Surgical Axillary Staging Research Articles

Treatment and Prognosis of Rare Breast Cancers.

Management algorithms for invasive and non-invasive ductal and lobular breast carcinomas are well-established. Because of their very nature, rare histologic types of primary breast cancers are not represented in practice guidelines and thus present a challenge to the practicing clinician who must make recommendations for surgical treatment, axillary staging, and adjuvant therapy, as well as counsel patients as to their expected disease course and prognosis. Herein, case reports and published series of rare types of primary breast cancer including adenoid cystic, mucoepidermoid, metaplastic, squamous, neuroendocrine, encysted papillary, and micropapillary types will be reviewed to provide a basis for treatment planning for patients presenting with these rare primary breast malignancies.

Breast cancer subtypes can be determinant in the decision making process to avoid surgical axillary staging: A retrospective cohort study

IntroductionThe need for performing axillary lymph-node dissection in early breast cancer when the sentinel lymph node (SLN) is positive has been questioned in recent years. The purpose of this study was to identify a low-risk subgroup of early breast cancer patients in whom surgical axillary staging could be avoided, and to assess the probability of having a positive lymph-node (LN). MethodsWe evaluated the cohort of 612 consecutive women affected by early breast cancer. We considered age, tumor size, histological grade, vascular invasion, lymphatic invasion and cancer subtype (Luminal A, Luminal B HER-2+, Luminal B HER-2−, HER-2+, and Triple Negative) as variables for univariate and multivariate analyses to assess probability of there being a positive SLN o nonsentinel lymph node (NSLN). Chi-square, Fisher's Exact test and Student's t tests were used to investigate the relationship between variables; whereas logit models were used to estimate and quantify the strength of the relationship among some covariates and SLN or the number of metastases. ResultsA significant positive effect of vascular invasion and lymphatic invasion (odds ratios are 4 and 6), and a negative effect of TN (odds ratios is 10) were noted. With respect to positive NSLN, size alone has a significant (positive) effect on tumor presence, but focusing on the number of metastases, also age has a (negative) significant effect. ConclusionThis work shows correlation between subtypes and the probability of having positive SLN. Patients not expressing vascular invasion, lymphatic invasion and, moreover, a triple-negative tumor subtype may be good candidates for breast conservative surgery without axillary surgical staging.

Abstract P2-01-05: Correlation of percutaneously biopsied axillary lymph nodes marked with black tattoo ink prior to neoadjuvant chemotherapy with sentinel lymph nodes in breast cancer patients

Abstract Introduction: Sonographic evaluation of the axilla and percutaneous biopsy of abnormal lymph nodes with fine needle aspiration (FNA) or core needle biopsy (CNB) has become more common practice in patients with newly diagnosed breast cancer prior to neoadjuvant chemotherapy (NAC). Sentinel lymph node (SLN) biopsy is considered the gold standard for axillary staging in clinically node negative breast cancer patients. Currently, there is no clear correlation of sonographically detected abnormal lymph nodes and open surgical assessment. We conducted an exploratory pilot study which marked suspicious axillary lymph nodes with black tattoo ink at the time of percutaneous needle biopsy prior to NAC. Black nodes visualized during axillary surgery were evaluated in comparison to SLNs. Methods: Breast cancer patients with clinical and/or sonographically suspicious axillary lymph nodes prior to NAC were included in the study. Following FNA or CNB biopsy of node, 0.1 to 0.5 ml of a sterile, highly purified, biocompatible fine carbon suspension (Spot™) was injected into the cortex of the lymph node and adjacent soft tissue. A total of 12 patients were injected with black ink prior to NAC. Intraoperative presence of black pigment was assessed and correlation between sentinel and tattooed nodes were evaluated. Results: Nine patients had a positive percutaneous lymph node biopsy prior to NAC. The average number of days that elapsed between injection and to surgery was 130 days. A successful SLN procedure was performed in all patients. A black tattooed node was identified in all patients and correlated to a SLN. 7 patients were down-staged in the axilla and 6 patients did not go onto completion axillary dissection. One patient with a negative SLN had a completion axillary dissection, but no additional positive lymph nodes were found. Four patients with positive SLN had a completion axillary dissection (1 of whom was a false negative percutaneous biopsy). In all four patients, the positive sentinel node contained visible black ink. There was one patient who had an additional positive sentinel node, which was not black. Two axillary dissections contained additional positive nodes. Conclusion: Black ink tattooing with sterile black ink (Spot™), successfully marked suspicious lymph nodes prior to NAC. These correlated to a SLN. In node positive patients with a partial response in the axillary lymph nodes following neoadjuvant chemotherapy, previously marked, black-inked node proved to be the persistent positive node. Tattooing of lymph nodes at the time of percutaneous biopsy may improve the accuracy of surgical axillary staging by aiding in the intra-operative identification of previously biopsied nodes. Citation Format: Nicole Choy, Jafi Lipson, Sunita Pal, Debra Ikeda, Long Trinh, Kimberly Allison, Michael Ozawa, Amanda Wheeler, Irene Wapnir. Correlation of percutaneously biopsied axillary lymph nodes marked with black tattoo ink prior to neoadjuvant chemotherapy with sentinel lymph nodes in breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-05.

Abstract P2-02-13: The clinical significance of breast MRI in the management of ductal carcinoma in situ diagnosed on needle biopsy

Abstract Background: About 10-40% of ductal carcinoma in situ (DCIS) cases diagnosed on needle biopsy have invasive disease in the surgical specimens, which require surgical axillary staging. However, there is controversy regarding which subgroups should be indicated for sentinel lymph node biopsy (SLNB) because of the upstage on final diagnosis. Therefore, our aim is to identify the associated factors with invasive disease in DCIS diagnosed on needle biopsy by analyzing breast MRI findings with the histopathological factors of biopsy specimens. Methods: Seventy-five consecutive DCIS patients diagnosed on needle-biopsy in our institution who underwent preoperative MRI were retrospectively reviewed. The morphological features and kinetic curves were assessed using the ACR BI-RADS MRI lexicon. We measured the signal intensity (SI) of detected breast lesions and surrounding normal breast tissue on dynamic MRI and calculated the SI ratio as the SI of detected lesion divided by that of surrounding normal breast tissue. The MRI and histopathological variables were assessed between pure DCIS and invasive breast cancer (IBC) diagnosed on surgical specimens. Multivariable-analyses were performed to determine the independent factors for invasion using logistic-regression-model. Results: On dynamic MRI, 60 cases of 75 (80%) were classified as non-mass-like enhancement (NMLE) type and 15/75 (20%) were Mass type. In NMLE, 11/60 (18%) were ultimately diagnosed as IBC. Lesion size (P = 0.027), signal intensity (SI) ratios (calculated as the SI of detected lesions divided by the SI of surrounding normal breast tissue) (P = 0.032) on MRI and the number of biopsy-cores containing cancer nests (cancer-cores) (P = 0.012) were each independently associated with invasion. Table 1. Comparison of MRI findings and clinicopathological factors between pure DCIS and IBC groups in NMLE type.VariablesDCIS (n = 49)IDC (n = 11)P value (univariate)P value (multivariate)Age (years) 0.0480.067Median5544 Range34-7639-66 Lesion size on MRI (mm) 0.0180.027Median1634 Range5-606-59 Signal intensity ratio 0.0010.032Median1.352.01 Range1.04-2.891.56-2.55 The number of Cancer-cores 0.0050.012Median32 Range1-101-7 According to the ROC and statistical analyses performed for these independent factors, the area under the curve (AUC) was 0.72 for lesion size on MRI, 0.92 for the SI ratio and 0.80 for the number of cancer-cores (Table 2). Among these three factors, the SI ratio was the most accurately correlated with the presence of invasive disease. Table 2. The statistical results of the predictive factors in multivariate analysis for NMLE type.VariablesAUCCut-off valueSensitivitySpecificityPPVNPVLesion size on MRI (mm)0.723164%84%47%92%Signal intensity ratio0.921.7691%88%63%98%The number of Cancer-cores0.80282%80%47%95% In Mass type, there were no statistically significant differences between the DCIS and IBC cases. Conclusion: Our study demonstrated that needle biopsy-proven DCIS cases of NMLE type might be sufficiently managed using breast MRI features such as enhanced lesion size and signal intensity, incorporating the number of cancer-cores at needle biopsy specimen in the clinical setting. (Jpn J Clin Oncol. 2013 Epub ahead of print). Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-02-13.

Axillary Node Interventions in Breast Cancer

Recent data from clinical trials have challenged traditional thinking about axillary surgery in patients with breast cancer. To summarize evidence regarding the role of axillary interventions (surgical and nonsurgical) in breast cancer treatment and to review the association of these axillary interventions with recurrence of axillary node metastases, mortality, and morbidity outcomes in patients with breast cancer. Ovid MEDLINE (1946-July 2013), Cochrane Database of Systematic Reviews (2005-July 2013), Cochrane Database of Abstracts of Reviews of Effects (1994-July 2013), and Cochrane Central Register of Controlled Trials (1989-July 2013) were searched for publications on axillary interventions in breast cancer. Clinical trials, observational studies, and meta-analyses with at least 2-year follow-up were included. A total of 1070 publications were reviewed, 17 of which met final inclusion criteria. Partial mastectomy followed by whole breast radiation is breast-conserving therapy. For women with no suspicious, palpable axillary nodes who undergo breast-conserving therapy, there is little evidence of benefit from surgical complete axillary node dissection compared with sentinel node biopsy alone. Complete axillary node dissection in patients with no palpable lymph nodes, compared with sentinel node biopsy, provides no survival benefit and is associated with a 1% to 3% reduction in recurrence of axillary lymph node metastases, but is associated with a 14% risk of lymphedema. Surgical axillary staging via sentinel node biopsy in patients with benign axillary nodes on radiological and clinical examination helps to inform decisions regarding adjuvant systemic and radiation therapy. Patients and physicians should tailor axillary lymph node interventions to maximize regional disease control and minimize morbidity. Complete axillary lymph node dissection is indicated in patients who present with palpable or needle biopsy-proven axillary metastases, patients with positive sentinel nodes undergoing mastectomy (who do not, as a standard, receive adjuvant radiation), patients with more than 3 positive sentinel nodes undergoing breast-conserving therapy, and patients not meeting eligibility criteria for recent trials establishing the safety of sentinel node biopsy alone in patients with breast cancer and metastases in their sentinel nodes. Available evidence suggests that axillary node dissection is associated with more harm than benefit in women undergoing breast-conserving therapy who do not have palpable, suspicious lymph nodes, who have tumors 3.0 cm or smaller, and who have 3 or fewer positive nodes on sentinel node biopsy.

Imaging Response and Residual Metastatic Axillary Lymph Node Disease after Neoadjuvant Chemotherapy for Primary Breast Cancer

Although surgical management of the breast after neoadjuvant chemotherapy (NAC) may be governed by treatment response, axillary management continues to be determined by stage at presentation. Axillary ultrasound (AUS) with fine-needle aspiration (FNA) is used to detect lymph node (LN) metastases for pre-NAC staging, but imaging assessment of treatment response in the axilla remains undefined. We evaluated post-NAC axillary imaging and surgical pathology to understand how imaging might direct axillary surgery. We evaluated pre- and post-NAC axillary imaging and clinicopathologic data in 272 patients who received NAC for primary breast cancer and underwent operation at our institution from 2010 to 2012. Treatment response on imaging was categorized as complete (CR), partial (PR), and none/progression (NR). Pre-NAC axillary staging classified patients as AUS negative/no FNA (n = 61), FNA/LN negative (n = 42), and FNA/LN positive (n = 169). Post-NAC axillary imaging included AUS (n = 146), MRI (n = 139), and PET-CT (n = 38). At operation, 128 of 272 patients (47 %) were LN positive: 23.3 % (24 of 103) of cN0 and 61.5 % (104 of 169) of cN1-AUS/FNA-positive patients at presentation. Of the 65 cN1-ypN0 patients, 58.1 % (25 of 43) had an imaging CR by US, 58.6 % (17 of 29) by MRI, and 84.6 % (11 of 13) by PET-CT. The sensitivity of post-NAC axillary imaging in detecting persistent LN metastases for cN1-AUS/FNA-positive patients was 69.8 % for US, 61.0 % for MRI, and 63.2 % for PET-CT. Performance characteristics of AUS, MRI, and PET-CT, while informative, were inadequate to preclude surgical axillary staging of in breast cancer patients after NAC. Whether this information might be used to tailor surgical and postsurgical treatment requires further investigation.

When is a Lymph Node Dissection a Lymph Node Dissection? The Number of Lymph Nodes Resected in Sentinel and Axillary Lymph Node Dissections

We sought to compare the number of lymph nodes (LN) resected in axillary lymph node dissections (ALND) and sentinel lymph node dissections (SLND), and to assess the validity of registry reporting for axillary staging in breast cancer. Women in the California Cancer Registry who underwent surgical axillary staging for T1/T2, M0 breast cancer between 2004 and 2008 were evaluated. The number of LN resected in patients reported as having SLND+ALND and ALND were assessed for compliance with 6 and 10 LN threshold definitions for ALND. The proportion of patients with ≤3 LN removed was assessed for patients receiving SLND only. Of 71,907 patients, 45.5 % had SLND, 24.0 %, SLND+ALND, and 30.5 %, ALND. The median number of LN resected with SLND cases was 2 (range 1-41); SLND+ALND, 9 (range 1-63); and ALND, 11 (range 1-81) (p < 0.0001). Of patients undergoing ALND, 56.7 % had ≥10 LN removed; 46.2 % of patients with SLND+ALND had ≥10 LN removed (p < 0.0001). Overall, 75.5 % of patients with ALND had ≥6 LN removed and 67.8 % of patients with SLND+ALND had ≥6 LN removed (p < 0.0001). Of those receiving only SLND, 83.4 % had ≤3 LN removed. A significant proportion of patients did not meet the minimum LN count thresholds for full ALND or had excess LN removed in a SLND. Further investigation is required to determine whether absolute LN number or reported operative procedure and implied surgical technique better defines axillary staging in a registry database.

P3-07-48: Axillary Imaging with Dynamic MRI Following Subcutaneous Injection of Superparamagnetic Iron Oxide Nanoparticles.

Abstract Background: Surgical axillary staging with sentinel node biopsy in clinically node negative patients is standard of care in the management of breast cancer. However sentinel node biopsy is associated with morbidity including a 5% risk of lymphoedema. Superparamagnetic iron oxide (SPIO) enhanced axillary MRI is a promising novel imaging modality that could be used to characterize sentinel nodes non-invasively. We evaluated subcutaneous SPIO enhanced axillary MRI for pre-operative axillary imaging. Material and methods: Patients scheduled for sentinel node biopsy as part of surgical management of early breast cancer were invited to undergo pre-operative axillary MRI. All images were acquired on a 1.5T scanner using a surface coil. The initial 7 scans were acquired on a Siemens Avanto and the later scans on a Achieva MRI scanner (Philips Best, Netherlands). Following a T2-weighted morphological scan, patients were injected with 2ml of SPIO (4ml in the final 3 patients) subcutaneously into the circumareolar margin in the upper outer quadrant of the affected breast. Post injection, a slightly T2*-weighted dynamic scan was performed (gradient echo, TE = 1.53ms, TR=2.9ms, flip angle 7 degrees, 3mm slice thickness). In addition to the dynamic scan, in 16 patients, a T2 mapping sequence was performed at 10minutes and 120 minutes post injection (turbo spin echo, 8 equi-spaced TEs from 10 to 80ms, TR=2136ms, 3mm slices with an in plane resolution of 1.4×1.4mm). Image analysis was undertaken using Osirix (v3.8, 64-bit). Two consultant radiologists experienced at reading breast and axillary MRI reported all scans. Results: A total of 23 patients underwent axillary MRI with subcutaneous SPIO. Of these in 18 patients (78%), uptake of SPIO was seen in sentinel nodes and lymphatic tracts. At least 1 sentinel node was identified in 17 patients (74%). A total of 106 nodes were identified (4.6 ± 1.7 nodes per patient) and of these 40 demonstrated a significant drop in signal intensity following SPIO injection (1.7 ± 1.3 nodes per patient). All 3 involved nodes were seen to contain a metastatic deposit on MRI. Discussion: Axillary MRI with subcutaneous SPIO injection is a robust method for imaging sentinel nodes. The normal node count of the axillary basin is lower than expected on histology, suggesting that only the larger nodes and those that take up SPIO are visualized on MRI. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-48.

P5-14-25: Disease Presentation, Treatment, and Outcome in Young and Elderly Women with Breast Cancer.

Abstract Aim: To determine the influence of age on disease presentation, treatment, and outcome in breast cancer patients who are not routinely screened by mammography, women younger than 40 and women older than 69 years. Methods: The records of 272 breast cancer patients who presented to the Emory University Department of Radiation Oncology between 1997 and 2010 were reviewed. We excluded women with inflammatory or Stage IV breast cancer and those diagnosed between the ages of 40 and 69. We compared presentation, staging, treatment, and outcomes in women younger than 40 with those older than 69. Results: The median age of the young and older patient groups were 31 (range 16–40) and 76 years (range 70–91), respectively. Young women more often presented with a symptomatic breast mass than older women whose cancers were more frequently detected on screening mammography (p&amp;lt;.001). Young women were less likely than older women to present with significant co-morbidities including hypertension, diabetes, or cardiac disease (2% vs 76%, p&amp;lt;.001). A higher proportion of young women had high grade (50% vs 25%), T2/T3 tumors (69% vs 26%), and node positive disease (50% vs 23%) (p&amp;lt;.001 for all comparisons) than older women. Also, more young women had triple negative (25% vs 12.5%, p=.048) or HER2 positive breast cancers (34.4% vs. 18.3%, p=.02). Regarding treatment, older patients were less likely to undergo surgical axillary nodal staging (72% vs. 88%, p&amp;lt;.04) or chemotherapy (23% vs 84%, p&amp;lt;.001). Among women treated with chemotherapy, older women more often received a non-anthracycline based regimen (82% vs 7% of young patients, p&amp;lt;.001). Following neoadjuvant chemotherapy, significantly more young women had a complete pathological response (23% vs 13% in older women, p&amp;lt;.03). Fifty-two percent of young women received mastectomy versus 14% of older women (p&amp;lt;.001). In part due to their low rates of breast conserving surgery, younger women trended toward less radiation treatment (81% vs 90% in older women, p=.12). Among estrogen receptor positive patients, more young women received adjuvant endocrine therapy than older women (91.4% vs 72%, p=.05). The median follow-up period for the entire group was 38 months (range 1–160). At 3 years, young women were more likely to recur locoregionally (10% vs. 2%, p=.06) and distantly (16% vs 5%, p=.04) than older women, though both groups had comparable breast cancer-specific (96% vs 96%, p=0.2) and overall survival (96% vs 93%, p=.3). On multivariate analysis, old age was a significant predictor of poorer overall survival (p=.05), whereas initial tumor size and nodal status were independent predictors of breast cancer recurrence (p&amp;lt;.05). Discussion: Our data suggest that young women present with more advanced stage tumors than older patients and are subsequently treated with more aggressive surgery and systemic treatments, including chemotherapy and endocrine therapy. In spite of this, young women are more likely to develop breast cancer recurrence largely due to their higher T and N stages at diagnosis. Select women less than the age of 40 may benefit from screening and early detection of their breast cancers. Regardless, future studies aimed at developing better systemic treatments for younger breast cancer patients are warranted. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-14-25.

Axillary fine needle aspiration cytology for pre-operative staging of patients with screen-detected invasive breast carcinoma

IntroductionFine needle aspiration cytology (FNAC) of radiologically abnormal axillary lymph nodes in patients with breast cancer can identify patients suitable for primary axillary clearance (AC) rather than sentinel node biopsy,...

Dynamic contrast-enhanced magnetic resonance imaging and invasive breast cancer: Primary lesion kinetics correlated with axillary lymph node extracapsular extension

To determine if dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) peak enhancement (PE) of primary breast cancer can predict the presence of lymph node extracapsular extension (LNECE) in patients with axillary metastatic disease. In all, 167 patients treated with radiotherapy for invasive breast cancer from January 1, 2006 to November 1, 2007 were retrospectively identified. Patients with DCE-MRI and surgical axillary staging were included in this study. PE of primary tumors was compared according to axillary nodal status: negative, positive without LNECE, or positive with LNECE. A receiver operator characteristic curve (ROC) was plotted to determine accuracy of PE to predict LNECE. Forty-six patients met the study criteria. Thirty-two (70%) were node-negative, 9 (19%) were node-positive without LNECE, and 5 (11%) were node-positive with LNECE. PE was greater for patients with LNECE (mean 365%) compared to node-positive patients without LNECE (mean 183%) P = 0.05 and node-negative patients (mean 144%) P = 0.0012. Area under the ROC curve was 0.93. DCE-MRI PE may be a surrogate marker for LNECE. If validated, DCE-MRI may provide noninvasive kinetic information informing axillary nodal status for patients who receive chemotherapy prior to surgical axillary staging or forego axillary dissection after a positive sentinel node biopsy.

Extensive Nodal Disease May Impair Axillary Reverse Mapping in Patients With Breast Cancer

The aim of axillary reverse mapping (ARM) is to preserve arm lymphatics in patients with breast cancer who underwent surgical axillary staging. From June 2007 to December 2008, 49 patients who required axillary dissection (AD) underwent ARM. One milliliter of patent blue dye was injected in the ipsilateral arm, and all blue nodes identified during AD were sent separately for pathologic examination. Main variables associated with the detection rates of blue lymphatics, the pathologic status of blue and nonblue nodes, and the complications of the procedure were analyzed. Results Identification rates of blue lymphatics and blue nodes were 73.5% and 55.1%, respectively. Blue node identification was influenced by the time elapsed between injection of blue dye and surgery (P = .002) but not by the learning curve of the procedure. Although the blue node was clear of metastases in 24 of 27 patients, three patients with extensive nodal metastatic involvement (ie, pN2a and pN3a) showed breast cancer metastatic cells in the blue nodes as well. The only adverse effect of the procedure was skin tattooing at the injection site, which disappeared within 4 months in almost 80% of the procedures. In patients with clinically negative axillary nodes, additional study is warranted to assess whether ARM may be used to spare the lymphatics from the arm. In the presence of extensive nodal disease, this technique may identify metastatic blue nodes, which demonstrates that there is not reliable separation of arm and breast lymphatic pathways.

NCCN Task Force Report: Breast Cancer in the Older Woman

Breast cancer is common in older women, and the segment of the U.S. population aged 65 years and older is growing rapidly. Consequently, awareness is increasing of the need to identify breast cancer treatment recommendations to assure optimal, individualized treatment of older women with breast cancer. However, the development of these recommendations is limited by the heterogeneous nature of this population with respect to functional status, social support, life expectancy, and the presence of comorbidities, and by the underrepresentation of older patients with breast cancer in randomized clinical trials. The NCCN Breast Cancer in the Older Woman Task Force was convened to provide a forum for framing relevant questions on topics that impact older women with early-stage, locally advanced, and metastatic breast cancer. The task force is a multidisciplinary panel of 18 experts in breast cancer representing medical oncology, radiation oncology, surgical oncology, geriatric oncology, geriatrics, plastic surgery, and patient advocacy. All task force members were from NCCN institutions and were identified and invited solely by NCCN. Members were charged with identifying evidence relevant to their specific expertise. During a 2-day meeting, individual members provided didactic presentations; these presentations were followed by extensive discussions during which areas of consensus and controversy were identified on topics such as defining the "older" breast cancer patient; geriatric assessment tools in the oncology setting; attitudes of older patients with breast cancer and their physicians; tumor biology in older versus younger women with breast cancer; implementation of specific interventions in older patients with breast cancer, such as curative surgery, surgical axillary staging, radiation therapy, reconstructive surgery, endocrine therapy, chemotherapy, HER2-directed therapy, and supportive therapies; and areas requiring future studies.

Sentinel lymph node biopsy and non-sentinel node involvement in special type breast carcinomas with a good prognosis

This study aimed at identifying factors related to sentinel lymph node (SLN) involvement in patients with tubular, cribriform, mucinous or papillary breast carcinoma and those related to non-SLN metastases if an SLN was positive. Multivariate analyses involved logistic and stepwise regressions. The SLNs harboured metastases in 85 of 572 cases, 78 of whom underwent axillary dissection; 19 presented non-SLN positive disease. Lack of lymphovascular invasion, a tumour size ⩽10 mm and a single SLN removed were the factors predicting an SLN metastasis rate <10%, and patients with these features could be candidates for no surgical axillary staging. A positive SLN proportion of ⩽50% and no lymphovascular invasion were associated with a <10% rate of non-SLN invasion; patients with a positive SLN and these features could be candidates for the omission of completion axillary dissection. The opposite presentation of these factors would mandate SLN biopsy and axillary dissection, respectively.

Comorbidity and outcomes in elderly women treated with breast-conserving therapy

599 Background: Breast cancer incidence increases with age and is a major cause of morbidity and mortality among elderly women. Co-morbidities are often considered in treatment management of elderly women. Methods: Between 1979 and 2002, 238 women age 70 or older with unilateral stage I or II invasive breast cancer underwent conventional breast conservation treatment with radiation. The age distribution was 122 women (51%) age 70–74 years, 71 women (30%) age 75–79 years, and 45 women (19%) age ≥80 years. Surgical axillary staging was performed in 73% (n= 173) of patients, of which 73% (n=126) were N0, and 27% (n=47) were N1. Co-morbidities were scored using the Charlson Comorbidity Index and Cumulative Illness Rating Scale (CIRS). Median follow-up was 6.2 years. Results: On analysis by age groups, the 10-year cancer specific outcomes were not significantly different (see Table ). However, distant metastases were the most common site of first failure in all age groups: 9% for age 70–74; 12% for age 75–79 and 11% for age &gt;/= 80. Second malignancies were the second most common cause of first failure in all age groups. Death from intercurrent disease was significantly more likely in the older age groups. In this cohort, moderate and severe co-morbidities were not significantly more common in the older age groups, and CIRS score did not correlate with overall survival. Conclusions: Breast conserving surgery and definitive breast irradiation provide excellent outcomes in appropriately selected elderly women. Older age itself is not a contraindication to breast conserving therapy. Women of any age with lower co-morbidity indices should be offered standard treatment. [Table: see text] No significant financial relationships to disclose.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (<or=0.2 mm) and 130 patients (87.8%) with macrometastases (>0.2 cm). Five patients had isolated tumor cells detected by IHC (<or=0.2 mm, N(0i)). Patients with tumor size more than 2 cm (T1, 29.8% versus T2, 51.6%; OR=2.31, 95% CI, 1.50-3.56) and lymphovascular invasion (LVI-, 30.3% versus LVI+, 51.3%; OR=2.07, 95% CI, 1.34-3.19) were more likely to have positive SLNs in both univariate and multivariate analyses. Among patients with a positive SLN biopsy, those with T2 tumors (versus T1; 63.1% versus 36.9; OR=2.93, 95% CI, 1.43-6.04), macrometastases in SLNs (versus micrometastases; 88.9% versus 11.1%; OR=8.83; 95% CI, 1.82-42.87) and extracapsular node extension (versus without extracapsular node extension; 65.4% versus 34.6%; OR, 2.23; 95% CI, 1.05-4.72) were more likely to have non-SLN metastases in both univariate and multivarite analyses. These results indicate that clinicopathologic factors might be helpful to select patients who were less likely to have negative SLN or non-SLNs. However, additional factors are still needed to be identified to omit surgical axillary staging.

MULTIDISCIPLINARY CARE FOR PATIENTS WITH BREAST CANCER

Breast cancer management requires a multidisciplinary approach that is tailored to the patient's stage at presentation, desire for breast conservation or reconstruction, estimation of risk of recurrence, and assessment of the benefits and toxicities of potential adjuvant therapies. At the Lahey Clinic Medical Center, breast surgeons, plastic surgeons, radiation oncologists, and medical oncologists staff the Breast Cancer Treatment Clinic, and work closely together to formulate treatment plans that will optimize the likelihood for cure with an acceptable cosmetic result. This involves careful preoperative work-up, surgical axillary staging, breast irradiation in the setting of breast conservation, and selection of chemotherapy or hormonal therapy if appropriate. Newer aspects of breast cancer care, including sentinal lymph node biopsy, postmastectomy radiation therapy, expanded use of hormonal therapy in younger women, new agents and chemotherapy combinations, and autogenous reconstruction techniques, have become an essential part of the multidisciplinary clinic approach.

Critical Commentary

The present literature is conflicting regarding the management of microinvasive ductal carcinoma in situ (miDCIS) as to following recommendations for DCIS (margin status, surgical axillary staging, and possible observation) versus invasive breast cancer. We hypothesize that miDCIS represents more aggressive disease than pure DCIS.We performed a retrospective review of female miDCIS patients compared with age-matched cohorts of DCIS and T1b/c patients with invasive breast cancer. We collected demographic, clinicopathologic, treatment, and outcome information. Analysis of variance or Kruskal–Wallis tests were used to analyze continuous variables and chi-square or Fisher's exact tests for categorical variables. Survival outcomes were analyzed using Kaplan–Meier curves.We included 375 patients (125 in each group) with median age 59 y (range 33-91 y). miDCIS tumors were more likely to be hormone receptor negative and human epidermal growth factor receptor 2 positive compared with DCIS or invasive ductal carcinoma (IDC; all P < 0.001). Subgroup analysis by miDCIS focality demonstrated no significant differences. The number of involved lymph nodes was not significantly different from DCIS patients but was significantly fewer than invasive cancer patients. Of 115 miDCIS patients (88%) staged with sentinel lymph node biopsy, eight (7%) had nodal metastases. Six miDCIS patients (5%) were treated with adjuvant chemotherapy. Over a median follow-up of 23.3 mo, there were no significant differences in local or distant recurrence.Based on our results, miDCIS has more aggressive pathologic features compared with DCIS and warrants surgical treatment and nodal staging similar to the management of IDC. In addition, similar to IDC, nodal and receptor status may influence medical management.

Therapeutic Effect of Sentinel Lymphadenectomy in T1 Breast Cancer

To evaluate whether the tumor status of the sentinel lymph node (SN) would alter the systemic adjuvant therapy administered to patients with T1 breast cancer. Consecutive breast cancer patients (tumors < or = 2 cm) who underwent successful sentinel lymphadenectomy. Metastatic tumor in the SN, primary tumor size, recommendations for systemic adjuvant therapy before and after histopathologic evaluation of the SN, and actual systemic adjuvant therapy received by the patient. Of 142 total patients, 14 had T1a tumors; 35, T1b; and 93, T1c. Recommendations for systemic adjuvant therapy were initially determined solely by primary tumor characteristics and menopausal status. These recommendations were compared with recommendations for systemic adjuvant therapy based on tumor characteristics, menopausal status, and SN status; and then were compared with actual systemic adjuvant therapy received by the patient. Among the 118 patients with T1a, T1b, and favorable (positive estrogen or progesterone receptors and a low S-phase percentage with respect to DNA content) T1c tumors, 15 (37.5%) of 40 premenopausal patients and 20 (25.6%) of 78 postmenopausal patients became candidates for chemotherapy when examination of the SN revealed axillary metastasis; chemotherapy was actually administered to all 15 premenopausal patients but to only 6 postmenopausal patients. In the remaining 24 patients with unfavorable T1c tumors, SN status did not change the recommendation for chemotherapy but may have altered the choice of specific chemotherapeutic agents. Identification of tumor-involved SN may alter systemic adjuvant therapy in patients with T1a, T1b, and favorable T1c tumors and may potentially change the type or dose of chemotherapeutic agents given to patients with unfavorable T1c tumors. Surgical axillary staging of the axilla remains an essential part of breast cancer management and should not be abandoned.