Underwent Breast Conservation Surgery Research Articles

Rapid Stereomicroscopic Imaging of HER2 Overexpression inEx VivoBreast Tissue Using Topically Applied Silica-Based Gold Nanoshells

Tumor margin detection for patients undergoing breast conservation surgery primarily occurs postoperatively. Previously, we demonstrated that gold nanoshells rapidly enhance contrast of HER2 overexpression in ex vivo tissue sections. Our ultimate objective, however, is to discern HER2 overexpressing tissue from normal tissue in whole, nonsectioned, specimens to facilitate rapid diagnoses. Here, we use targeted nanoshells to quickly and effectively visualize HER2 receptor expression in intact ex vivo human breast tissue specimens. Punch biopsies of human breast tissue were analyzed after a brief 5-minute incubation with and without HER2-targeted silica-gold nanoshells using two-photon microscopy and stereomicroscopy. Labeling was subsequently verified using reflectance confocal microscopy, darkfield hyperspectral imaging, and immunohistochemistry to confirm levels of HER2 expression. Our results suggest that anti-HER2 nanoshells used in tandem with a near-infrared reflectance confocal microscope and a standard stereomicroscope may potentially be used to discern HER2-overexpressing cancerous tissue from normal tissue in near real time and offer a rapid supplement to current diagnostic techniques.

Intra-operative re-excision of margins in breast-conserving surgery: How well are we able to judge tumour proximity?

s / International Journal of Surgery 10 (2012) S1–S52 S15 ABSTRACTS 1127: INTRA-OPERATIVE RE-EXCISION OF MARGINS IN BREASTCONSERVING SURGERY: HOW WELL ARE WE ABLE TO JUDGE TUMOUR PROXIMITY? Lorna Cook, Debasish Debnath, Zoe Lin, Raouf Daoud, Isabella Karat, Ian Laidlaw. Frimley Park Hospital, Frimley, UK Introduction: In breast-conserving surgery (BCS), specimen margin involvement with tumour often necessitates re-operation. For this reason, extra margins are often taken at the time of primary operation. The aim of this study was to determine how often such re-excisions are appropriate. Methods: The records of 100 consecutive patients undergoing BCS for cancer during 2011 were analysed. Data was collected on demographics, tumours characteristics, surgery performed and final histology. Results: All 100 patients were female, median age 56 years (range 33-83 years). 66% had intra-operative re-excision of margins. In 26/66 (40%), re-excision was the correct decision. 25 of the 34 patients who had no extramargins taken at all were managed appropriately with the remaining 9 patients having close/positive margins. Unnecessary re-excisions were performed in 40/66 patients. The correct intraoperative decision was therefore made in 51% of patients. Conclusion: The decision regarding intra-operative margin re-excision was appropriate in just over half of all cases and a second operation was avoided in 26%. However, in order to preserve as much uninvolved breast tissue as possible, further work should be done on methods to improve accuracy and to determine whether there are any patient, radiological or pathological predictors to guide intra-operative re-excision. 1181: FACTORS PREDICTING POSITIVE MARGIN STATUS IN BREAST CANCER PATIENTS UNDERGOING BREAST CONSERVING SURGERY Euan Harris , Andrew Lee . University of Dundee, Dundee, Tayside, UK; Abertawe Bro Morgannwg University Healthboard, Swansea, West

Propuesta de una nueva estrategia terapéutica multidisciplinar en la mujer con cáncer de mama y afectación del ganglio centinela

Sentinel lymph node (SLN) biopsy is the standard of practice for assessing axillary spread in clinically node-negative breast cancer patients. On the other hand, axillary lymph node dissection (ALND) is the ideal procedure for patients with SLN metastasis. Different studies over the last few years have suggested that some patients with positive SLN can be treated without ALND. This article presents a literature review carried out by our multidisciplinary group and its strategy for avoiding routine ALND in women with SLN metastases. In this new strategy ALND should not be performed on women with T1 tumours, with 1-2 positive SLN and undergoing breast conservative surgery. On the other hand, ALND would be indicated in those patients with three or more positive SLN, presence of extracapsular invasion, mastectomised women and triple negative subtype or HER2+ tumours that have not received biological treatment with antibodies.

P4-18-04: Hypofractionated Radiotherapy for Breast Ductal Carcinoma In Situ.

Abstract Background Conventional radiotherapy at a dose of 50 Gy in 25 fractions after breast conservative surgery is the standard treatment for ductal carcinoma in situ of the breast (DCIS). Hypofractionation is an interesting alternative for the treatment of breast cancer, providing a less intense treatment scheme for the patient. While the hypofractionated regimen of 42.5 Gy in 16 fractions has been shown to be equivalent to 50 Gy in 25 in infiltrating ductal carcinoma, few studies and no prospective study have reported results using hypofractionation in DCIS. Materials and Methods: In this multicenter collaborative effort, we retrospectively reviewed the records of women with a diagnosis of DCIS at two Canadian institutions, treated with conservative surgery followed by hypofractionated radiotherapy (42.5 Gy in 16 fractions) to the whole breast. Tumor, patient and treatment factors were collected. Local control was evaluated using the Kaplan Meier method. Curves were compared using log rank. Results: Between 2003 to 2008, 292 patients with DCIS underwent conservative surgery followed by hypofractionated radiation in 16 fractions for a total dose of 42.5 Gy. Treatment delivery was similar at both institutions. Mean age at diagnosis was 59 years, with 70 % of women being postmenopausal. Nuclear grade was 1–2 in 65 % of patients while 28 % had grade 3 tumors. Complete surgical excision with negative margins was achieved in 92 % of patients. Radiotherapy boost was given to 92 patients (31.5 %) at the discretion of the radiation oncologist. After a mean follow up of 3.35 years (range 1–8 years), 10 patients (3.4 %) had ipsilateral local relapse resulting in a disease-free survival (DFS) of 96 % at 4 years. The histology at recurrence was DCIS for 8 patients; infiltrative disease for one patient and one patient had an unknown histology at recurrence. Age was statistically associated with local relapse (DFS 89 % for patients under 50 years old vs 97 % for those older than 50, p=0.027). Grade was also a significant prognostic factor (DFS 98% for grade 1–2 vs 91 % for grade 3, p = 0.015). Finally, administration of boost did not have an impact on local control (DFS boost 98 % vs 95 % for no boost, p=0.44). Discussion: Hypofractionated radiotherapy (42.5 Gy in 16 fractions) provides excellent local control for patients with DCIS undergoing breast conservative surgery. This regimen is more convenient to both patient and physician since it is less time consuming. Further work needs to be done to determine if this regimen is as effective as conventional radiotherapy in younger women (age less than 50) and those with grade 3 tumors. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-18-04.

Local therapy for breast cancer in malignant lymphoma survivors

Breast cancer is the most frequent secondary tumor in young women previously treated with mantle radiation for Hodgkin's disease. Prior therapeutic radiation to the breast region is considered an absolute contraindication to breast conservative surgery, and mastectomy is considered the treatment of choice. We performed a retrospective review to assess the potential of performing breast conservative surgery and intraoperative radiotherapy with electrons (ELIOT), in these patients. Forty-three patients affected by early breast cancer, previously treated with mantle radiation for malignant lymphoma, who underwent breast conservative surgery and ELIOT, were identified in our institution. Median age at diagnosis of lymphoma was 26 years (49% were less than 25). Median interval between lymphoma and breast cancer occurrence was 19 years. A total dose of 21 Gy (prescribed at 90% isodose) in 39 patients (91%), of 17 Gy (prescribed at 100% isodose) in 1 patient and 18 Gy (prescribed at 90% isodose), was delivered. ELIOT was well tolerated in all patients without any unusual acute or late reactions. After a median follow-up of 52 months, local recurrence occurred in 9% of the patients and metastases in 7% patients. In patients previously treated for lymphoma, partial breast irradiation, and in particular ELIOT, permits breast conservative surgery without acute local complications, decreasing the number of avoidable mastectomies.

High resolution intra-operative two-dimensional specimen mammography and its impact on second operation for re-excision of positive margins at final pathology after breast conservation surgery

Background In the United States, about 50% to 66% of women undergoing breast conservation surgery for cancer undergo subsequent mastectomy for positive margins on initial lumpectomy. This is despite the fact that screening mammography has resulted in a decrease in the size of newly diagnosed breast cancer to <2 cm. Methods A retrospective review of 128 patients who underwent breast conservation surgery for early breast cancer was performed using intraoperative 2-dimensional Faxitron high-resolution specimen mammography without specimen compression as the only margin assessment technique. Of these, 29 patients had histories of lumpectomy with positive margins. Results A total of 131 procedures were performed. Margins were histologically clear at initial breast conservation surgery in 84.3% of patients who underwent primary lumpectomy. Subsequent reexcision for positive margins was required in 14.7% of patients. Two-dimensional Faxitron mammographically guided intraoperative reexcision cleared the margins in 95.8% of patients (23 of 24) who would have otherwise required subsequent reexcision. Conclusions Intraoperative 2-dimensional Faxitron high-resolution specimen mammography can decrease rates of margin positivity and has the potential to diminish the number of subsequent undesired mastectomies for positive margins.

Uncommon Breast Mass

A 40-year old female presented to the Breast Clinic with a painless lump in the right breast for one month with no associated fever, nipple discharge or skin redness. The patient gave a history of a hard, slightly painful lump in the left breast for which she had undergone breast conservation surgery. Review of the records revealed that the patient had an early stage invasive ductal carcinoma. On local inspection, the right breast was normal in size with no nipple retraction and obvious swelling. On palpation; a 5×4 cm soft mobile lump was felt in the upper outer quadrant. It was non-tender and the skin was freely mobile over it. A separate 2×2 cm firm, non-tender, mobile lump was palpated in the upper outer quadrant, below the larger lump. There were no palpable lymph nodes in the axilla. The left breast was asymmetrically small with a large scar as a result of the previous operation. On palpation, no lump could be palpated and there was no axillary lymphadenopathy. The patient was referred to the mammography unit for bilateral mammograms. Selected mammogram (Figs. 1, ​,2]2] and ultrasound images (Fig. 3) are given as below. Figure 1 Right mammogram with craniocaudal and mediolateral oblique views show a large mass in the upper outer quadrant with heterogeneous density containing both lucent and dense areas and showing a well-defined margin in part of its circumference. A smaller, ... Figure 2 A repeat previous mammogram of the same patient at six months (craniocaudal and mediolateral oblique views). Based on this comparison of the two mammograms more than 6 months apart with no change in the size or density of the lesions, a diagnosis of definite ... Figure 3 Sagittal and transverse images of the mammographic lesions showing larger lesion (5 × 3.5 cm) to be well defined, transversely oval, heteroechoic with no posterior acoustic shadowing or enhancement, with a well defined capsule around the entire ... Question What would be your diagnosis?

SU-E-T-596: High Dose Brachytherapy Planning of a Left Breast Cancer Patient with in Situ Pacemaker:

Purpose: To investigate the benefits of multilumen partial breast Brachytherapy device, SAVI, in reducing dose to in situ pacemakers in patients with cancer of the left breast. Methods: A left breast cancer patient with an in situ pacemaker underwent breast conservative surgery and was referred for Partial Breast Irradiation (PBI) using Ir‐192 High Dose Rate Brachytherapy. The preliminary estimation of the pacemaker dose from a pre‐insertion CT study was about 8 % of the prescribed dose which exceeded the generally accepted dose of 2Gy. The challenge was to use a suitable applicator to treat the tumor bed and 1 cm margin without exceeding the 2Gy limit to the pacemaker and the leads. A seven catheter SAVI device was selected and implanted in the left breast in an optimal direction and a 3D treatment plan was generated following a post insertion CT scan, using the Oncentra Brachy treatment planning system. Several optimization tools available in the planning system namely inverse, graphical, and dose point optimization were utilized to selectively load the catheters and reduce the dose to pacemaker and leads. A set of calibrated TLD chips were used to determine the surface dose on the pacemaker, which was then compared to the calculated surface dose. The pacemaker parameters were monitored before and after the 10 fraction (bid 5days) HDR brachytherapy, by a vendor representative and were found to functioning properly. Results: Using the seven catheter SAVI device it was possible to limit the pacemaker/ leads dose to less than 2 Gy, with an overall satisfactory dose to the target volume. Conclusions: By combining the optimization tools of today's Brachytherapy planning system and a multilumen SAVI applicator, HDR partial breast irradiation can be successfully delivered for left breast cancer patients with in situ pacemaker, with out the concern of interrupting pacemaker functionality

Role and Efficacy of Intraoperative Evaluation of Resection Adequacy in Conservative Breast Surgery

In the present study we considered the histology of 51 patients who have undergone breast conservative surgery and the related 54 re-excisions that were performed in the same surgical procedure or in delayed procedures, in order to evaluate the role of intraoperative re-excisions in completing tumor removal. In 13% of the cases the re excision obtained the resection of the target lesion. In this study, the occurrence of residual neoplastic lesions in intraoperative re-excisions (24%) is lower than in delayed re-excisions (62%; P = .03). The residual lesions that we could find with definitive histology of re excision specimens are related with lesions with ill defined profile. In 77% of the cases of re excision with tumoral residual the lesion was close to the new resection margin, thus the re-excisions couldn't achieve an adequate ablation of the neoplasm. Invasive or preinvasive nature of the main lesion resected for each case and the approach to the evaluation of the first resection specimen adequacy (surgical or radiological) don't affect the rate of tumoral residual in intraoperative re-excisions. In conclusion, our data are consistent with a low efficacy of intraoperative re excision in obtaining a complete removal of the tumor; intraoperative radiologic evaluation of the first resection specimen is however imperative in defining the effective removal of the target lesion.

Hepatic Irradiation during Modern Radiotherapy Protocols after Breast Conservation

Introduction The standard - supine with arms abducted to 90o - position for breast radiotherapy is stable, but raises the sub-diaphragmatic organs superiorly. A volume of liver may consequently be included within the radiation portal. The novel aim of this report is to quantify the dose-volume characteristics of hepatic irradiation and to seek relationships with interleukin-6 soluble receptor (IL-6sR), an inflammatory mediator potentially induced by damaged hepatocytes. Methods Participants comprised 98 women with 0–IIa stage breast cancer; undergone breast conservation surgery; prescribed 4000cGy/15 fractions/3 weeks; no prior or concurrent systemic therapies. The liver was outlined on contiguous CT slices and the volume irradiated to 10 and 50% of the dose (Liver10,50) derived via dose-histogram analysis. Enzyme-linked immunosorbent assay kits determined sera concentrations of IL-6sR. Results Liver50 ranged between 0–92 cm3, mean (SD) = 11.7 cm3 (1.1). This was consistent with up to 8% of the liver being irradiated, with a mean of 1.7% and 0.03% for right and left-sided tumours respectively. For right-sided tumours (n = 52), the mean (SD) Liver10 was 56.3 cm3 (52.8). The maximal dose was 113.1% of the prescribed 40Gy, with a mean (SD) value of 87.1% (32.3). A correlation between IL-6sR and Liver10 was non-significant pre-radiotherapy (ρ = .17, p = 0.2), but significant during (ρ = .32, p = 0.02), and four weeks post-radiotherapy (ρ = .38, p = 0.007). No significant correlations were found for left-sided tumours. Conclusions Up to 8% of the liver is irradiated within the primary beam during breast conservation therapy. This volume is insufficient to precipitate radiation-induced liver disease. However, low-dose effects are evident for right-sided treatments, rendering moderate-strength positive associations with IL-6sR. Elevated IL-6sR is associated with fatigue and depression in women with breast cancer. Given the liver’s metabolic role, multi-modal therapy may enhance the findings.

Single-incision bilateral laparoscopic oophorectomy

Although single-incision laparoscopic surgery made an appearance on the surgical scene only recently, it is being increasingly applied in the treatment of a variety of disorders. We report single-incision bilateral laparoscopic oophorectomy and salpingooophorectomy performed in two patients who had previously undergone breast conservation surgery for early breast cancer. Each procedure was undertaken using two 5-mm and one 3-mm ports inserted through a 2-cm transverse supraumbilical incision and standard laparoscopic instruments. The operative time was 50 and 65 min respectively and the blood loss negligible. The patients were discharged 36 and 24 h after surgery, required minimal postoperative analgesia and remain well at a follow up of 19 and 17 months, respectively. With the benefit of improved cosmesis, the single-incision approach holds the potential to replace the traditional bilateral laparoscopic oophorectomy.

Abstract P4-11-17: Can We Specifiy the Minimum Breast Size at Which Therapeutic Mammoplasty Should Be Considered To Mitigate Radiotherapy Toxicity in Patients Undergoing Breast Conserving Surgery for Breast Cancer?

Abstract Background For breast cancer patients undergoing breast conserving surgery, local complications after breast radiotherapy have in the past been shown to be proportional to breast size. Therapeutic mammoplasty is an option to extend the role of breast conserving surgery. In our units, it has been used in larger breasted women undergoing breast conserving surgery to reduce the risk of local radiotherapy complications. Aim The aim of this multicentre study was to determine, with modern radiotherapy dosing schedules, if it is possible to specify a minimum bra cup size at which therapeutic mammoplasty should be considered. Methods Recurrence free breast cancer patients (at least 3 years post conservative surgery and radiotherapy) were identified from three oncology follow up clinics in the United Kingdom. 50Gy in 25 fractions over 5 weeks prescribed to the 100% isodose at the ICRU reference point, on the central outline of the breast had been a typical dosing schedule. Radiotherapy effects were graded using the Late Effects of Normal Tissue-Subjective Objective Management Analytical (LENT-SOMA) score. A score of two or above was taken as representing that the particular toxicity variable was present. The relationship between radiotherapy toxicity variables was calculated using the Pearson correlation co-efficient. Results 479 breast cancer patients were assessed. Increasing cup size correlated with oedema (Pearson correlation co-efficient r=0.30, p=&amp;lt;0.0001), induration (r=0.31, p=&amp;lt;0.0001), telangiectasia (r=0.24, p=&amp;lt;0.0001), breast retraction (r=0.15, p=0.002) and pain (r=0.10, p=0.030). 2.3% of patients with cup size AA/A exhibited fibrosis, 6.6% with cup size B or C, 11.8% cup size D and 25.5% with cup size DD and above. Conclusion Local radiotherapy complications following breast conserving surgery for breast cancer remain proportional to breast size even with modern radiotherapy equipment and dosing schedules. This effect is most pronounced in women with a bra cup size D and above. For these women, therapeutic mammoplasty should be considered. Further work to identify the genetic determinants of normal-tissue radiation damage is underway to optimise the surgical decision. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-11-17.

Quality Assessment of Interstitial Implants in High- Dose- Rate Brachytherapy After Lumpectomy in Patients of Early Stage Breast Cancer

To assess the quality of high dose rate (H,D,R.) interstitial implants in breast cancer by using different volumetric indices and correlating them with skin and subcutaneous tissue toxicity. Out of 15 patients who were selected for interstitial implants after undergoing breast conservation surgery, five were treated radically with 34Gy in 10 fractions in 5days @ 3.4Gy # twice daily and 10 patients recieved boost dose of 12Gy in 4 fractions @ 3Gy /# twice daily. The median follow up was 15months. During each follow up assessment of late skin and subcutaneous tissue toxicity as per RTOG criteria was done . Various dosimetric indices were analysed. Dose Volume Histogram for dose per unit volume of skin for 10cc,5cc,2cc,1cc,0.1cc and 0.01cc was calculated. Best estimates and correlation of toxicity was revealed by assessment of Dose Nonuniformity Ratio(DNR) which also correlated well with geometry defining indices like Uniformity Index (UI).Volumetric assessment of skin dose for less than 2 cc correlated most with toxicity. DNR and UI can help us to assess and correlate late skin and subcutaneous tissue toxicity and thus serve useful to determine the quality of implant.

Objective Assessment of Dermatitis Following Post-operative Radiotherapy in Patients with Breast Cancer Treated with Breast-conserving Treatment

To evaluate radiation dermatitis objectively in patients with breast cancer who had undergone post-operative radiotherapy after breast-conserving surgery. Skin color (L*, a*, and b* values) and moisture analyses were performed for both breasts (before, after, 1 month, 6 months, and 1 year after radiotherapy) to examine irradiated and non-irradiated skin divided into four quadrants in 118 patients. These patients underwent breast conservative surgery followed by 50 Gy/25 fractions (median) of radiotherapy with or without boost irradiation (10 Gy/5 fractions). L*, a*, and moisture values were changed by irradiation and maximized at completion or 1 month after radiotherapy. One year after radiotherapy, the skin color had returned to the range observed prior to radiotherapy. However, moisture did not return to previous values even 1 year after treatment. The lateral upper side (quadrant C) showed greater changes than other quadrants in the L* value (darker) at the end of radiotherapy. The Common Toxicity Criteria version 3 scores were found to correlate well with a* and L* values at the completion and 1 month after radiotherapy. Boost radiotherapy intensified reddish and darker color changes at the completion of radiotherapy, while chemotherapy did not intensify the skin reaction caused by radiotherapy. Moisture impairment as a result of irradiation lasts longer than color alterations. Objective assessments are useful for analyzing radiation dermatitis.

Breast Conservation in Women with Multifocal-Multicentric Breast Cancer: Is It Feasible?

The incidence of preoperatively identified multifocal and multicentric breast cancer is rising with improved sensitivity of imaging modalities. Based on retrospective, historic data, breast conservation in women with multiple tumors has been discouraged because of high rates of local regional recurrence (LRR). These studies, however, do not extrapolate to contemporary practice as they do not incorporate the use of modern therapies and surgical techniques. This study is designed to evaluate the feasibility of breast conservation in women with multiple breast primaries. We retrospectively reviewed the charts of 22 women who underwent breast conservation surgery for 2 or more synchronous, ipsilateral cancers between 1998 and 2008. We extracted data including tumor size, nodal staging, receptor status, adjuvant therapies administered, and local-regional recurrence. A total of 22 patients were identified. Average follow up is 3.5years. One patient (4.5%) experienced an in-breast recurrence. Both initial tumors in this patient were invasive ductal carcinoma, ER/PR, negative and HER2 positive. Time to LRR was 2.5years. Our data are consistent with those of recent studies in which multifocal/multicentric local regional recurrence in multicentric/multifocal breast is equivalent to that seen in women with unifocal cancer. The single local recurrence in this study occurred in a premenopausal women with ER/PR- disease who were HER2+. Prior retrospective studies have identified ER/PR- and HER2 overexpression as independent risk factors for recurrence following breast conservation. Additional prospective trials are warranted to better assess the oncologic safety of breast conservation in this population.

O-58 Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

O-58 Factors influencing local control in patients undergoing breast conservation surgery for ductal carcinoma in situ

Planning With Intensity-Modulated Radiotherapy and Tomotherapy to Modulate Dose Across Breast to Reflect Recurrence Risk (IMPORT High Trial)

To establish planning solutions for a concomitant three-level radiation dose distribution to the breast using linear accelerator- or tomotherapy-based intensity-modulated radiotherapy (IMRT), for the U.K. Intensity Modulated and Partial Organ (IMPORT) High trial. Computed tomography data sets for 9 patients undergoing breast conservation surgery with implanted tumor bed gold markers were used to prepare three-level dose distributions encompassing the whole breast (36 Gy), partial breast (40 Gy), and tumor bed boost (48 or 53 Gy) treated concomitantly in 15 fractions within 3 weeks. Forward and inverse planned IMRT and tomotherapy were investigated as solutions. A standard electron field was compared with a photon field arrangement encompassing the tumor bed boost volume. The out-of-field doses were measured for all methods. Dose-volume constraints of volume >90% receiving 32.4 Gy and volume >95% receiving 50.4 Gy for the whole breast and tumor bed were achieved. The constraint of volume >90% receiving 36 Gy for the partial breast was fulfilled in the inverse IMRT and tomotherapy plans and in 7 of 9 cases of a forward planned IMRT distribution. An electron boost to the tumor bed was inadequate in 8 of 9 cases. The IMRT methods delivered a greater whole body dose than the standard breast tangents. A contralateral lung volume >2.5 Gy was increased in the inverse IMRT and tomotherapy plans, although it did not exceed the constraint. We have demonstrated a set of widely applicable solutions that fulfilled the stringent clinical trial requirements for the delivery of a concomitant three-level dose distribution to the breast.

262 What constitutes an adequate margin in patients undergoing breast conservation surgery for ductal carcinoma in situ?

262 What constitutes an adequate margin in patients undergoing breast conservation surgery for ductal carcinoma in situ?

Outcomes After Breast Conservation Treatment with Radiation in Women with Ductal Carcinoma In Situ and Prior Nonbreast Malignancy

Management of ductal carcinoma in situ (DCIS) of the breast is controversial, as not all patients progress to invasive carcinoma. This report analyzes the outcomes after breast conservation treatment (BCT) with radiation in patients with DCIS following prior malignancy at another anatomic site. The study cohort was comprised of 14 women with DCIS who were treated between 1978 and 2003. The median age at diagnosis of DCIS was 54 years (mean 56; range 37-78) and for the prior nonbreast malignancy was 44 years (mean 47; range 27-76). All patients underwent breast conservation surgery followed by whole breast radiation and tumor bed boost. The median and mean follow-up times after treatment of DCIS were 8.0 and 9.1 years, respectively (range 2-18). The median and mean interval period between the prior malignancy and DCIS was 6.0 and 8.2 years, respectively (range 1-30). There was one (7%) local failure, two (14%) contralateral breast cancers, and one (7%) death from breast cancer that occurred 7 years after BCT following contralateral invasive breast cancer. In this cohort of 14 patients treated for DCIS of the breast after a prior nonbreast malignancy, treatment for DCIS resulted in a high rate of local control and should be considered for curative intent.

Effect of breast-duct anatomy and wound-healing responses on local tumour recurrence after primary surgery for early breast cancer

Despite the improvement in outcome for women with early breast cancer undergoing breast conservation surgery and radiotherapy, there are significant gaps in our understanding of local tumour relapse. In this Personal View, we propose two hypotheses: early-onset changes in breast-duct anatomy limit the degree of intraductal spread and explain much of the substantial age-related difference in risk of local tumour relapse; and wound-healing proteins stimulate the growth of cancer cells left behind after surgery. These mechanisms help to explain why generous surgical margins offer no greater protection against local tumour relapse than narrow margins after complete microscopic tumour excision.