Use Of Breast-conserving Therapy Research Articles

Disparities in Breast-Conserving Therapy vs. Mastectomy among Asian American and Pacific Islander Women

Multiple randomized trials support the use of breast-conserving therapy (BCT), defined as lumpectomy followed by adjuvant radiotherapy, as an alternative to mastectomy for definitive treatment of early-stage (T1-2N0) breast cancer. However, data suggest that Asian American, Native Hawaiian, and Pacific Islander (AANHPI) may undergo mastectomy at higher rates than BCT and may experience barriers to receipt of BCT. The purpose of this study was to examine BCT utilization by disaggregated AANHPI groups to identify differences in receipt of mastectomy versus BCT. The 2004-2017 National Cancer Database was queried to identify women age ≥18 years old diagnosed with cT1-2N0M0 breast cancer treated with either BCT or mastectomy without post-mastectomy radiation therapy. Women were classified based on self-reported race. Multivariable logistic regression defined adjusted odds ratios (OR) assessing the association between race and receipt of BCT versus mastectomy for all patients and separately by cT1-2 stage. All models were adjusted for relevant sociodemographic and clinical factors. Of 794,403 women with cT1-2N0M0 breast cancer, 239,801 (30%) received mastectomy and 554,602 (70%) received BCT. After adjusting for clinical and sociodemographic factors, AANHPI women had greater odds of receiving mastectomy over BCT, compared to White women (OR [95% CI], 1.35 [1.30-1.39]; p<0.001). In contrast, Black women were less likely than White women to receive mastectomy (0.86 [0.84-0.87]; p<0.001). Upon disaggregation, Chinese, Japanese, Filipino, Korean, Vietnamese, and Asian Indian & Pakistani women were more likely to receive mastectomy over BCT compared to White women (p<0.001 for all). Treatment at academic (1.30 [1.27-1.32]), integrated (1.24 [1.21-1.27]), and comprehensive community cancer centers (1.15 [1.13-1.17]) were all associated with greater odds of mastectomy compared to treatment at community cancer programs (all p<0.001). Greater distance from treatment facility (≥50 mi. vs. 0 to <10 mi. [reference], OR 1.50 [1.47-1.53]) and cT2 disease (1.85 [1.82-1.87]) were also associated with greater odds of receiving mastectomy (all p<0.001). In this evaluation of women with early-stage breast cancer, women from several AANHPI groups were more likely to receive mastectomy (as opposed to BCT) compared to White women. While sociocultural preferences, differences in access to and interest in reconstruction, as well as prevalent tumor-to-breast ratios may partially explain the disparities, collectively our data suggest an ongoing need for greater patient involvement in shared-decision making, particularly in vulnerable and understudied Asian populations.

The Breast Edema Enigma: Features, Diagnosis, Treatment, and Recommendations.

Breast edema most commonly occurs after breast cancer treatment involving breast-conserving therapy, although it may have a variety of other causes. As compared to research on breast cancer treatment-related lymphedema, breast edema and its objective measurement and diagnosis is far behind. Consequences of this disparity contribute to uncertainty and variability in its diagnosis, its treatment, and even the characterization of its incidence and morbidity. Moreover, consensus on a standardized definition, objective diagnostic method, and treatment techniques for breast edema has not yet been reached, making it difficult to provide appropriate guidelines with respect to its management. Given the recent rise in breast edema incidence as an outcome of the increasing use of breast-conserving therapy, this timely review examines the current state of breast edema assessment and makes a case for standardization in part via quantitative methods to diagnose and track breast edema.

Comparing the effect of distance to treatment facility on reconstruction and breast conservation therapy for early-stage invasive ductal carcinoma between the nation and the mountain region

BackgroundOur objective is to evaluate the effect of distance to facility on the use of breast conservation therapy and reconstruction for early stage breast cancer. MethodsUtilizing the National Cancer Database, we identified females, age <65, with Stage I invasive ductal carcinoma from 2004 to 2015. Using logistic regression, we compared radiation, mastectomy, and reconstruction treatment patterns. A subgroup analysis was performed within the mountain region (MR). ResultsNationwide, there are decreasing odds of radiation, increasing odds of mastectomy, and increasing odds of reconstruction. Patients living farther were less likely to receive radiation, more likely to undergo mastectomy, with no effect on reconstruction. Within the MR, patients living farther from their facility were less likely to receive radiation, more likely to undergo mastectomy, however, they were less likely to undergo reconstruction. ConclusionsNationwide and within the MR, patients living farther from their facility are less likely to receive radiation and more likely to undergo mastectomy. There is a disparity between the MR and the nation in use of reconstruction for this population.

New guideline: 2‐mm margin width adequate for breast‐conserving surgery in patients with DCIS

Three national cancer organizations have come together to issue a consensus guideline intended to provide clarity regarding the optimal negative margin width for treating women diagnosed with ductal carcinoma in situ (DCIS) who have undergone breast-conserving surgery and whole-breast irradiation (WBRT). The Society of Surgical Oncology, the American Society for Radiation Oncology, and the American Society of Clinical Oncology published the new guideline in their respective journals, the Annals of Surgical Oncology, Practical Radiation Oncology, and the Journal of Clinical Oncology.1 To create the new guideline, the Society of Surgical Oncology put together a multidisciplinary panel of experts that included clinicians and researchers from all three organizations in addition to a patient advocate. The group used a meta-analysis of margin width and ipsilateral breast tumor recurrence (IBTR) from a systematic review of 20 studies, including 7883 patients, and other published literature as the basis for the consensus. The guideline authors say that retrospective single-institution studies have suggested that a negative margin width of 1 cm or more may eliminate the reduction in IBTR seen in patients undergoing WBRT. Furthermore, despite the widespread use of breast-conserving therapy (BCT) for DCIS, the panel says that there was no previous consensus on what constitutes an optimal negative margin width. Thus, approximately 1 in 3 women attempting BCT for DCIS undergo re-excision. It was this lack of consensus that lead the panel to convene. The panel concluded that the use of a 2-mm margin as the standard in women diagnosed with DCIS and treated with WBRT is associated with low rates of IBTR and has the potential to decrease re-excision rates, improve cosmetic outcome, and decrease the cost of care. They also concluded that margins wider than 2 mm do not significantly reduce the rates of recurrence when compared with 2-mm margins, and their routine use is not supported by the evidence. See “Summary of Key Recommendations from the New DCIS Consensus Guideline,” left, for the main points of the panel's recommendations. Bruce G. Haffty, MD, immediate past chair of the American Society for Radiation Oncology board of directors, said that the new guideline will assist clinicians who have struggled with margin width in this patient population. “While the guideline appropriately allows for some flexibility and clinical judgment in interpretation,” he says, “the conclusion that a 2-mm margin width is adequate in patients with DCIS will be helpful and reassuring to clinicians and patients in clinical decision making.” There are some limitations to the guideline: It applies only to patients who have been diagnosed with DCIS and DCIS with microinvasion and treated with WBRT, and the findings should not be applied to patients with DCIS treated with accelerated partial-breast irradiation or to those who have invasive carcinoma.

Disparities in the Use of Breast-Conserving Therapy Among Patients With Early-Stage Breast Cancer.

Although breast-conserving therapy (BCT) is an accepted modality for treatment of early-stage breast cancer, many women continue to undergo mastectomy. Detailing the factors associated with choice of BCT may assist with overcoming barriers in the use of this treatment modality. To conduct a population-based examination of the factors that influence the use of BCT. Using the National Cancer Data Base, we examined the surgical choices of women with stage T1 or T2 breast cancer treated between 1998 and 2011. Logistic regression analysis conducted between September 19, 2013, and August 26, 2014, was used to assess the multivariate association between patient and facility variables and the probability of undergoing BCT. Factors associated with the use of BCT. A cohort of 727,927 women was identified in the National Cancer Data Base. Use of BCT, determined using odds ratio (OR) and 95% CI, was greater in patients aged 52 to 61 years compared with younger patients (1.14; 1.12-1.15) and in those with the highest educational level (1.16; 1.14-1.19). Rates of BCT were lower in patients without insurance compared with those with private insurance (0.75; 0.72-0.78) and in those with the lowest median income (0.92; 0.90-0.94). Academic cancer programs, US Northeast location, and residence within 27.8 km of a treatment facility were associated with greater BCT rates than were community cancer programs (1.13; 1.11-1.15), Southern location (1.50; 1.48-1.52), and residence farther from a treatment facility (1.25; 1.23-1.27). When comparing BCT use in 1998 with use in 2011, increases were seen across age groups (from 48.2% to 59.7%), in community cancer programs (48.4% in 1998 vs 58.8% in 2011), and in facilities located in the South (45.1% in 1998 vs 55.3% in 2011). Although the use of BCT has increased during the past 14 years, nonclinical factors, including socioeconomic demographics, insurance, and travel distance to the treatment facility, persist as key barriers to receipt of BCT. Interventions that address these barriers may facilitate further uptake of BCT.

The effects of radiation therapy of early breast cancer on the cardiovascular system

Aim-Background Improvements and developments in the treatment of early breast cancer include the use of breast-conserving therapy and radiotherapy in place of radical mastectomy, chemotherapy, monoclonal antibodies and hormone therapy. Radiation to the heart causes both acute and chronic symptoms of cardiac toxicity. Acute symptoms include acute pericarditis, pericardial effusion and arrhythmias. Among the long-term effects are constrictive pericarditis and increased atherosclerosis. The risk is greatest with left breast irradiation and radiation involving internal mammary lymph nodes. In this paper, we discuss the cardiovascular effects of radiation therapy treatment of early breast cancer.

Breast cancer multifocality-multicentricity and locoregional recurrance.

1029 Background: The impact of multifocality (MF) and multicentricity (MC) on locoregional (LR) control for invasive breast cancer, and the optimal local treatment strategy for these tumors, is unknown. In particular, there is disagreement in the literature regarding the use of Breast Conservation Therapy (BCT). We evaluated a large single institution cohort of MF and MC breast cancers to determine if they had inferior LR control rate when compared to their unifocal counterparts. Methods: MF and MC were defined pathologically as more than one lesion in the same quadrant and more than one lesion in separate quadrants, respectively. Patients were categorized by presence or absence of MF or MC disease and by the LR treatment modality received – BCT (n=256), mastectomy alone (n=466), or mastectomy plus post-mastectomy radiation therapy (n=184). 10 patients who underwent BCT for MC disease against physician advice were excluded. MF and MC tumors were analyzed both as a group and as separate entities. Kaplan-Meier product limit method was used to calculate 5-year LR control rate. Cox proportional hazards models were fit to determine independent associations of MF/MC disease with LR control. Results: Median follow up was 52 months. Out of 3722 patients with stage I-III disease who did not receive neoadjuvant chemotherapy, 906 (24%) had MF (n=673) or MC (n=233) disease. 5-year rate of LR control rate was 99% in the MF group, 96% in the MC group, and 98% in the unifocal group, (P = 0.44). Subset analysis revealed no statistical difference in LR control regardless of the type of LR treatment, (P = 0.67 in the BCT group, P = 0.37 in the mastectomy alone group, and P = 0.29 in the mastectomy plus post-mastectomy radiation therapy group). There were 21 in-breast recurrences after BCT (8.2%). After controlling for other risk factors, MF and MC did not have an independent impact on LR control rate. Conclusions: MF and MC disease are not independent risk factors for LR recurrence. Patients with MF and MC breast cancer had similar rates of LR control to their unifocal counterparts, regardless of LR treatment modality. Our data suggest that BCT is a safe option for patients with MF tumors and that MF or MC disease alone is not an indication for post-mastectomy radiation therapy.

Standard use of breast-conserving therapy justified?

Standard use of breast-conserving therapy justified?

Influence of uncommon histology on breast conservation therapy for breast cancer‐biology dictates technique?

Although trends and variations in the use of breast conservation therapy (BCT) for ductal carcinoma have been studied, little is known about uncommon breast cancer histologies. The Surveillance, Epidemiology and End Results (SEER) database was used to identify 338,682 patients with T1 or T2 (≤5 cm) ductal, lobular, tubular, mucinous, medullary, or papillary carcinoma of the breast from 1998 to 2008. Multivariate logistic regression analysis was used to identify predictors of BCT. The majority of patients underwent BCT (60%). The rate of BCT remained relatively constant from 1998 to 2008 overall but varied from 50% for lobular to 79% for tubular. The highest rate of mastectomy was seen in lobular (49%). Nodal positivity following surgical staging was lowest for tubular (6%) and mucinous (8%). Adjuvant radiation was given to 72% overall and was lowest for papillary (58%). Predictors of BCT included tubular (OR 1.8, 95% CI 1.7-1.9) and medullary (OR 2.0, 95% CI 1.8-2.2) subtypes (vs. ductal). Patients with uncommon breast cancer histologies show wide variation in the application of BCT depending on the primary tumor. This suggests that an individualized approach in the use of BCT depending on histology should be used.

Assessing the clinical effectiveness of breast reconstruction through patient-reported outcome measures

Breast cancer remains the most common malignancy in women worldwide. Early detection and treatment means that over 70 per cent survive for more than 10 years, with approximately 60 per cent of women predicted to be alive 20 years following their initial diagnosis1. There is an increasing focus on the issues of ‘survivorship’ and the impact of surgical and other treatments on patients’ health-related quality of life (HRQoL). Although the growing practice of oncoplastic breast surgery has increased the use of breast conservation therapy for stage I and II disease, about a third of the 44 000 women diagnosed annually with breast cancer in the UK have mastectomy recommended or choose it as their preferred option1,2. In assessing clinical effectiveness, evidence of the importance of considering not only patient morbidity and mortality, but also patient perceptions of the results of surgery is increasing3. The growth of research into patient-reported outcome measures (PROMs) is based on the main goal of breast reconstruction to satisfy the patient with respect to psychosocial sequelae, physical function and perception of the aesthetic result3. PROMs are questionnaires that quantify HRQoL and/or other significant outcome variables, such as patient satisfaction3. The US Food and Drug Administration has defined PROMs as a ‘measurement of any aspect of a patient’s health status that comes directly from the patient’3. PROMs should assess the impact of disease, treatment and surgical intervention on various aspects of outcome. They should be clinically meaningful, scientifically sound and practical3,4. PROMs may differ significantly from those recorded by a clinical evaluator, and are important complementary assessments of clinical effectiveness. HRQoL measurement covers the impact of breast cancer and its treatment on some aspect of physical or psychological well-being or function, for example physical, role, cognitive or social5. There is a an underlying belief that mastectomy has important consequences on a patient’s quality of life, including psychosocial, physical, aesthetic, body image and sexual effects6. The evidence for this, however, remains equivocal, based on a systematic review of HRQoL outcomes in all types of immediate and delayed breast reconstructions from 1978 to 20097. Thirty-four studies were included and evaluated according to the Efficace criteria, which define a minimum standard checklist for quality of methodological reporting of HRQoL8. The quality of the evidence was still generally poor with only 13 level I (n = 2) and level II (n = 11) studies. Although some used breast cancerspecific instruments that have been validated in line with internationally accepted criteria for assessing HRQoL, including the Functional Assessment of Cancer Therapy for Breast Cancer (FACT-B), the European Organization for Research and Treatment of Cancer breast cancer module (EORTC QLQ-BR23) and the Body Image Scale, none has been specifically validated inwomen undergoing breast reconstruction7. They may prove valid and reliable, but have not been designed specifically to reflect changes resulting from breast reconstruction4. A systematic review to identify PROMs developed and validated for use in cosmetic and reconstructive breast surgery revealed that only seven of 227 PROMsmeasuring satisfaction and/or breast-related quality of life had undergone development and validation in a cosmetic or reconstructive breast surgery population4. Of these, only two were applicable to breast reconstruction, both related to the Michigan Breast ReconstructionOutcomes Study (MBROS). One examined patient satisfaction (MBROS-S) and the other body image (MBROSI)4. Neither questionnaire, however, was developed in keeping with current internationally accepted criteria, nor did they specifically address key issues relating to either the donor site, nipple reconstruction or the reconstructed breast. As they were developed exclusively in the context of expander/implant or transverse rectus abdominis myocutaneous flap reconstruction, neither has been validated across the spectrum of breast reconstructive procedures such as preservation of the skin envelope and/or nipple-sparing mastectomy with a variety of immediate breast reconstructionmethods, and delayed methods that relate to the use of implantonly, implant-assisted tissue flaps or

Risk Factors of Local Recurrence after Breast Conserving Therapy in Invasive Breast Cancer

유방보존술이증가하면서유방보존술후발생하는국소재발 Purpose: Twenty-year follow-up results of two pioneering randomized controlled trials have demonstrated equal patient survival after mastectomy and breast conservation therapy. The use of breast conservation therapy has undoubtedly provided substantial progress towards a better quality of life for women with breast cancer. Outcomes of breast conservation therapy performed at Asan medical center were retrospectively reviewed and analyses were performed to determine significant risk factors of local recurrence. Methods: A total of 578 women with stage I, stage II or stage III breast cancer were treated with conservative surgery and radiation therapy between January 1997 and December 2002. Outcomes of local recurrence and survival were recorded. Results: During a median follow-up of 54.1 months, 21 patients (3.6%) developed local recurrence as first event and 10 patients (1.7%) developed regional recurrence and 19 patients (3.3%) developed systemic recurrence. Univariate analysis of the prognostic factors determined that age (p=0.005), nuclear grade (p=0.013), estrogen receptor negativity (p=0.008), lymphovascular invasion (p=0.009), progesterone receptor negativity (p=0.016) and lack of hormone therapy (p=0.005) were statistically significant factors associated only with locoregional recurrence. Results of multivariate analysis determined that lymphovascular invasion (p=0.045) strongly independent predictors for local recurrence. Conclusion: Age, nuclear grade, estrogen receptor negativity, lymphovascular invasion, progesterone receptor negativity and lack of hormone therapy were associated with local recurrence after Breast conserving surgery. The lymphovascular invasion was the strongest independent risk factors for local recurrence.

Clinical Result and Prognosis of Locoregional Recurrent Carcinoma after Mastectomy

Purpose: Despite the increasing use of breast-conserving therapy, modified radical mastectomy retains an important primary treatment of breast cancer. The aim of this study was to evaluate the survival of patients with isolated locoregional recurrence (LR) and the prognostic factors for LR after mastectomy. Methods: We retrospectively analyzed 76 patients who were treated for LR after mastectomy at our hospital between 1987 and 2002. These patients had only isolated LR. The following parameters were analyzed: primary tumor size, primary nodal status, stage, estrogen receptor status, treatment modalities for LR, disease free interval from primary operation and re-recurrence interval. Results: The median time to develop LR was 18.4 months and the median follow-up period from LR was 19.3 months (range 1.3∼113 months). The 2-year overall survival rate from LR showed 46% and 5-year overall survival rate was 15%. Out of 76 patients, 47 patients (61.8%) developed re-recurrence and the median duration to re-recurrence was 9.6 months. The pattern of re-recurrence showed 45 patients with systemic recurrence and 2 patients with LR. The initial node status (P=0.041), the estrogen receptor status (P=0.009) and re-recurrence interval from LR (P=0.017) were statistically significant factors for survival. The primary tumor size, the stage, the disease free interval, and the treatment modalities for LR were not statistically significant. Conclusion: The re-recurrence rate after isolated LR in patients with breast cancer showed 61.8% and these patients almost always had systemic recurrence. This study could not show the difference of survival according to the treatment modality for LR but the systemic treatment should be considered for the patients with unfavorable prognostic factors.

Margins in breast-conserving therapy: have we lost sight of the big picture?

There are few, if any, surgical procedures for cancer treatment that are based on a foundation of high-quality evidence equivalent to that which supports the use of breast-conserving therapy (BCT)....

Angiosarcoma of the Breast

This article describes the imaging findings, pathologic correlation, and clinical presentation of rare primary and secondary angiosarcomas of the breast. With the increasing use of breast conservation therapy for breast cancer, reports of postirradiation angiosarcoma have increased. Both primary and secondary angiosarcomas may present with bruiselike skin discoloration, which may delay the diagnosis. Imaging findings are nonspecific. MRI may be used to determine lesion extent by showing rapid enhancement and washout in high-grade tumors.

Problems with the Use of Breast Conservation Therapy for Breast Cancer in a Patient with Neurofibromatosis Type 1: A Case Report

Patients with neurofibromatosis type I and breast cancer represent a subset of people who may be considered at high risk for secondary cancers after conventional whole breast radiation therapy and breast conservation surgery. A case of a 49-year-old woman with neurofibromatosis type I is presented. She was diagnosed with a 1.1-cm right breast infiltrating ductal carcinoma. Clinical, diagnostic imaging, and pathologic features are discussed. Her initial treatment plan of breast conserving therapy was thwarted when her sentinel node biopsy was positive for micrometastatic disease in 1/14 lymph nodes. She elected to have a bilateral simple mastectomy. This case addresses the rare dilemma of offering breast conservation therapy as a viable option for patients with neurofibromatosis type I. Current data on radiation-induced secondary cancers such as sarcoma after treatment for breast and other cancers are reviewed.

Treatment of invasive lobular carcinoma with breast conserving therapy

11046 Background: Invasive lobular carcinoma (ILC) is the second most common histological type of breast carcinoma .There is still a persisting concern regarding the use of breast-conserving therapy(BCT) in patients with ILC.Difficulty to identify the exact size , location of ILC and multifocality and/or multicentricity are the reasons to suggest that patients with ILC might be poor candidates for BCT. The aim of our current study was to evaluate the possibilty of risk adapted BCT for patients with ILC with or without breast irradiation. Methods: 277 patients with ILC pure or mixed type between 1994 and 2006 were accrued for pospective risk adapted therapy. Contraindications for BCT are multicentricity , inability to obtain negative margins or poor cosmesis. Palpation, mammograpy,ultrasound were routinely done and preoperative MRI in cases with no sharp tumor image. Breast conserving surgery was standardised by performing a radial segmental resection. Inking margins,histological semiserial step sections and specimen radiography was done. Sharp dileneated ILC with a free margins of &gt;/= 1cm and no lymphvesel invasion(LVI) were treated by BCT without breast irradiation(Rx). Patients with ER + were treated with endocrine therapy.Mean follow-up time was 74 months. Results: Of the 277 ILC cases , 55(19,8%) were treated by mastectomy and five patients palliatively because of distant metastases. 217 ILC (79%) were treated with BCT (T1:108/48%;T2:45(21%);T3:67/31% ; NO:135/62%; ER+: 295/94%). 6 patients(2,8%) had local recurrence(LR). 161 ILC (T1 38%; T2 22%; T3 39%; N0 55%) were treated with BCT with Rx. Patients mean age was 57 years. 6(3,7%) of the patients had local recurrence (4 LR only, 2 LR and distant metastases). 56 ILC (T1 69%; T2 15% T3 22% ; NO 81%) were treated with BCT without Rx. Mean age 66 years. There were no LR , 2 patients had distant metastases. Conclusions: Using strict selecting criteria with a standardized breast conserving surgical procedure, thorough histological examination and using all breast imaging possibilities risk adapted BCT for ILC are not more likely to fail than BCT of other types of breast cancer. These results support the use of BCT for ILC patients. No significant financial relationships to disclose.

The Role of Sentinel Lymph Node Biopsy in Paget’s Disease of the Breast

Sentinel lymph node (SLN) biopsy has become a standard of care for axillary lymph node staging in breast cancer and appears suitable for virtually all patients with clinically node-negative (cN0) invasive disease. However, its role in Paget's disease of the breast, a condition in which invasion may or may not be present, remains undefined. Among 7,083 consecutive SLN biopsy procedures, we retrospectively identified 39 patients with Paget's disease of the breast. Nineteen patients had no associated clinical/radiographic features ("Paget's only"), and 20 patients had associated clinical/radiographic findings ("Paget's with findings"). The mean ages for the Paget's alone and with findings groups were 63.6 and 49.6 years, respectively. The use of breast conservation therapy was 32% in the Paget's alone group and 10% in the Paget's with findings group. Invasive carcinoma was found in 27% of patients in the Paget's alone group and 55% of patients in the Paget's with findings group. The success rate of SLN biopsy was 98%, and the mean number of SLNs removed was 3 in both groups. In the entire cohort of Paget's disease, 28% (11/39) of the patients had positive SLNs (11%, Paget's alone; 45%, Paget's with findings). In our "Paget's only" cohort, invasive cancer was found in 27% of cases and positive SLNs in 11%. SLN biopsy should be considered in all patients with Paget's disease of the breast, whether associated clinical/radiographic findings are present.

Local recurrence after mastectomy for breast cancer: analysis of clinicopathological, biological and prognostic characteristics

Despite the increasing use of breast-conserving therapy, modified radical mastectomy retains an important role in primary as well as in salvage treatment of breast cancer. Nevertheless, a significant number of patients will eventually develop a local recurrence (LR). To identify the potential prognostic factors at the time of the first isolated LR, and to compare the expression of several parameters of the molecular biology of breast carcinomas by primary tumors and paired isolated LRs. We analyzed the medical records from 1,087 women who underwent mastectomy for breast cancer, out of which 98 developed LRs as the first manifestation of tumor progression. We investigated the prognostic value of various classical prognostic factors, at the time of mastectomy as well as when the diagnosis of LR was made. In addition, by using tissue microarrays and immunohistochemical techniques, we analyzed the expression of estrogen (ER), progesterone (PR) and androgen receptors (AR), ki67, p53, c-erbB-2 and apolipoprotein D in primary tumors and paired isolated LRs from a subset of patients (n = 25). Patients who developed distant metastases as well as patients with local recurrent disease showed a significantly higher percentage of larger tumors, node-positive status and higher tumoral grade than patients without evidence of tumoral recurrence. Furthermore, patients with LR had a better outcome compared with those with distant metastases, although the former received less frequently adjuvant systemic therapy and/or radiotherapy. Tumor size, histological grade, ER and PR status, and a shorter disease-free interval (<12 months) were significantly associated with overall survival amongst mastectomized patients that developed isolated LR. There was a significant concordance between primary tumors and LRs regarding the expression of the following factors: ER, PR and p53. However, we were not able to demonstrate similar findings for AR, c-erbB-2 and ki67. In addition, ER, PR and p53 status in the LRs were significantly associated with a poorer overall survival. Based on classical clinicopathological factors as well as on some new biological parameters we have been able to identify subgroups of mastectomized patients with LR differing in their prognosis. Thus, at the present time it would be possible to select group of patients candidates for further and individualized therapeutic strategies.

The prognosis of patients with local recurrence more than five years after breast conservation therapy for invasive breast carcinoma

Aims The increasing use of breast-conserving therapy (BCT) and the rising incidence and improved prognosis of early breast are causing a substantial increase in the absolute number of patients with a late local recurrence following BCT. This study examined the characteristics and the prognosis of patients with a local recurrence occurring more than 5 years after BCT. Methods In the period 1982–1997, 3280 patients with invasive breast cancer underwent breast-conserving therapy in one of the eight community hospitals in the South-eastern part of The Netherlands. Of these patients, 98 developed a local recurrence in the breast more than 5 years after BCT. Results Eighty-five of the 98 recurrences were invasive, 12 were purely in situ and for one patient this information was not available. The 5 years distant recurrence-free survival rate of 85 patients with a late invasive local recurrence was 68% (95% confidence interval [CI], 56–80) and significantly better than the rate of 41% (95% CI, 33–48) in an existing cohort of 173 patients with invasive recurrence within 5 years after BCT ( p=0.007). Local excision of the recurrence was followed by a significantly lower local control rate than salvage mastectomy (50 vs 89%; p=0.004). Conclusion The prognosis of patients with a local recurrence more than 5 years after BCT is significantly better than of patients with local recurrence within 5 years after BCT.

Accurate Axillary Nodal Staging Can be Achieved after Neoadjuvant Therapy for Locally Advanced Breast Cancer

Lymph node status remains the most important prognostic indicator for breast cancer. Recent reports have established that the accuracy of assessing lymph node status is proportional to the number of nodes dissected. The accuracy of axillary staging following neoadjuvant chemotherapy has been cited as a technical concern due to limited node retrieval. The current study attempts to evaluate the ability to perform sentinel node biopsy (SNB) and formal axillary node dissection (AND) following neoadjuvant chemotherapy and to compare these results with non-neoadjuvant patients. One hundred sixteen consecutive patients undergoing SNB with simultaneous AND were retrospectively reviewed. Forty-two of these patients were treated with neoadjuvant chemotherapy prior to AND. Overall success rate in performing SNB in the neoadjuvant group was 95 per cent, and no false negatives have been noted to date. The overall SNB success rate in the non-neoadjuvant group was also 95 per cent with a false negative rate of 3 per cent. After AND in each group, a mean of 21 nodes were retrieved in the neoadjuvant group and 17.9 nodes in the non-neoadjuvant group (P = 0.018). In the neoadjuvant group, there were 19 node positive patients (42%) and 21 patients (28%) in the non-neoadjuvant group (P = 0.16). The mean number of positive nodes per patient was also similar between the two groups (2.9 in the neoadjuvant group vs 1.67 in the non-neoadjuvant group, P = 0.10). Following neoadjuvant therapy, accurate evaluation of the axilla is feasible. In this study, the mean number of nodes is significantly different in favor of the neoadjuvant group, but there is no significant difference in the number of node positive patients identified or in the mean number of positive nodes identified per patient. SNB is technically feasible with accuracy similar to that seen in patients with no history of neoadjuvant therapy. Neoadjuvant chemotherapy extends the use of breast-conserving therapy without sacrificing the ability to accurately stage the axilla either by use of standard axillary dissection or SNB.