Nomograms for Predicting Axillary Response to Neoadjuvant Chemotherapy in Clinically Node-Positive Patients with Breast Cancer

BACKGROUND

Many patients with clinically node-positive breast cancer receive neoadjuvant chemotherapy (NAC). Recent trials suggest the potential for limiting axillary surgery in patients who convert to pathologically node-negative disease. The authors developed a nomogram to predict axillary response to NAC in patients with cN1 disease that can assist clinicians in treatment planning.

METHODS

Patients with cT1-4N1M0 breast cancer who received NAC and underwent axillary lymph node dissection from 2001 through 2013 were identified (n = 584). Uni- and multivariate logistic regression analyses were performed to determine factors predictive of nodal conversion. A nomogram to predict the likelihood of nodal pathologic complete response (pCR) was constructed based on clinicopathologic variables and validated using an external dataset.

RESULTS

Axillary pCR was achieved for 217 patients (37 %). Patients presenting with high nuclear grade [grade 3 vs. 1, odds ratio (OR) 13.4], human epidermal growth factor receptor 2-positive (OR 4.7), estrogen receptor (ER)-negative (OR 3.5), or progesterone receptor-negative (OR 4.3) tumors were more likely to achieve nodal pCR. These factors, together with clinically relevant factors including presence of multifocal/centric disease, clinical T stage, and extent of nodal disease seen on regional nodal ultrasound at diagnosis were used to create nomograms predicting nodal conversion. The discrimination of the nomogram using ER+ status (>1 % staining) versus ER- status [area under the curve (AUC) 78 %] was improved slightly using the percentage of ER staining (AUC 78.7 %). Both nomograms were validated using an external cohort.

CONCLUSION

Nomograms incorporating routine clinicopathologic parameters can predict axillary pCR in node-positive patients receiving NAC and may help to inform treatment decisions.

Evaluation of BRCAPRO Risk Assessment Model in Patients with Ductal Carcinoma In situ Who Underwent Clinical BRCA Genetic Testing

The authors retrospectively aimed to determine which of the following three scenarios, related to DCIS entry into BRCAPRO, predicted BRCA mutation status more accurately: (1) DCIS as an invasive breast cancer (IBC) entered using the actual age of diagnosis, (2) DCIS as IBC entered with 10 years added to the actual age of diagnosis, and (3) DCIS entered as no cancer. Of the 85 DCIS patients included in the study, 19% (n = 16) tested positive for a BRCA mutation, and 81% (n = 69) tested negative. DCIS patients who tested positive for a BRCA mutation had a higher BRCAPRO risk estimation (34.61%) than patients who tested negative (11.4%) when DCIS was entered at the actual age of diagnosis. When DCIS was entered with 10 years added to the actual age at diagnosis, the BRCAPRO estimate was still higher amongst BRCA positive patients (25.4%) than BRCA negative patients (7.1%). When DCIS was entered as no cancer, the BRCAPRO estimate remained higher among BRCA positive patients (2.56%) than BRCA negative patents (1.98%). In terms of accuracy of BRCA positivity, there was no statistically significant difference between DCIS at age at diagnosis, DCIS at 10 years later than age at diagnosis, and DCIS entered as no cancer (AUC = 0.77, 0.784, 0.75, respectively: p = 0.60). Our results indicate that regardless of entry approach into BRCAPRO, there were no significant differences in predicting BRCA mutation in patients with DCIS.

Ten-Year Outcomes of Patients With Breast Cancer With Cytologically Confirmed Axillary Lymph Node Metastases and Pathologic Complete Response After Primary Systemic Chemotherapy

IMPORTANCE

The long-term effect of axillary pathologic complete response (pCR) on survival among women with breast cancer treated with primary systemic chemotherapy (PST) is unknown.

OBJECTIVE

To assess the long-term effect of axillary pCR on relapse-free survival (RFS) and overall survival (OS) in women with breast cancer with cytologically confirmed axillary lymph node metastases treated with PST.

DESIGN, SETTING, AND PARTICIPANTS

We retrospectively analyzed the effect of axillary pCR on 10-year OS and RFS among all women who received a diagnosis of breast cancer stages II to III with cytologically confirmed axillary metastases between 1989 and 2007 who received PST at a large US comprehensive cancer center. Women were stratified by post-PST axillary status, and survival outcomes were estimated and compared according to response in the breast and axilla.

MAIN OUTCOMES AND MEASURES

Outcomes of interest were RFS and OS.

RESULTS

Of 1600 women treated, median (range) age at diagnisis was 49 (21-86) years. A total of 454 (28.4%) achieved axillary pCR. These patients were more likely to have human epidermal growth factor receptor 2 (HER2)-positive and triple-negative disease (P < .001), pCR in the breast (P < .001), high-grade tumors (P < .001), and lower clinical and pathologic T stage (P = .002). Ten-year OS rates were 84% (95% CI, 79%-88%) and 57% (95% CI, 54%-61%) (P < .001) and 10-year RFS rates 79% (95% CI, 74%-83%) and 50% (95% CI, 46%-53%) (P < .001) for patients with axillary pCR and residual axillary disease, respectively. For patients with axillary pCR, 10-year OS rates were 90% (95% CI, 84%-94%) for those with breast pCR and 72% (95% CI, 61%-80%) for those with residual breast disease (P < .001). For patients with residual axillary disease, 10-year OS rates were 66% (95% CI, 56%-74%) for patients with and 56% (95% CI, 52%-60%) for patients without breast pCR (P = .02). Of patients receiving HER2-targeted therapy for HER2-positive disease, 67.1% (100 of 149) achieved axillary pCR; 10-year OS rates were 92% (95% CI, 84%-96%) and 57% (95% CI, 20%-82%) (P = .003) and 10-year RFS rates 89% (95% CI, 81%-94%) and 44% (95% CI, 18%-68%) (P < .001) for those with axillary pCR and residual axillary disease, respectively.

CONCLUSIONS AND RELEVANCE

Axillary pCR was associated with improved 10-year OS and RFS. Patients with axillary and breast pCR after PST had superior long-term survival outcomes. Patients undergoing HER2-targeted therapy for HER2-positive disease had high rates of axillary pCR, and those with axillary pCR had excellent 10-year OS.

Value-Based Breast Cancer Care: A Multidisciplinary Approach for Defining Patient-Centered Outcomes

PURPOSE

Value in healthcare-i.e., patient-centered outcomes achieved per healthcare dollar spent-can define quality and unify performance improvement goals with health outcomes of importance to patients across the entire cycle of care. We describe the process through which value-based measures for breast cancer patients and dynamic capture of these metrics via our new electronic health record (EHR) were developed at our institution.

METHODS

Contemporary breast cancer literature on treatment options, expected outcomes, and potential complications was extensively reviewed. Patient perspective was obtained via focus groups. Multidisciplinary physician teams met to inform a 3-phase process of (1) concept development, (2) measure specification, and (3) implementation via EHR integration.

RESULTS

Outcomes were divided into 3 tiers that reflect the entire cycle of care: (1) health status achieved, (2) process of recovery, and (3) sustainability of health. Within these tiers, 22 patient-centered outcomes were defined with inclusion/exclusion criteria and specifications for reporting. Patient data sources will include the Epic Systems EHR and validated patient-reported outcome questionnaires administered via our institution's patient portal.

CONCLUSIONS

As healthcare costs continue to rise in the United States and around the world, a value-based approach with explicit, transparently reported patient outcomes will not only create opportunities for performance improvement but will also enable benchmarking across providers, healthcare systems, and even countries. Similar value-based breast cancer care frameworks are also being pursued internationally.

Selective elimination of breast cancer surgery in exceptional responders: historical perspective and current trials

With improvements in chemotherapy regimens, targeted therapies, and our fundamental understanding of the relationship of tumor subtype and pathologic complete response (pCR), there has been dramatic improvement in pCR rates in the past decade, especially among triple-negative and human epidermal growth factor receptor 2-positive breast cancers. Rates of pCR in these groups of patients can be in the 60 % range and thus question the paradigm for the necessity of breast and nodal surgery in all cases, particularly when the patient will be receiving adjuvant local therapy with radiotherapy. Current practice for patients who respond well to neoadjuvant chemotherapy (NCT) is often to proceed with the same breast and axillary procedures as would have been offered women who had not received NCT, regardless of the apparent clinical response. Given these high response rates in defined subgroups among exceptional responders it is appropriate to question whether surgery is now a redundant procedure in their overall management. Further, definitive radiation without surgical resection with or without systemic therapy has been proven effective for several other malignant disease sites including some stages of esophageal, anal, laryngeal, prostate, cervical, and lung carcinoma. The main impediments for potential elimination of surgery have been the fact that prior and current standard and functional breast imaging methods are incapable of accurate prediction of residual disease and that integrating percutaneous biopsy of the breast primary and nodes following NCT may circumvent this issue. This article highlights historical attempts at omission of surgery following NCT in an earlier era, the current status of breast and nodal imaging to predict residual carcinoma, and ongoing and planned trials designed to identify appropriate patients who might be selected for clinical trials designed to test the safety of selected elimination of breast cancer surgery in percutaneous image-guided biopsy-proven exceptional responders to NCT.

Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection

PURPOSE

Placing clips in nodes with biopsy-confirmed metastasis before initiating neoadjuvant therapy allows for evaluation of response in breast cancer. Our goal was to determine if pathologic changes in clipped nodes reflect the status of the nodal basin and if targeted axillary dissection (TAD), which includes sentinel lymph node dissection (SLND) and selective localization and removal of clipped nodes, improves the false-negative rate (FNR) compared with SLND alone.

METHODS

A prospective study of patients with biopsy-confirmed nodal metastases with a clip placed in the sampled node was performed. After neoadjuvant therapy, patients underwent axillary surgery and the pathology of the clipped node was compared with other nodes. Patients undergoing TAD had SLND and selective removal of the clipped node using iodine-125 seed localization. The FNR was determined in patients undergoing complete axillary lymphadenectomy (ALND).

RESULTS

Of 208 patients enrolled in this study, 191 underwent ALND, with residual disease identified in 120 (63%). The clipped node revealed metastases in 115 patients, resulting in an FNR of 4.2% (95% CI, 1.4 to 9.5) for the clipped node. In patients undergoing SLND and ALND (n = 118), the FNR was 10.1% (95% CI, 4.2 to 19.8), which included seven false-negative events in 69 patients with residual disease. Adding evaluation of the clipped node reduced the FNR to 1.4% (95% CI, 0.03 to 7.3; P = .03). The clipped node was not retrieved as an SLN in 23% (31 of 134) of patients, including six with negative SLNs but metastasis in the clipped node. TAD followed by ALND was performed in 85 patients, with an FNR of 2.0% (1 of 50; 95% CI, 0.05 to 10.7).

CONCLUSION

Marking nodes with biopsy-confirmed metastatic disease allows for selective removal and improves pathologic evaluation for residual nodal disease after chemotherapy.

Is Sentinel Lymph Node Dissection Warranted for Patients with a Diagnosis of Ductal Carcinoma In Situ?

BACKGROUND

Positive sentinel lymph node (SLN) findings in ductal carcinoma in situ (DCIS) range from 1 to 22 % but have unknown biologic significance. This study sought to identify predictors of positive SLNs and to assess their clinical significance for patients with an initial diagnosis of DCIS.

METHODS

The study identified 1234 patients with an initial diagnosis of DCIS who underwent SLN dissection (SLND) at our institution from 1997 through 2011. Positive SLN findings were categorized as isolated tumor cells (ITCs) (≤0.2 mm), micrometastases (>0.2-2 mm), or macrometastases (>2 mm). Predictors of positive SLNs were analyzed, and survival outcomes were examined.

RESULTS

Positive SLN findings were identified in 132 patients (10.7 %): 66 patients with ITCs (5.4 %), 36 patients with micrometastases (2.9 %), and 30 patients with macrometastases (2.4 %). Upstaging to microinvasive (n = 68, 5.5 %) or invasive (n = 259, 21.0 %) cancer occurred for 327 patients (26.5 %). Factors predicting positive SLNs included diagnosis by excisional biopsy (odds ratio [OR] 1.90; P = 0.007), papillary histology (OR 1.77; P = 0.006), DCIS larger than 2 cm (OR 1.55; P = 0.030), more than three interventions before SLND (4 interventions: OR 2.04; P = 0.022; ≥5 interventions: OR 3.87; P < 0.001), and occult invasion (microinvasive: OR 3.44; P = 0.001; invasive: OR 6.21; P < 0.001). The median follow-up period was 61.7 months. Patients who had pure DCIS with and without positive SLNs had equivalent survival rates (100.0 vs 99.7 %; P = 0.679). Patients with occult invasion and positive SLNs had the worst survival rate (91.7 %; P < 0.001).

CONCLUSIONS

Occult invasion and more than three total interventions were the strongest predictors of positive SLN findings in patients with an initial diagnosis of DCIS. This supports the theory of benign mechanical transport of breast epithelial cells. Except for patients at high risk for invasive disease, routine use of SLND in DCIS is not warranted.

Locoregional Control According to Breast Cancer Subtype and Response to Neoadjuvant Chemotherapy in Breast Cancer Patients Undergoing Breast-conserving Therapy

BACKGROUND

Our group previously published data showing that patients could be stratified by constructed molecular subtype with respect to locoregional recurrence (LRR)-free survival after neoadjuvant chemotherapy and breast-conserving therapy (BCT). That study predated use of trastuzumab for human epidermal growth factor receptor 2 (HER2)-positive patients. The current study was undertaken to determine the impact of subtype and response to therapy in a contemporary cohort.

METHODS

Clinicopathologic data from 751 breast cancer patients who received neoadjuvant chemotherapy (with trastuzumab if HER2(+)) and BCT from 2005 to 2012 were identified. Hormone receptor (HR) and HER2 status were used to construct molecular subtypes: HR(+)/HER2(-) (n = 369), HR(+)/HER2(+) (n = 105), HR(-)/HER2(+) (n = 58), and HR(-)/HER2(-) (n = 219). Actuarial rates of LRR were determined by the Kaplan-Meier method and compared by the log-rank test. Multivariate analysis was performed to determine factors associated with LRR.

RESULTS

The pathologic complete response (pCR) rates by subtype were as follows: 16.5% (HR(+)/HER2(-)), 45.7% (HR(+)/HER2(+)), 72.4% (HR(-)/HER2(+)), and 42.0% (HR(-)/HER2(-)) (P < 0.001). Median follow-up was 4.6 years. The 5-year LRR-free survival rate for all patients was 95.4%. Five-year LRR-free survival rates by subtype were 97.2 % (HR(+)/HER2(-)), 96.1% (HR(+)/HER2(+)), 94.4% (HR(-)/HER2(+)), and 93.4% (HR(-)/HER2(-)) (P = 0.44). For patients with HR(-)/HER2(+) disease, the LRR-free survival rates were 97.4 and 86.7% for those who did and those who did not experience pCR, respectively. For patients with HR(-)/HER2(-) disease, the LRR-free survival rates were 98.6% (pCR) versus 89.9% (no pCR). On multivariate analysis, the HR(-)/HER2(-) subtype, clinical stage III disease, and failure to experience a pCR were associated with LRR.

CONCLUSIONS

Patients undergoing BCT after neoadjuvant chemotherapy have excellent rates of 5-year LRR-free survival that are affected by molecular subtype and by response to neoadjuvant chemotherapy.

Microcalcifications in 1657 Patients with Pure Ductal Carcinoma in Situ of the Breast: Correlation with Clinical, Histopathologic, Biologic Features, and Local Recurrence

PURPOSE

This study was designed to determine the relationship of microcalcification morphology and distribution with clinical, histopathologic, biologic features, and local recurrence (LR) in patients with pure ductal carcinoma in situ (DCIS) of the breast.

METHODS

All patients with pure DCIS who underwent preoperative mammography at our institution from 1996 through 2009 were identified. Mammographic findings were classified according to the ACR BI-RADS lexicon. Associations between mammographic findings and clinical, histopathologic, biologic characteristics, and LR were analyzed. Statistical inference used multiple logistic regression and Cox proportional hazards regression adjusted for age and confounding due to bias from nonrandomized selection of radiation therapy.

RESULTS

We identified 1657 patients with microcalcifications visualized on mammography. The mean age at diagnosis was 55 years (SD, 11). The mean follow-up was 7 years (range 1-16). Ipsilateral LR was 4 % in segmentectomy (987) and 1.5 % in mastectomy (670) patients. Increased LR risk was seen in patients with dense breast tissue (p < 0.05) and larger DCIS size (p < 0.01). Radiation therapy was associated with a 2.8-fold decrease in the LR risk. Fine linear (branching) microcalcifications were associated with 5.2-fold increase in LR. Extremely dense breast tissue was associated with positive/close margins (p = 0.04) and multicentricity (p < 0.01). Younger women were more likely to have extremely dense breast tissue (p < 0.0001), multicentric disease (p < 0.0004), and undergo mastectomy (p < 0.0001).

CONCLUSIONS

Dense breast tissue, large DCIS size, and fine linear (branching) microcalcifications were associated with increased LR, yet overall LR rates remained low. Extremely dense breast tissue was a risk factor for multicentricity and positive margins in DCIS.

Circulating Tumor Cells and Recurrence After Primary Systemic Therapy in Stage III Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is rare and aggressive, with poor survival. While circulating tumor cells (CTCs) predict outcome in non-IBC patients, little data exists regarding their prognostic significance in IBC. This prospective study analyzed blood samples for CTCs from 63 stage III IBC patients to determine if CTCs present after primary systemic chemotherapy predicted relapse. CTC identification was not associated with tumor characteristics, lymph node positivity, or complete pathologic response to systemic therapy. At mean follow-up of 38 months, multivariable analysis demonstrated that detection of one or more CTCs predicted shortened relapse-free (log-rank P = 0.005, hazard ratio [HR] = 4.22, 95% confidence interval [CI] = 1.67 to 10.67, Cox P = 0.002) but not overall survival (log-rank P = 0.54, HR = 1.53, 95% CI = 0.41 to 5.79, Cox P = 0.53). All statistical tests were two-sided. In this study, CTCs after primary chemotherapy identified IBC patients at high risk for relapse.

Breast Cancer Management Updates: Young and Older, Pregnant, or Male

Every year, more and more patients fall into rare or extreme categories of breast cancer-young, elderly, pregnant, or male. Contributing factors may be improved risk assessment and screening techniques (especially of dense breast tissue), delayed childbearing, and the aging population. These patients can challenge usual medical decision making because of their unique situation. There might be a concern for the fetus, worry about future fertility, a question of local control in a man, or concern for overdiagnosis or overtreatment in an older patient. Because these populations are seldom included in the large breast cancer trials from which standard treatment recommendations are made, an update on management for young, elderly, pregnant, and male breast cancer patients may be helpful.

Targeting and limiting surgery for patients with node-positive breast cancer

The presence of axillary nodal metastases has a significant impact on locoregional and systemic treatment decisions. Historically, all node-positive patients underwent complete axillary lymph node dissection; however, this paradigm has changed over the last 10 years. The use of sentinel lymph node dissection has expanded from its initial role as a surgical staging procedure in clinically node-negative patients. Clinically node-negative patients with small volume disease found on sentinel lymph node dissection now commonly avoid more extensive axillary surgery. There is interest in expanding this role to node-positive patients who receive neoadjuvant chemotherapy as a way to restage the axilla in hopes of sparing women who convert to node-negative status from the morbidity of complete nodal clearance. While sentinel lymph node dissection alone may not accomplish this goal, there are novel techniques, such as targeted axillary dissection, that may now allow for reliable nodal staging after chemotherapy.

Predictors that Influence Election of Contralateral Prophylactic Mastectomy among Women with Ductal Carcinoma in Situ who are BRCA-Negative

The authors retrospectively examined the contralateral prophylactic mastectomy (CPM) rate among 100 women with ductal carcinoma in situ who are BRCA negative. Of 100 women with ductal carcinoma in situ, 31 elected contralateral prophylactic mastectomy (CPM). Factors associated with increased likelihood of undergoing contralateral prophylactic mastectomy (CPM) among this cohort were: family history of ovarian cancer, marital status, reconstruction, mastectomy of the affected breast, and tamoxifen use.

Selective surgical localization of axillary lymph nodes containing metastases in patients with breast cancer: a prospective feasibility trial

IMPORTANCE

Nodal ultrasonography with needle biopsy of abnormal lymph nodes helps to define the extent of breast cancer before neoadjuvant chemotherapy. A clip can be placed to designate lymph nodes with documented metastases. Targeted axillary dissection or selective removal of lymph nodes known to contain metastases (clip-containing nodes) as well as sentinel lymph nodes (SLNs) may provide more accurate assessment of the pathologic response after neoadjuvant chemotherapy.

OBJECTIVE

To determine the feasibility of image-guided localization and resection of lymph nodes containing known metastases.

DESIGN, SETTING, AND PARTICIPANTS

This prospective feasibility trial performed at MD Anderson Cancer Center, Houston, Texas, included 12 patients with axillary nodal metastases confirmed by results of fine-needle aspiration biopsy who had a clip placed in the lymph node targeted for biopsy from December 1, 2012, through November 30, 2013.

INTERVENTIONS

Preoperative targeting of the clip-containing lymph node under ultrasonographic guidance consisting of wire localization in 2 patients and placement of radioactive iodine I 125 (125I)-labeled seeds in 10 patients. Surgeons removed the localized lymph node before completion axillary lymph node dissection and used radiography of the specimen to confirm removal of the clip-containing lymph node and seed.

MAIN OUTCOMES AND MEASURES

Confirmation of the removal of the clip-containing lymph node.

RESULTS

Image-guided localization and selective removal were successful in all 12 patients. Five patients underwent SLN dissection in addition to removal of the clip-containing lymph node. Placement of 125I seeds did not interfere with lymphoscintigraphy or intraoperative identification of SLNs. In 4 of the 5 patients (80%), the clip-containing lymph node was one of the SLNs. Ten patients completed neoadjuvant chemotherapy before surgery. Of the 9 patients who underwent lymph node dissection, 4 (44%) had residual nodal disease after chemotherapy; all had disease identified in the clip-containing lymph node.

CONCLUSIONS AND RELEVANCE

Axillary lymph nodes marked with a clip can be localized and selectively removed to accomplish targeted axillary dissection, which is technically possible after chemotherapy and is easily performed with other axillary surgery, such as SLN dissection. The ability to add selective removal of the clip-containing lymph nodes to SLN dissection may identify patients for limited nodal surgery after chemotherapy with increased accuracy for determining residual disease compared with SLN identification alone.

Racial disparities in adoption of axillary sentinel lymph node biopsy and lymphedema risk in women with breast cancer

IMPORTANCE

Racial disparities exist in many aspects of breast cancer care. Sentinel lymph node biopsy (SLNB) was developed to replace axillary lymph node dissection (ALND) for staging early breast cancer to minimize complications. Racial disparities in the use of SLNB remain incompletely characterized, and their effect on lymphedema risk is not known.

OBJECTIVE

To determine racial differences in SLNB use among patients with pathologically node-negative breast cancer during the period when SLNB became the preferred method for axillary staging as well as whether such differences affect lymphedema risk.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective study was conducted using the Surveillance, Epidemiology, and End Results-Medicare-linked database from 2002 through 2007 to identify cases of incident, nonmetastatic, pathologically node-negative breast cancer in women aged 66 years or older.

MAIN OUTCOMES AND MEASURES

Sentinel lymph node biopsy use and 5-year cumulative incidence of lymphedema by race.

RESULTS

Of 31 274 women identified, 1767 (5.6%) were black, 27 856 (89.1%) were white, and 1651 (5.3%) were of other or unknown race. Sentinel lymph node biopsy was performed in 73.7% of white patients and 62.4% of black patients (P < .001). The use of SLNB increased by year for both black and white patients (P < .001); however, a fixed disparity of approximately 12 percentage points in SLNB use persisted through 2007. In adjusted analysis, black patients were significantly less likely than white patients to undergo SLNB (odds ratio, 0.67; 95% CI, 0.60-0.75; P < .001). Overall, the 5-year cumulative lymphedema risk was 8.2% in whites and 12.3% in blacks (hazard ratio [HR], 1.43; 95% CI, 1.23-1.67; P < .001). When stratified by type of axillary surgery, 5-year lymphedema risk was 6.8% in whites undergoing SLNB (HR, 1 [reference]), 8.8% in blacks undergoing SLNB (HR, 1.28; 95% CI, 1.02-1.60; P = .03), 12.2% in whites undergoing ALND (1.79; 1.63-1.96; P < .001), and 18.0% in blacks undergoing ALND (2.76; 2.25-3.39; P < .001).

CONCLUSIONS AND RELEVANCE

Although SLNB use increased in both black and white patients with pathologically node-negative breast cancer from 2002 through 2007, the rates of SLNB remained lower in black than white patients during this entire period by approximately 12 percentage points. This racial disparity in SLNB use contributed to racial disparities in lymphedema risk. Improvements in the dissemination of new techniques are needed to avoid disparities in breast cancer care and patient outcomes, particularly in disadvantaged groups.

Predicting the extent of nodal disease in early-stage breast cancer

BACKGROUND

The role of regional nodal ultrasound (US) has been questioned since publication of the American College of Surgeons Oncology Group (ACOSOG) Z0011 data. The goal of this study was to determine if imaging and clinicopathologic features could predict the extent of axillary nodal involvement in breast cancer.

STUDY DESIGN

Patients with T1-T2 tumors who underwent regional nodal US and axillary lymph node dissection from 2002 to 2012 were identified from a prospective database excluding those who received neoadjuvant chemotherapy. Patients whose metastases were identified by US confirmed by needle biopsy were compared with those identified by sentinel lymph node dissection (SLND) after a negative US.

RESULTS

Metastases were identified by US in 190 patients, and by SLND in 518 patients. SLND patients had fewer positive nodes (2.2 vs. 4.1; p < 0.0001), smaller metastases (5.3 vs. 13.8 mm; p < 0.0001), and a lower incidence of extranodal extension (24 vs. 53 %; p < 0.0001) than the US group. Even when US identified ≤2 abnormal nodes, patients were still more likely to have ≥3 positive nodes (45 %) than SLND patients (19 %; p < 0.001). After adjusting for tumor size, receptor status, and histology, multivariate analysis revealed that metastases identified by US [odds ratio (OR) 4.01; 95 % confidence interval (CI) 2.75-5.84] and lobular histology (OR 1.77; 95 % CI 1.06-2.95) predicted having ≥3 positive nodes.

CONCLUSIONS

Imaging and clinicopathologic features can be used to predict the extent of nodal involvement. Patients with US-detected metastases, even if small volume, have a higher burden of nodal involvement than patients with SLND-detected metastases and may not be comparable with patients in the ACOSOG Z0011 trial.

Timing of infectious complications following breast-conserving therapy with catheter-based accelerated partial breast irradiation

BACKGROUND

Accelerated partial breast irradiation (APBI) has been used as an alternative to whole-breast irradiation as part of breast-conserving therapy. Indications and outcomes are topics of ongoing investigation. Previous publications have focused on early postoperative infections and reported low rates of delayed infection. We investigated the pattern of infection after catheter-based APBI at our institution.

METHODS

Patients who underwent single-entry catheter-based APBI were identified from an institutional prospective registry including data regarding comorbidities and outcomes. Time of infection was calculated from the date of definitive catheter insertion and classified as early (≤30 days) or delayed.

RESULTS

A total of 91 breast cancer patients were treated with APBI and enrolled in the registry from 2009 to 2011. The median follow-up was 484 days. Breast infection occurred in 13 (14.3 %), with 3 (3.3 %) occurring within 30 days of catheter placement and 10 (11.0 %) in a delayed fashion. Four patients required hospital admission, five underwent percutaneous aspiration, and one underwent incision and drainage. Eight were treated as outpatients with oral antibiotics alone.

CONCLUSIONS

Consistent with other reports, we found an overall infection rate of 14.3 % with single-entry catheter-based APBI. There were substantially fewer infections in the early postoperative period than reported elsewhere, but there were more delayed infections. The intensive follow-up in our study likely identified late infections that may not have otherwise been recognized. Vigilance for infectious complications must continue beyond the immediate treatment period in patients undergoing catheter-based APBI. These infections can range in severity but typically can be managed in an outpatient setting.

Implementation of the american college of surgeons oncology group z1071 trial data in clinical practice: is there a way forward for sentinel lymph node dissection in clinically node-positive breast cancer patients treated with neoadjuvant chemotherapy?

For clinically node-positive breast cancer patients receiving neoadjuvant chemotherapy, approximately 40 % will be found to be pathologically node negative. The American College of Surgeons Oncology Group Z1071 trial was therefore conducted to evaluate sentinel lymph node dissection (SLND) in these patients. The trial's primary end point was to determine the false-negative rate (FNR) among patients with clinical N1 disease in whom at least 2 sentinel lymph nodes (SLNs) were identified. The FNR was 12.6 %, which exceeded the prespecified end point of 10.0 %. After data publication, our multidisciplinary team discussed the trial results and how we may incorporate the findings into clinical practice. Patient selection and surgical technique are critical. As an example, when dual tracer technique was used, the FNR was 10.8 %. Data from the trial presented at the San Antonio Breast Cancer Symposium suggested that the FNR could be improved if a clip was placed in the biopsy-proven positive lymph node and removal of that node during SLND was confirmed. Taking this into consideration, we have proposed an approach to surgical management of the axilla in clinically node-positive patients receiving neoadjuvant chemotherapy termed targeted axillary dissection (TAD). TAD involves placing a clip at the time a lymph node is determined to be positive. After completion of neoadjuvant chemotherapy, the clipped node is localized by using a wire or radioactive seed, and during the SLND procedure, all SLNs and the clipped node are removed. We are currently evaluating the efficacy of TAD in axillary staging after neoadjuvant chemotherapy.

Locoregional recurrence risk for patients with T1,2 breast cancer with 1-3 positive lymph nodes treated with mastectomy and systemic treatment

PURPOSE

Postmastectomy radiation therapy (PMRT) has been shown to benefit breast cancer patients with 1 to 3 positive lymph nodes, but it is unclear how modern changes in management have affected the benefits of PMRT.

METHODS AND MATERIALS

We retrospectively analyzed the locoregional recurrence (LRR) rates in 1027 patients with T1,2 breast cancer with 1 to 3 positive lymph nodes treated with mastectomy and adjuvant chemotherapy with or without PMRT during an early era (1978-1997) and a later era (2000-2007). These eras were selected because they represented periods before and after the routine use of sentinel lymph node surgery, taxane chemotherapy, and aromatase inhibitors.

RESULTS

19% of 505 patients treated in the early era and 25% of the 522 patients in the later era received PMRT. Patients who received PMRT had significantly higher-risk disease features. PMRT reduced the rate of LRR in the early era cohort, with 5-year rates of 9.5% without PMRT and 3.4% with PMRT (log-rank P=.028) and 15-year rates 14.5% versus 6.1%, respectively; (Cox regression analysis: adjusted hazard ratio [AHR] 0.37, P=.035). However, PMRT did not appear to benefit patients treated in the later cohort, with 5-year LRR rates of 2.8% without PMRT and 4.2% with PMRT (P=.48; Cox analysis: AHR 1.41, P=.48). The most significant factor predictive of LRR for the patients who did not receive PMRT was the era in which the patient was treated (AHR 0.35 for later era, P<.001).

CONCLUSION

The risk of LRR for patients with T1,2 breast cancer with 1 to 3 positive lymph nodes treated with mastectomy and systemic treatment is highly dependent on the era of treatment. Modern treatment advances and the selected use of PMRT for those with high-risk features have allowed for identification of a cohort at very low risk for LRR without PMRT.

Predictors that influence contralateral prophylactic mastectomy election among women with ductal carcinoma in situ who were evaluated for BRCA genetic testing

BACKGROUND

Patients with ductal carcinoma in situ (DCIS) are at increased risk for developing contralateral breast cancer (CBC). Consequently, more women with DCIS are electing to undergo contralateral prophylactic mastectomy (CPM). We evaluated factors associated with CPM in patients with DCIS who underwent genetic counseling for BRCA testing.

METHODS

This retrospective study involved 165 women with DCIS referred for genetic counseling between 2003 and 2011. Patient characteristics were age, marital and educational status, tumor markers, nuclear grade, family history of breast cancer (BC) and ovarian cancer (OC), race, Ashkenazi Jewish ancestry, and BRCA results. Univariate and multivariate logistic regression analyses were used to determine predictive factors associated with CPM election.

RESULTS

Of 165 patients, 44 (27 %) underwent CPM. Patients <45 years of age were more likely to elect CPM (p = 0.0098). A BRCA+ mutation was found in 17 patients (10.3 %), and BRCA+ women were more likely to elect CPM than BRCA or untested women (p = 0.0001). Patients who had a family history of OC (57.7 %) were more likely to choose CPM than those with no family history (p = 0.0004). Younger age, BRCA+, and an OC family history remained significant in the multivariate model (p < 0.008).

CONCLUSION

The CPM rate among patients with DCIS who undergo genetic counseling is high. Factors associated with increased likelihood of CPM among this group were age, BRCA+, and a family history of OC. Further studies are needed to evaluate patients' perceptions of CBC risk and their role in the likelihood of CPM choice.

Breast conservation therapy after neoadjuvant chemotherapy: optimization of a multimodality approach

Neoadjuvant chemotherapy (NAC) is routinely used in locally advanced breast cancer, but is increasingly used in early stage patients. Even patients with advanced disease can achieve excellent outcomes with breast conservation therapy (BCT) after NAC. The use of NAC followed by BCT is an example of how multimodality therapy can optimize outcomes while limiting morbidity and preserving cosmetic outcomes. Open communication between the multidisciplinary team is crucial to selecting appropriate candidates for this approach.

Which threshold for ER positivity? a retrospective study based on 9639 patients

BACKGROUND

Guidelines for the use of chemotherapy and endocrine therapy recently recommended that estrogen receptor (ER) status be considered positive if ≥1% of tumor cells demonstrate positive nuclear staining by immunohistochemistry. In clinical practice, a range of thresholds are used; a common one is 10% positivity. Data addressing the optimal threshold with regard to the efficacy of endocrine therapy are lacking. In this study, we compared patient, tumor, treatment and survival differences among breast cancer patients using ER-positivity thresholds of 1% and 10%.

METHODS

The study population consisted of patients with primary breast carcinoma treated at our center from January 1990 to December 2011 and whose records included complete data on ER status. Patients were separated into three groups: ≥10% positive staining for ER (ER-positive ≥10%), 1%-9% positive staining for ER (ER-positive 1%-9%) and <1% positive staining (ER-negative).

RESULTS

Of 9639 patients included, 80.5% had tumors that were ER-positive ≥10%, 2.6% had tumors that were ER-positive 1%-9% and 16.9% had tumors that were ER-negative. Patients with ER-positive 1%-9% tumors were younger with more advanced disease compared with patients with ER-positive ≥10% tumors. At a median follow-up of 5.1 years, patients with ER-positive 1%-9% tumors had worse survival rates than did patients with ER-positive ≥10% tumors, with and without adjustment for clinical stage and grade. Survival rates did not differ significantly between patients with ER-positive 1%-9% and ER-negative tumors.

CONCLUSIONS

Patients with tumors that are ER-positive 1%-9% have clinical and pathologic characteristics different from those with tumors that are ER-positive ≥10%. Similar to patients with ER-negative tumors, those with ER-positive 1%-9% disease do not appear to benefit from endocrine therapy; further study of its clinical benefit in this group is warranted. Also, there is a need to better define which patients of this group belong to basal or luminal subtypes.

Primary tumor resection as a component of multimodality treatment may improve local control and survival in patients with stage IV inflammatory breast cancer

BACKGROUND

To the authors' knowledge, the benefit of primary tumor resection among patients with metastatic inflammatory breast cancer (IBC) is unknown.

METHODS

The authors reviewed 172 cases of metastatic IBC. All patients received chemotherapy with or without radiotherapy and/or surgery. Patients were classified as responders or nonresponders to chemotherapy. The 5-year overall survival (OS) and distant progression-free survival (DPFS) and local control at the time of last follow-up were evaluated.

RESULTS

A total of 79 patients (46%) underwent surgery. OS and DPFS were better among patients treated with surgery versus no surgery (47% vs 10%, respectively [P<.0001] and 30% vs 3%, respectively [P<.0001]). Surgery plus radiotherapy was associated with better survival compared with treatment with surgery or radiotherapy alone (OS rate: 50% vs 25% vs 14%, respectively; DPFS rate: 32% vs 18% vs 15%, respectively [P<.0001 for both]). Surgery was associated with better survival for both responders (OS rate for surgery vs no surgery: 49% vs 23% [P<.0001] and DPFS rate for surgery vs no surgery: 31% vs 8% [P<.0001]) and nonresponders (OS rate for surgery vs no surgery: 40% vs 6% [P<.0001] and DPFS rate for surgery vs no surgery: 30% vs 0% [P<.0001]). On multivariate analysis, treatment with surgery plus radiotherapy and response to chemotherapy were found to be significant predictors of better OS and DPFS. Local control at the time of last follow-up was 4-fold more likely in patients who underwent surgery with or without radiotherapy compared with patients who received chemotherapy alone (81% vs 18%; P<.0001). Surgery and response to chemotherapy independently predicted local control on multivariate analysis.

CONCLUSIONS

The results of the current study demonstrate that for select patients with metastatic IBC, multimodality treatment including primary tumor resection may result in better local control and survival. However, a randomized trial is needed to validate these findings.

Abstract P5-14-07: Comparison of infectious complications between breast conserving therapy with catheter-based accelerated partial irradiation and whole breast irradiation

Standard treatment after breast conserving surgery (BCS) has been whole breast irradiation (WBI), however, accelerated partial breast irradiation (APBI) has recently been shown to be an alternative in a select group of patients. APBI has been associated with early postoperative as well as delayed infections. In the current study, we compared rates of infectious complications between patients treated with catheter-based APBI and WBI.

Patients were identified from a single-institution prospective registry from 2009 to 2011. Selection criteria included patients who underwent BCT with either single-entry APBI or WBI and fulfilled criteria for ABPI including ≥50 years, tumor size ≤ 3cm, pN0, and no lympho-vascular invasion. Data regarding treatment, patient comorbidities, and outcomes were obtained. Infectious complications were assessed from the date of APBI catheter insertion or from the date of surgery to start of WBI. Infectious complications were classified as early (≤ 30 days) or delayed (&gt; 30 days). Fisher's exact test was used to compare the rate of infection between APBI and WBI.

91 patients were treated with single-entry catheter-based APBI and 267 patients were treated with WBI. Median follow-up time was 76.2 weeks for APBI patients and 115 weeks for WBI patients. Re-excision was required in 20 patients (21.7%) who underwent APBI and in 51 patients (19.1%) who underwent WBI. Overall, infection occurred in 13 patients (14.1%) who underwent APBI versus 39 patients (14.6%) who underwent WBI. In the APBI group, three (3.3%) patients had infection within 30 days and 10 (10.9%) had infection more than 30 days after catheter insertion. 24 (9.0%) patients had infections within 30 days after surgery and 15 (5.6%) patients occurred more than 30 days after surgery in the WBI group. Patients began WBI within an average of 84 days after surgery. In the APBI group, 4 patients required hospital admission, 5 patients had percutaneous aspiration, and one needed incision and drainage. 8 patients were managed with outpatient oral antibiotics. In the WBI group, 5 patients required hospital admission, 13 patients had percutaneous aspiration, and 30 patients were managed with outpatient oral antibiotics. Diabetes, smoking, and BMI &gt;25 were factors commonly associated with infectious complications in both APBI and WBI but not statistically significant (P = 0.6, 0.09, 0.1. respectively).

In contrast to other studies showing that patients treated with catheter-based APBI have higher rates of infection than patients treated with WBI, our study found no statistically significant difference in infection rates between the two groups. A majority of infections following APBI or WBI can be medically managed as an outpatient basis.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-07.

Clinical course of breast cancer patients with isolated sternal and full-thickness chest wall recurrences treated with and without radical surgery

BACKGROUND

The role and outcome of radical surgery in contemporary multidisciplinary management of breast cancer patients presenting with isolated sternal or fullthickness chest wall (SCW) recurrence are undefined compared with patients treated without surgery.

METHODS

Detailed analyses of all patients with isolated SCW recurrence treated from 1992 to 2011 at a large cancer institution were performed. Univariate and multivariate comparisons of clinicopathologic and treatment characteristics were analyzed. Overall and progression-free survival were compared using the Kaplan–Meier method.

RESULTS

Seventy-six patients were identified, 44 treated surgically and 32 nonsurgically. Overall survival at 5 years was not statistically different between patients who underwent surgery and those who did not (30.6 and 49.6 %, respectively; P = 0.52) although patients selected for surgery presented with more advanced and biologically aggressive disease. Surgically treated patients were more likely to have triple-negative breast cancer at recurrence (52 vs. 17 %; P = 0.006). Among surgical patients, 95 % received preoperative systemic therapy. Clinical response with systemic therapy was significantly different, with surgically treated patients more likely to have responsive or stable disease (54 vs. 25 %, P = 0.04). Complications related to radical surgical resection occurred in 25 % of patients. For hormone receptor–positive recurrence, 5-year progression-free survival was significantly higher among surgical patients (46.3 vs. 14.5 %; P = 0.01).

CONCLUSIONS

Among patients with isolated SCW recurrence, hormone receptor-positive recurrence is associated with improved survival. Systemic therapy should be the initial treatment, and clinical response can be used to help select patients who may benefit from radical resection.

Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial

IMPORTANCE

Sentinel lymph node (SLN) surgery provides reliable nodal staging information with less morbidity than axillary lymph node dissection (ALND) for patients with clinically node-negative (cN0) breast cancer. The application of SLN surgery for staging the axilla following chemotherapy for women who initially had node-positive cN1 breast cancer is unclear because of high false-negative results reported in previous studies.

OBJECTIVE

To determine the false-negative rate (FNR) for SLN surgery following chemotherapy in women initially presenting with biopsy-proven cN1 breast cancer.

DESIGN, SETTING, AND PATIENTS

The American College of Surgeons Oncology Group (ACOSOG) Z1071 trial enrolled women from 136 institutions from July 2009 to June 2011 who had clinical T0 through T4, N1 through N2, M0 breast cancer and received neoadjuvant chemotherapy. Following chemotherapy, patients underwent both SLN surgery and ALND. Sentinel lymph node surgery using both blue dye (isosulfan blue or methylene blue) and a radiolabeled colloid mapping agent was encouraged.

MAIN OUTCOMES AND MEASURES

The primary end point was the FNR of SLN surgery after chemotherapy in women who presented with cN1 disease. We evaluated the likelihood that the FNR in patients with 2 or more SLNs examined was greater than 10%, the rate expected for women undergoing SLN surgery who present with cN0 disease.

RESULTS

Seven hundred fifty-six women were enrolled in the study. Of 663 evaluable patients with cN1 disease, 649 underwent chemotherapy followed by both SLN surgery and ALND. An SLN could not be identified in 46 patients (7.1%). Only 1 SLN was excised in 78 patients (12.0%). Of the remaining 525 patients with 2 or more SLNs removed, no cancer was identified in the axillary lymph nodes of 215 patients, yielding a pathological complete nodal response of 41.0% (95% CI, 36.7%-45.3%). In 39 patients, cancer was not identified in the SLNs but was found in lymph nodes obtained with ALND, resulting in an FNR of 12.6% (90% Bayesian credible interval, 9.85%-16.05%).

CONCLUSIONS AND RELEVANCE

Among women with cN1 breast cancer receiving neoadjuvant chemotherapy who had 2 or more SLNs examined, the FNR was not found to be 10% or less. Given this FNR threshold, changes in approach and patient selection that result in greater sensitivity would be necessary to support the use of SLN surgery as an alternative to ALND.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00881361.

Outcomes and predictive factors for salvage therapy after local--regional recurrence following neoadjuvant chemotherapy and breast conserving therapy

BACKGROUND

There are few data addressing local-regional recurrence (LRR) and salvage therapies in patients treated with neoadjuvant chemotherapy (NCT) compared to those treated with surgery first. We characterize the clinical course and predictive features of salvage treatment for LRR after breast conserving therapy (BCT) analyzed by initial treatment.

METHODS

We identified 1,589 patients who underwent BCT; 1,141 (72 %) patients underwent initial surgery, and 448 (28 %) received NCT. Kaplan-Meier and Cox regression analyses were performed to analyze factors associated with overall survival (OS), local control (LC) of recurrence, and distant metastasis-free survival (DMFS) following LRR.

RESULTS

56 patients had a LRR, for a crude recurrence rate of 3 %. For patients with potentially curable recurrence (excluding distant metastases within 3 months of LRR), the 5-year OS, LC, and DMFS rates were 52, 77, and 69 %. On multivariate analysis, initial pathologically negative node status and use of surgery for salvage were significant factors associated with higher OS. Additionally, older age was associated with higher LC rates after salvage. Estrogen receptor-positive disease and surgery for LRR were associated with reduced risk of distant metastases; regional recurrence and use of initial adjuvant chemotherapy were associated with increased risk of distant metastases. For each of these endpoints, the addition of NCT to the multivariate model did not approach significance.

CONCLUSIONS

LRR is an uncommon event after BCT and many patients with LRR remain curable (5-year OS >50 %). Our data indicate that NCT does not compromise salvage after LRR, providing further assurance that this strategy is safe for appropriately selected breast cancer patients.

Feasibility of confocal fluorescence microscopy for real-time evaluation of neoplasia in fresh human breast tissue

Breast cancer management could be improved by developing real-time imaging tools to assess tissue architecture without extensive processing. We sought to determine whether confocal fluorescence microscopy (CFM) provides sufficient information to identify neoplasia in breast tissue. Breast tissue specimens were imaged following proflavine application. Regions of interest (ROIs) were selected in histologic slides and in the corresponding region on confocal images, and then divided into sets for training and validation. Readers reviewed images in the training set and evaluated images in the validation set for the presence of neoplasia. Accuracy was assessed using histologic diagnosis as the gold standard. Seventy tissue specimens from 31 patients were imaged; 235 ROIs were identified and diagnosed as neoplastic or non-neoplastic. A training set was assembled using 23 matched ROIs; 49 matched ROIs were assembled into a validation set. Neoplasia was identified in histologic images: 93% sensitivity, 97% specificity [area under the curve (AUC=0.987)] and in confocal images: 93% sensitivity 93% specificity (AUC=0.957). CFM produced images of architectural features in breast tissue comparable with conventional histology, while requiring little processing. Potential applications include assessment of excised tissue margins and evaluation of tissue adequacy for bio-banking and genomic studies.

Incidence and consequence of close margins in patients with ductal carcinoma-in situ treated with mastectomy: is further therapy warranted?

BACKGROUND

The impact of close margins in patients with ductal carcinoma-in situ (DCIS) treated with mastectomy is unclear; however, this finding may lead to a recommendation for postmastectomy radiotherapy (PMRT). We sought to determine the incidence and consequences of close margins in patients with DCIS treated with mastectomy.

METHODS

The records of 810 patients with DCIS treated with mastectomy from 1996 through 2009 were reviewed. Clinical and pathologic factors were analyzed with respect to final margin status. Median follow-up was 6.3 years.

RESULTS

Overall, 94 patients (11.7 %) had close margins (positive, n = 5; negative but ≤1 mm, n = 54; 1.1-2.9 mm, n = 35). Independent risk factors for close margins included multicentricity, pathologic lesion size ≥1.5 cm, and necrosis, but not age, use of skin-sparing mastectomy, or immediate reconstruction (p > 0.05). Seven patients received PMRT, and none had a locoregional recurrence (LRR). Among the remaining 803 patients, the 10-year LRR rate was 1 % (5.0 % for margins ≤1 mm, 3.6 % for margins 1.1-2.9 mm, and 0.7 % for margins ≥3 mm [p < 0.001]). The 10-year rate of contralateral breast cancer was 6.4 %. On multivariate analysis, close margins was the only independent predictor of LRR (p = 0.005).

CONCLUSIONS

Close margins occur in a minority of patients undergoing mastectomy for DCIS and is the only independent risk factor for LRR. As the LRR rate in patients with close margins is low and less than the rate of contralateral breast cancer, PMRT is not warranted except for patients with multiple close/positive margins that cannot be surgically excised.

Establishing a program for individuals at high risk for breast cancer

Our need to create a program for individuals at high risk for breast cancer development led us to research the available data on such programs. In this paper, we summarize our findings and our thinking process as we developed our own program. Breast cancer incidence is increasing worldwide. Even though there are known risk factors for breast cancer development, approximately 60% of patients with breast cancer have no known risk factor, although this situation will probably change with further research, especially in genetics. For patients with risk factors based on personal or family history, different models are available for assessing and quantifying risk. Assignment of risk levels permits tailored screening and risk reduction strategies. Potential benefits of specialized programs for women with high breast cancer risk include more cost -effective interventions as a result of patient stratification on the basis of risk; generation of valuable data to advance science; and differentiation of breast programs from other breast cancer units, which can result in increased revenue that can be directed to further improvements in patient care. Guidelines for care of patients at high risk for breast cancer are available from various groups. However, running a high-risk breast program involves much more than applying a guideline. Each high-risk program needs to be designed by its institution with consideration of local resources and country legislation, especially related to genetic issues. Development of a successful high-risk program includes identifying strengths, weaknesses, opportunities, and threats; developing a promotion plan; choosing a risk assessment tool; defining "high risk"; and planning screening and risk reduction strategies for the specific population served by the program. The information in this article may be useful for other institutions considering creation of programs for patients with high breast cancer risk.

Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status

The clinicopathologic, mammographic, and sonographic findings in patients with pure ductal carcinoma in situ (DCIS) were assessed by estrogen receptor (ER) expression. After institutional review board approval, patients with pure DCIS evaluated from January 1996 to July 2009 with known ER status and available imaging were identified. Images were reviewed as per the ACR BI-RADS(®) lexicon (4th edition). Clinical, pathologic, and imaging characteristics were analyzed by ER status using t test, Chi square test, and Fisher's exact test. Of 1,219 patients with pure DCIS and known ER status identified, 1,187 with complete data were included. Mammography was performed in all 1,187 patients and sonography in 519 (44 %). There were 972 (82 %) patients with ER-positive and 215 (18 %) with ER-negative disease. ER-negative DCIS was more likely to be high grade (93 vs 44 %, p < 0.0001), associated with comedonecrosis (64 vs 29 %, p < 0.0001), and multifocal (23 vs 15 %, p = 0.009). On sonography, ER-negative DCIS was more likely to be visible (61 vs 46 %, p = 0.004), larger (mean size, 2.3 vs 1.6 cm, p = 0.006), and show posterior shadowing (53 vs 28 %, p = 0.006). Mastectomy was more frequently performed for ER-negative DCIS (47 vs 37 %, p = 0.008). Palpable DCIS was visible on sonography in 55 % of cases and mammography in 81 %. Compared with ER-positive palpable DCIS, ER-negative palpable DCIS was larger and more likely to be visible on sonography. Compared with ER-positive noncalcified DCIS, ER-negative noncalcified DCIS was less likely to be visible on mammography. ER-positive and ER-negative pure DCIS have different clinicopathologic and imaging characteristics. ER-negative DCIS is associated with worse prognostic factors than ER-positive DCIS. On sonography, ER-negative DCIS is more frequently visible than ER-positive DCIS, tends to be larger, and more frequently demonstrates posterior shadowing.

Case control study of women treated with chemotherapy for breast cancer during pregnancy as compared with nonpregnant patients with breast cancer

BACKGROUND

The purpose of this analysis was to compare disease-free survival (DFS), progression-free survival (PFS), and overall survival (OS) between pregnant and nonpregnant patients with breast cancer.

METHODS

From 1989 to 2009, 75 women were treated with chemotherapy during pregnancy. Each pregnant case was matched on age and cancer stage to two nonpregnant patients with breast cancer (controls). Fisher's exact test, the Kaplan-Meier method, and Cox proportional hazards regression models were used.

RESULTS

Median follow-up time for patients who were alive at the end of follow-up (n = 159) was 4.20 years (range: 0.28-19.94 years). DFS at 5 years was 72% (95% confidence interval [CI]: 58.3%-82.1%) for pregnant patients and 57% (95% CI: 46.7%-65.8%) for controls (p = .0115). Five-year PFS was 70% (95% CI: 56.8%-80.3%) for pregnant patients and 59% (95% CI: 49.1%-67.5%) for controls (p = .0252). Five-year OS was 77% (95% CI: 63.9%-86.4%) for pregnant patients and 71% (95% CI: 61.1%-78.3%) for controls (p = .0461). Hazard ratio estimates favored improved survival for pregnant patients in univariate analyses and multivariate analyses, controlling for age, year of diagnosis, stage, and tumor grade.

CONCLUSIONS

For patients who received chemotherapy during pregnancy, survival was comparable to-if not better than-that of nonpregnant women. Pregnant patients with breast cancer should receive appropriate local and systemic therapy for breast cancer.

Pathologic complete response to neoadjuvant chemotherapy with trastuzumab predicts for improved survival in women with HER2-overexpressing breast cancer

BACKGROUND

We sought to determine the prognostic value of pathologic response to neoadjuvant chemotherapy with concurrent trastuzumab.

PATIENTS AND METHODS

Two hundred and twenty-nine women with HER2/neu (HER2)-overexpressing breast cancer were treated with neoadjuvant chemotherapy plus trastuzumab between 2001 and 2008. Patients were grouped based on pathologic complete response (pCR, n = 114) or less than pCR (<pCR, n = 115); as well as by pathologic stage. Locoregional recurrence-free (LRFS), distant metastasis-free (DMFS), recurrence-free (RFS), and overall survival (OS) rates were compared.

RESULTS

The median follow-up was 63 (range 53-77) months. There was no difference in clinical stage between patients with pCR or <pCR. Compared with patients achieving <pCR, those with the pCR had higher 5-year rates of LRFS (100% versus 95%, P = 0.011), DMFS (96% versus 80%, P < 0.001), RFS (96% versus 79%, P < 0.001), and OS (95% versus 84%, P = 0.006). Improvements in RFS and OS were seen with decreasing post-treatment stage. Failure to achieve a pCR was the strongest independent predictor of recurrence (hazard ratio [HR] = 4.09, 95% confidence interval [CI]: 1.67-10.04, P = 0.002) and death (HR = 4.15, 95% CI: 1.39-12.38, P = 0.011).

CONCLUSIONS

pCR and lower pathologic stage after neoadjuvant chemotherapy with trastuzumab are the strongest predictors of recurrence and survival and are surrogates of the long-term outcome in patients with HER2-overexpressing disease.

Primary tumor extirpation in breast cancer patients who present with stage IV disease is associated with improved survival

PURPOSE

Previous evaluation of our institutional experience with stage IV breast cancer patients with an intact primary tumor (IPT) did not reveal an overall survival (OS) benefit for surgery at 32.1 months median follow-up. We assessed the impact of surgery after 74.2 months median follow-up, and the effect of systemic therapy and local radiotherapy (RT).

METHODS

We reviewed the records of all patients presenting from 1997 to 2002 with stage IV disease with an IPT. Cox proportional hazards modeling was used to assess differences in survival between treatment groups.

RESULTS

Seventy-four (35.6 %) of 208 patients underwent resection of the IPT. After adjustment for covariates, surgery was associated with improved OS (p = 0.04). Multivariable analysis revealed that estrogen receptor (ER) positivity (p = 0.002) and having only a single focus of metastatic disease (p = 0.05) were also associated with improved OS. Surgery was highly associated with receipt of RT (p = 0.0003). RT was significantly associated with improved survival (p = 0.015) in an exploratory analysis.

CONCLUSIONS

Stage IV breast cancer patients with an IPT treated surgically had significantly improved OS. Radiation to the primary was also associated with improved survival, but this was evident only with adjustment for the effect of surgery. These findings may be limited by selection bias. Completion of ongoing prospective randomized trials is needed to conclusively determine whether stage IV patients with an IPT should be offered aggressive locoregional therapy.

Abstract S2-3: Disparities in the utilization of axillary sentinel lymph node biopsy among black and white patients with node-negative breast cancer from 2002–2007

Background: Disparities exist in many aspects of standard breast cancer treatment in certain patient populations. In the mid-1990s, axillary sentinel lymph node biopsy (SLNB) was introduced as an alternative to axillary lymph node dissection (ALND) for staging clinically node-negative breast cancer. During the early 2000s, the validity of SLNB was being determined and its technique was being disseminated throughout the surgical community. By the mid to late-2000s, SLNB had been shown to provide accurate axillary staging with lower complications and no difference in survival compared to ALND in node-negative patients. SLNB has now replaced ALND as the accepted method for staging early breast cancer. The purpose of this study is to examine differences in the utilization of SLNB in pathologic node-negative invasive black breast cancer patients compared to white patients as SLNB became standard axillary staging and whether this difference impacted patient complications.

Methods: Using the population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data, cases of incident, non-metastatic, pathologic node-negative breast cancer in women age≥66 were identified. Patients were considered to have undergone SLNB if specified by SEER records or if a billing claim for axillary lymphatic mapping was identified. Unadjusted associations of SLNB with race were evaluated using the chi-square test. The Cochran-Armitage test evaluated trends over time. Multivariate logistic regression tested whether race was associated with the use of SLNB after adjustment for clinicopathologic factors. Five-year cumulative incidence of lymphedema assessed via ICD-9 diagnosis codes was measured using the Kaplan-Meier method. Adjusted proportional hazards regression evaluated assiciations of race and ALND with lymphedema risk.

Results: Of 31,274 women identified, 1,767 (5.7%) were Black, 27,856 (89%) were White and 1,651 (5.3%) were of other/unknown race. SLNB was performed in 74% of white patients compared to 62% of black patients (P&lt;0.001). Although use of SLNB increased by year for both black and white patients (P&lt;0.001), a fixed disparity in the use of SLNB persisted through 2007.

Abstract P4-15-02: Timing of infectious complications following breast conserving therapy with catheter-based accelerated partial breast irradiation

Background: Accelerated partial breast irradiation (APBI) has been introduced as an alternative to whole breast irradiation as part of breast conserving therapy for selected patients. The long-term outcomes remain under investigation. Previous publications have emphasized early postoperative infections with APBI with less focus on delayed infection. In the current study, we evaluated patients enrolled on a prospective registry trial for infectious complications after treatment with catheter-based APBI.

Methods: Patients who underwent single-entry catheter-based APBI were identified from a single-institution prospective registry from 2009 to 2011. Data regarding treatment, patient comorbidities, complications, and outcomes were obtained from registry and retrospective chart review. Infectious complications were assessed from the date of APBI catheter insertion and were classified as early (≤30 days) or delayed (&gt;30 days). All patients were maintained on oral antibiotics while the catheter was in place.

Results: A total of 91 patients with 92 cases of primary breast cancer were enrolled on a prospective registry at a comprehensive cancer center between 2009 and 2011 and treated with single-entry catheter-based APBI. The median follow-up time was 76.2 weeks. A temporary catheter was placed at the time of initial operation in 40 cases (43.5%) and left in place a median of 6 days prior to definitive catheter insertion. There were 20 patients (21.7%) who required re-excision. Overall, breast infection occurred in 13 (14.1%) patients. Three (3.3%) patients had infection within 30 days of catheter placement and 10 (10.9%) occurred more than 30 days after catheter insertion (median 112.5 days, interquartile range 51–154). Eight patients were managed with oral antibiotics alone on an outpatient basis. The remainder required a combination of admission, intravenous antibiotics, and aspiration of abscess. One patient underwent operative drainage.

Conclusion: We found an overall infection rate of 14.1% in patients treated with catheter-based APBI. This is consistent with other reports; however, we found that the majority of infections occurred more than 30 days after definitive catheter placement. Vigilance for infectious complications must continue beyond the immediate treatment period in patients undergoing catheter-based APBI. Most infections following APBI can be managed on an outpatient basis without operative intervention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-15-02.

Abstract P1-07-09: Estrogen receptor positivity: 10% or 1%?

Background. Guidelines by the American Society of Clinical Oncology and the College of American Pathologists recently recommended that estrogen receptor (ER) status should be considered positive if 1% of tumor cells demonstrate positive nuclear staining by immunohistochemistry. Historically, 10% nuclear staining defined ER-positive status and impacted decision-making regarding endocrine therapy. Currently, no optimal threshold exists for ER either by clinically validating patient outcomes in prospective clinical trials or independently validated from systematically collected archived specimens from randomized clinical trials. In this study, we examined patient, tumor and treatment differences among patients by ER status: ER-positive ≥10%, ER-positive 1–10% and ER negative (&lt;1%). We compared recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) among patients with different ER staining categories and adjusted by clinical stage, adjuvant chemo and endocrine therapy.

Method. Patients with primary breast carcinoma treated at our center who had complete ER status from January 1990 to December 2011 were included in this study. Patients were excluded if they presented with recurrent or metastatic disease. For statistical analyses, patients who underwent surgery for breast cancer were separated into three groups: ER-positive ≥10%, ER-positive 1–10% and ER negative. Analyses comparing various clinical and pathologic characteristics among patients with different ER status were performed. Survival rates were calculated by the Kaplan-Meier method.

Result. Patients whose tumors were ER-positive 1–10% (2.7%) were younger (median age 53 Vs. 56 years, P &lt; 0.0001), more likely to have invasive ductal carcinoma histology with more advanced disease (clinical stage II/III 50.4% Vs. 37.3%, p &lt; 0.0001), and were more likely to receive neoadjuvant chemotherapy (40.9% vs. 25.6%, P &lt; 0.0001), adjuvant chemotherapy (45.5% vs. 31.2%, P &lt; 0.0001), and less likely to receive adjuvant endocrine therapy (19.5% vs. 78.6%, P &lt; 0.0001) compared to patients with ER-positive tumors ≥ 10%. They were also more likely to have HER-2-positive (29.1% vs. 13.4%, P &lt; 0.0001) and grade III disease (82.1% vs. 29.6%, P &lt; 0.0001). Compared to patients with ER negative, patients with ER-positive 1–10% had earlier stage disease (clinical stage II/III 50.4% Vs. 59.3%, p = 0.01), were less likely to receive neoadjuvant chemotherapy (40.9% vs. 48.2%, p = 0.02), and more likely to receive adjuvant endocrine therapy (19.5% vs. 12.6%, p = 0.002). At a median follow-up of 5.1 years, patients with ER-positive 1–10% had worse RFS, DFS and OS rates compared to patients with ER-positive tumors ≥ 10%. The RFS, DFS and OS rates between patients with ER-positive 1–10% and ER negative did not differ significantly. Patients with ER-positive 1–10% and negative still had worse RFS, DSS and OS rates compared to patients with ER-positive tumors ≥ 10% after adjusted by clinical stage, adjuvant chemo and endocrine therapy.

Conclusion. Patients whose tumors are ER-positive at 1–10% have clinical and pathologic characteristics different from those whose tumors are ER-positive ≥10%. Similar to patients whose tumors are ER negative, those with ER-positive disease at 1–10% do not appear to benefit from endocrine therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-09.

Other primary malignancies in breast cancer patients treated with breast conserving surgery and radiation therapy

BACKGROUND

Our purpose was to examine the incidence and impact on survival of other primary malignancies (OPM) outside of the breast in breast cancer patients and to identify risk factors associated with OPM.

METHODS

Patients with stage 0-III breast cancer treated with breast conserving therapy at our center from 1979 to 2007 were included. Risk factors were compared between patients with/without OPM. Logistic regression was used to identify factors that were associated with OPM. Standardized incidence ratios (SIRs) were calculated.

RESULTS

Among 4,198 patients in this study, 276 (6.6 %) developed an OPM after breast cancer treatment. Patients with OPM were older and had a higher proportion of stage 0/I disease and contralateral breast cancer compared with those without OPM. In a multivariate analysis, older patients, those with contralateral breast cancer, and those who did not receive chemotherapy or hormone therapy were more likely to develop OPM after breast cancer. Patients without OPM had better overall survival. The SIR for all OPM sites combined after a first primary breast cancer was 2.91 (95 % confidence interval: 2.57-3.24). Significantly elevated risks were seen for numerous cancer sites, with SIRs ranging from 1.84 for lung cancer to 5.69 for ovarian cancer.

CONCLUSIONS

Our study shows that breast cancer patients have an increased risk of developing OPM over the general population. The use of systemic therapy was not associated with increased risk of OPM. In addition to screening for a contralateral breast cancer and recurrences, breast cancer survivors should undergo screening for other malignancies.

Impact of the american college of surgeons oncology group Z0011 criteria applied to a contemporary patient population

BACKGROUND

The American College of Surgeons Oncology Group (ACOSOG) Z0011 trial concluded that axillary lymph node dissection (ALND) may not be necessary for all patients with sentinel lymph node (SLN) metastasis undergoing breast-conserving therapy (BCT). The aim of this study was to assess applicability of Z0011 results to our patient population and determine what percentage may be affected by these results.

STUDY DESIGN

Patients with clinical T1-2, N0 breast cancer, treated with surgery first between 1994 and 2009, who had 1 to 2 positive SLNs, were included in this study. Kaplan-Meier survival curves were calculated and log-rank used to compare overall survival (OS) and disease-free survival (DFS) for ALND vs SLN dissection (SLND) alone in 2 patient populations: patients undergoing BCT or total mastectomy (TM) and patients undergoing BCT only.

RESULTS

Of 861 patients, 188 (21.8%) underwent SLND alone. Of 488 (56.7%) patients who underwent BCT, 125 (25.6%) had SLND alone. Of 412 patients undergoing TM, 67 (16.3%) had SLND alone. Patients undergoing ALND were significantly younger, had larger tumors, macrometastasis, and extranodal extension in both populations. Compared with the Z0011 cohort, our BCT patients had more T1 tumors (76.0% vs 69.3%, p = 0.01) and more grade II to III tumors (87.3% vs 76.2%, p < 0.0001). After adjusting for T-stage, there were no significant differences in DFS and OS between patients undergoing SLND alone or ALND in both populations.

CONCLUSIONS

Examination of our breast cancer patients with Z0011 trial criteria suggests that almost 75% of SLN-positive patients would be candidates to avoid ALND if they undergo BCT.

The role for sentinel lymph node dissection after neoadjuvant chemotherapy in patients who present with node-positive breast cancer

BACKGROUND

Sentinel lymph node (SLN) dissection has been investigated after neoadjuvant chemotherapy and has shown mixed results. Our objective was to evaluate SLN dissection in node-positive patients and to determine whether postchemotherapy ultrasound could select patients for this technique.

METHODS

Between 1994 and 2010, 150 patients with biopsy proven axillary metastasis underwent SLN dissection after chemotherapy and 121 underwent axillary lymph node dissection (ALND). Clinicopathologic characteristics were analyzed before and after chemotherapy. Statistical analyses included Fisher's exact test for nodal response and multivariate logistic regression for factors associated with false-negative events.

RESULTS

Median age was 52 years. Median tumor size at presentation was 2 cm. The SLN was identified in 93 % (139/150). In 111 patients in whom a SLN was identified and ALND performed, 15 patients had a false-negative SLN (20.8 %). In the 52 patients with normalized nodes on ultrasound, the false-negative rate decreased to 16.1 %. Multivariate analysis revealed smaller initial tumor size and fewer SLNs removed (<2) were associated with a false-negative SLN. There were 63 (42 %) patients with a pathologic complete response (pCR) in the nodes. Of those with normalized nodes on ultrasound, 38 (51 %) of 75 had a pCR. Only 25 (33 %) of 75 with persistent suspicious/malignant-appearing nodes had a pCR (p = 0.047).

CONCLUSIONS

Approximately 42 % of patients have a pCR in the nodes after chemotherapy. Normalized morphology on ultrasound correlates with a higher pCR rate. SLN dissection in these patients is associated with a false-negative rate of 20.8 %. Removing fewer than two SLNs is associated with a higher false-negative rate.

American College of Surgeons Oncology Group (ACOSOG) Z0011: impact on surgeon practice patterns

INTRODUCTION

The ACOSOG Z0011 trial has been described as practice-changing. The goal of this study was to determine the impact of the trial on surgeon practice patterns at our institution.

METHODS

This is a review of practice patterns comparing the year before release of Z0011 to the year after an institutional multidisciplinary meeting discussing the results. Patients meeting Z0011 inclusion criteria were identified. Clinicopathologic data were compared between the cohorts.

RESULTS

There were 658 patients with clinical T1-2 tumors planned for breast conservation: 335 in the pre-Z0011 cohort and 323 post-Z0011. Sixty-two (19 %) patients were sentinel lymph node (SLN) positive in the pre-Z0011 group versus 42 (13 %) post-Z0011 (p = 0.06). Before Z0011, 85 % (53/62) of SLN-positive patients underwent axillary node dissection (ALND) versus 24 % (10/42) after Z0011 (p < 0.001). After Z0011, surgeons were more likely to perform ALND on patients with larger tumors (2.2 vs. 1.5 cm, p = 0.09), lobular histology (p = 0.01), fewer SLNs (1 vs. 3, p = 0.09), larger SLN metastasis size (4 vs. 2.5 mm, p = 0.19), extranodal extension present (20 vs. 6 %, p = 0.16), or a higher probability of positive non-SLNs (p = 0.03). Surgeons were less likely to perform intraoperative nodal assessment post-Z0011 (26 vs. 69 %, p < 0.001) resulting in decreased median operative times for SLN-negative patients (79 vs. 92 min, p < 0.001).

CONCLUSIONS

Surgeons at our institution have implemented Z0011 results for the majority of patients; however, clinicopathologic factors still impact the decision to perform ALND. Z0011 results have significantly impacted practice by decreasing rates of ALND, use of intraoperative nodal evaluation, and operative times.