5 stage 0 (31.3%), 2 stage I (12.5%), 7 stage II (43.8%), and 2 stage III (12.5%) patients. Among the subpectoral group, there were 4 stage 0 (25.0%), 7 stage I (43.8%), 5 stage II (31.3%), and no stage III or IV patients. There was no significant difference in the axillary status between the 2 implant location groups. Eleven of the total 32 (34%) patients were treated with radiation therapy. Of these patients, 2 received breast conservation therapy and the other 9 underwent mastectomy. Of the 11 augmented breasts that received radiation therapy, 9 had flaps used in their reconstruction, including 5 latissimus dorsi and 4 trans-rectus abdominis muscle flaps. The average length of follow-up for the entire group was 26.4 months (range, 1-109 months). A history of breast augmentation was demonstrated to have consequences for future management of cancer in the areas of detection, cancer management, and reconstruction options. In addition, it was shown that the site of implantation may have an effect on the effectiveness of breast imaging.

COX-2 and PPARγ expression are potential markers of recurrence risk in mammary duct carcinoma in-situ

BackgroundIn women with duct carcinoma in-situ (DCIS) receiving breast conservation therapy (BCT), in-breast recurrences are seen in approximately 10%, but cannot be accurately predicted using clinical and histological criteria. We performed a case-control study to identify protein markers of local recurrence risk in DCIS.MethodsWomen treated for DCIS with BCT, who later developed in-breast recurrence (cases) were matched by age and year of treatment to women who remained free of recurrence (controls).ResultsA total of 69 women were included in the study, 31 cases and 38 controls. Immunohistochemical evaluation of DCIS tissue arrays was performed for estrogen receptor, progesterone receptor, HER-2/neu, cyclin D1, p53, p21, cycloxygenase-2 (COX-2) and peroxisome proliferator activated receptor γ (PPARγ). Two markers were significantly different between cases and controls on univariate analysis: strong COX-2 expression was associated with increased risk of recurrence, with 67% vs. 24% positivity in cases and controls p = 0.006; and nuclear expression of PPARγ was associated with protection from recurrence with 4% vs. 27% positivity in cases and controls, p = 0.024. In a multivariate model which included size, grade, COX-2 and PPARγ positivity, we found COX-2 positivity to be a strong independent risk factor for recurrence (OR 7.90, 95% CI 1.72–36.23)., whereas size and grade were of borderline significance. PPARγ expression continued to demonstrate a protective trend, (OR 0.14, 95% CI 0.06–1.84).ConclusionOur findings suggest that COX-2 and PPARγ should be investigated further as biologic markers to predict DCIS recurrence, particularly since they are also potential therapeutic targets.

Patients’ subjective evaluation of early and late sequelae in patients with breast cancer irradiated with short fractionation for breast conservation therapy: comparison with conventional fractionation

To compare the frequency of "subjective" complications and their severity between conventional and short fractionation and to analyze the differences between the two groups. Data from 350 patients with breast cancer who received breast conservation therapy between 1992 and 2003 were retrospectively analyzed. One hundred and ninety-six patients and 154 patients received 50 Gy in 25 fractions over 35 days (group C) and 44 Gy in 16 fractions over 22 days (group S), respectively. Early sequelae were evaluated at the end of radiation therapy (point A) and 7-10 days after the treatment (point B). Late sequelae were assessed at least 6 months after the end of radiation therapy (point C). The most commonly observed toxicity at point A was erythema, followed by heat sensation, sense of discomfort, and pain. There were no significant differences in these symptoms between the two groups. The frequency of these symptoms hardly changed between points A and B. At point C a sense of hardness more frequently appeared in group S than in group C with a significant difference. Other commonly noted symptoms had no significant difference between the two groups. Short fractionation results in acceptable patient "subjective" sequelae comparable to the sequelae experienced following conventional fractionation.

Placement of radiopaque clips for tumor localization in patients undergoing neoadjuvant chemotherapy and breast conservation therapy

The objective of this study was to determine whether patients with breast cancer who received breast-conservation therapy after neoadjuvant chemotherapy had improved outcomes if radiopaque clips were placed to mark the primary tumor. The authors retrospectively reviewed the records of 410 patients with nonmetastatic breast cancer who received doxorubicin-based neoadjuvant chemotherapy and breast-conservation therapy from January 1990 to September 2005. Thirty-seven of those patients were omitted because of the inability to verify radiopaque clip placement in the primary tumor. Of the 373 patients who were analyzed, 145 patients had radiopaque clips placed to mark the primary tumor before or during neoadjuvant chemotherapy, and 228 patients did not. The distribution of clinical T classification, nuclear grade, estrogen receptor status, final margin status, and extent of residual primary disease was similar between the 2 groups. After a median follow-up of 49 months (range, 20-177 months), 21 patients developed a local recurrence in the treated breast. The 5-year rate of local control was 98.6% in patients who had radiopaque clips placed versus 91.7% in patients who did not have tumor marker clips placed (P=.02; log-rank test). On multivariate analysis, the omission of tumor bed clips was associated with a hazard ratio of 3.69 for increased local recurrence compared with patients who did have radiopaque clip placement (P=.083; 95% confidence interval, 0.84-16.16). The placement of radiopaque clips in patients who were receiving neoadjuvant chemotherapy and breast-conservation therapy was associated with better local control independent of stage and other clinicopathologic findings. The authors concluded that the placement of tumor-marker clips should be an integral part of the multidisciplinary approach in appropriate patients.

The impact of young age on locoregional recurrence after doxorubicin-based breast conservation therapy in patients 40 years old or younger: How young is “young”?

The aim of this study was to investigate whether patients <35 years old have similar risk of locoregional recurrence after breast conservation therapy compared with patients 35 to 40 years old. We retrospectively reviewed records of 196 consecutive patients < or =40 years old who received breast conservation therapy (BCT) from 1987 to 2000 for breast cancer and compared outcomes between patients <35 years old with patients 35 to 40 years old. The majority of patients received neoadjuvant chemotherapy as part of their treatment. Multivariate analysis was performed to assess risk factors for locoregional recurrence. After a median follow-up of 64 months, 22 locoregional recurrences (LRR) were observed. Twenty patients developed locoregional recurrence as their first site of relapse. Two patients had bone-only metastases before their locoregional recurrence. On multivariate analysis, age <35 years was associated with a statistically significant increased risk of locoregional recurrence. The 5-year rate of locoregional control was 87.9% in patients <35 years old compared with 91.7% in patients 35 to 40 years old (p = 0.042). Our finding supports an increased risk of locoregional recurrence as a function of younger age after breast conservation therapy, even among young patients 40 years old and younger.

Risk of lymphedema after regional nodal irradiation with breast conservation therapy

Purpose To evaluate the risk factors for lymphedema in patients receiving breast conservation therapy for early-stage breast cancer. Methods and materials Between 1982 and 1995, 727 Stage I–II breast cancer patients were treated with breast conservation therapy at Massachusetts General Hospital. A retrospective analysis of the development of persistent arm edema was performed. Lymphedema was defined as a >2-cm difference in forearm circumference compared with the untreated side. The median follow-up was 72 months. Breast and regional nodal irradiation (BRNI) was administered in 32% of the cases and breast irradiation alone in 68%. Results Persistent arm lymphedema was documented in 21 patients. The 10-year actuarial incidence was 4.1%. The median time to edema was 39 months. The only significant risk factor for lymphedema was BRNI. The 10-year risk was 1.8% for breast irradiation alone vs. 8.9% for BRNI ( p = 0.001). The extent of axillary dissection did not predict for lymphedema even within the subgroups of patients defined by the extent of irradiation. Most patients underwent Level I or II dissection. In this subgroup, the lymphedema risk at 10 years was 10.7% for BRNI vs. 1.0% for breast irradiation alone ( p = 0.0003). Conclusion Nodal irradiation was the only significant risk factor for arm lymphedema in patients receiving breast conservation therapy for early-stage breast cancer. Our data suggest that this risk is low with Level I/II dissection and breast irradiation. However, even after the addition of radiotherapy to the axilla and supraclavicular fossa, the development of lymphedema was only 1 in 10, lower than generally recognized.

Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy

Background Patients receiving breast conservation therapy have a lifelong risk of local recurrence. To minimize this risk, surgeons have explored various approaches to examining the surgical margins of the resection specimen. If tumor cells are found at the margin, there is a high probability that residual tumor remains in the surgical cavity. This review examines published reports about standard and innovative approaches to assessing surgical margins, the clinical significance of margin size, and risk factors for positive margins. Methods: Published literature abstracted in Medline was reviewed using the Gateway site from the National Library of Medicine. Conclusions It is still not clear whether obtaining a radical margin will decrease the rate of local recurrence after breast conserving surgery. What is clear is that it is absolutely unacceptable to have tumor cells directly at the cut edge of the excised specimen, regardless of the type of post-surgical adjuvant therapy.

Reduction mammoplasty improves breast conservation therapy in patients with macromastia

Background: Macromastia has been considered a contraindication to breast conservation therapy because of difficulties with radiation therapy. This study evaluates the feasibility of bilateral reduction mammoplasty as a component of breast conservation therapy for breast cancer patients with pendulous breasts. Methods: Of 153 patients undergoing reduction mammoplasty at the University of Texas M. D. Anderson Cancer Center, 28 were identified as breast cancer patients with macromastia receiving breast conservation therapy. Median follow-up was 23.8 months. Results: Median patient age was 55 years. Nearly all patients were described as obese. Median weight of the reduction mammoplasty specimen on the cancerous side was 766 g. One patient (4%) required completion mastectomy for inadequate margin control. Major postoperative complications occurred in 2 patients (7%). There were no major postradiation complications. Patient survey revealed a satisfaction rate of 86%. Conclusion: Bilateral reduction mammoplasty is a reasonable and safe option for breast cancer patients with macromastia who desire breast conservation therapy.

MR IMAGING: ITS CURRENT AND POTENTIAL UTILITY IN THE DIAGNOSIS AND MANAGEMENT OF BREAST CANCER

The rapid evolution of the treatment of breast cancer has been paralleled by a similar rapid improvement in the imaging of breast cancer. High-resolution contrast-enhanced MR imaging of the breast has recently emerged as a sensitive instrument for the detection of breast cancer. The sensitivity of MR imaging makes it an excellent tool in specific clinical situations, such as the detection of local recurrence in patients who have received breast-conservation therapy. Furthermore, MR imaging of the breast has the potential to be a powerful aid in presurgical planning and to be a useful adjunct to mammography in selected patients. MR imaging, however, has a significant false-positive rate, is not readily available in all areas, and is more expensive than mammography and sonography. It also remains unclear if alterations of management plans based on MR imaging findings actually benefit affected patients. Therefore rigorous clinical trials are needed to define precisely the exact role that MR imaging should play in the diagnosis and management of breast cancer patients.

Invited Commentary

This study addresses the question of whether all patients receiving breast conservation therapy require an axillary dissection. While the authors acknowledge that axillary node status gives prognostic information, they state that axillary dissection may be unnecessary because good local control rates can be achieved by using axillary radiation therapy without surgery and that many patients, regardless of their node status, receive adjuvant therapy outside the protocol setting. There are two issues that deserve comment. First, the authors clearly advocate using axillary radiation therapy when a node dissection is not performed. They state that 15% to 25% of patients with clinically negative axillae will experience a nodal relapse. This implies that 75% to 85% of the patients will not have a nodal relapse and thus, these patients will have received unnecessary axillary radiation. Would it not be more reasonable to spare patients axillary radiation and use axillary dissection selectively to control