Results of conservative surgery for limited-sized infiltrating breast cancer: analysis of 962 tested patients: 24 years of experience

Outcome and Medial Presentation of Breast Cancer: European Institute of Oncology Experience

BACKGROUND

No analyses have investigated the prognostic role of medial presentation in breast cancer patients on disease-free survival (DFS) and overall survival according to immunohistochemically-defined subtypes.

PATIENTS AND METHODS

We collected information from the institutional clinical database on consecutive breast cancer patients who underwent conservative surgery at the European Institute of Oncology, Milan, Italy, between 1994 and 2008. We compared the outcomes of patients with medial breast cancer with those of patients with nonmedial tumors observed at the institution during the same period.

RESULTS

Among 7369 evaluable patients, 2254 (24%) had their primary tumors in medial quadrants and 7015 (76%) in other areas. Five-year DFS was 84.7% and 86.6% (P = .008) in patients with medial and nonmedial disease, respectively. In multivariate analysis, medial location was correlated with greater risk of recurrence (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.11-1.35; P < .0001) and death (HR, 1.27; 95% CI, 1.09-1.49; P = .0028).

CONCLUSION

Medial presentation is an adverse prognostic factor for breast cancer patients.

Results of breast conserving surgery in clinical stage I-II breast carcinoma

BACKGROUND

The role of breast conserving surgery with radiotherapy is well established and has become a widely used procedure in breast cancer. Patient selection, a multidisciplinary approach, and expert surgical technique are important factors to avoid locoregional recurrence. The aim of this study was to analyse the outcomes of patients treated with breast conserving surgery in stage I-II breast cancer.

METHODS

In this study, the results of 135 breast conserving surgery cases are reported. The majority of patients received radiotherapy and adjuvant systemic treatment.

RESULTS

At a median follow-up period of 54 months, 5 patients (3.7%) developed locoregional recurrence. The 5 years overall and disease-free survival rates were 90% and 84%, respectively. Young age, lymph node involvement, and oestrogen receptor negativity were independent predictors for overall survival.

CONCLUSION

In selected patients, breast conserving surgery using good surgical technique in conjunction with radiotherapy can achieve a high survival rate with a low locoregional recurrence rate.

Breast cancer sagittal/horizontal plane location influences axillary lymph node involvement

AIM

To assess the influence of tumour location on axillary lymph node involvement (ALNI) and prognosis in breast cancer by evaluating the significance of the sagittal/horizontal alignment.

METHODS

We compared 57 patients with superficially located breast carcinomas up to 3.0 cm with patients having lesions in posterior planes of the breast. Both groups were matched according to age, time of diagnosis, tumour size, grade, hormonal receptor status and tumour site within the frontal plane. Histologic evidence of skin involvement, excluding tumours fulfilling the criteria for pT4b, was defined as inclusion criteria and reference plane for superficial tumour location.

RESULTS

Tumours situated in the superficial region of the breast, compared to those located in deeper planes, have an increased risk of ALNI (p=0.023), whereas no difference was observed with reference to disease-specific survival (p=0.203).

CONCLUSION

This study shows that ALNI is dependent on sagittal/horizontal as well as frontal tumour location. Clinicians should be aware that tumours lying posteriorly may be at increased risk of occult spread outside axillary lymph nodes.

Audit of local recurrence rates following ‘ultra’-conservative surgery for invasive breast cancer—a boost to the breast?

BACKGROUND

Conservative breast surgery with postoperative radiotherapy and appropriate systemic therapy is associated with similar outcomes when compared with mastectomy. The reported 5 year local recurrence rate varies between 3% and 15%. We prefer a more conservative 'complete' local excision rather than 'wide' local excision combined with post-operative radical radiotherapy and tumour bed boost with the aim of achieving optimal cosmesis.

AIMS

Our review was undertaken to assess whether or not this 'ultra' conservative approach was compromising long-term local control.

METHODS

Case notes and pathology reports of patients who underwent conservative surgery for breast cancer from January 1983 to February 2001 were accessed for this audit. Patient demographic data and tumour characteristics were noted. The primary outcome data were the number of local recurrences following invasive breast cancer at 5 and 10 years and the distance from the tumour to the closest margin of excision.

RESULTS

At 5 and 10 years there were 16/451 and 5/124 local recurrences, with a local recurrence rate of 3.5% (95% CI, 1.7-4.7%) and 4.1% (95% CI, 0.47-6.5%), respectively. Complete data with regards to the closest histological margin of excision were available in 423 patients. One hundred and sixty-five patients (39%) had their tumours excised with a distance of less than 1 mm to the closest margin. Nearly, all tumours (97.8%) were excised with the distance to the closest margin less than 1 cm and 81% with 5 mm or less.

CONCLUSION

It is possible to achieve low local recurrence rates after very conservative surgery for breast cancer when this is combined with radical radiotherapy and an additional tumour bed boost.

Management of T1a Breast Cancer

Identification of early-stage breast cancers has increased over the past 2 decades primarily because of mammographic screening. The general guidelines to management of breast cancer may not apply to the smallest of these tumors, as their metastatic potential may be smaller than larger tumors. Tumors < 5 mm (T1a) carry an excellent prognosis, despite a variety of treatment approaches. However, some patients' cancer returns. There appear to be some histologic features that can predict a higher risk of axillary metastases, and therefore, a higher risk of distant metastases. Controversy exists over the extent of treatment, as to whether less than conventional treatment, such as mastectomy, axillary evaluation, and breast-conserving surgery and radiation, can be done. T1a lesions associated with extensive ductal carcinoma in situ and T1a lesions in young patients should be treated with caution if less than conventional breast treatment is to be considered. In older patients with good histologic features, axillary assessment may not be necessary. Very wide excision alone may be appropriate for some patients, but partial breast irradiation is under study and may provide a reasonable compromise. Systemic therapy for node-negative patients is not recommended. Recurrences within the breast occur later in early-stage breast cancers than with extensive-stage breast cancers, requiring annual imaging and evaluation for many years.

Can we select which patients with small breast cancers should receive adjuvant chemotherapy?

OBJECTIVE

To identify the risk of systemic metastases from T1a and T1b N0 breast cancers in patients treated in an academic center, and to seek factors to identify the patients at greatest risk of such failure.

SUMMARY BACKGROUND DATA

With the demonstration that adjuvant chemotherapy reduces the death rate from breast cancer by roughly one quarter across all risk groups, controversy has reigned regarding possible exclusions from therapy. T1a and T1b N0 tumors (1-cm diameter and smaller with negative axillary nodes) have been considered at low risk for metastasis since the report from Memorial Sloan-Kettering Cancer Center of a 90% survival rate at 10 years. Subsequent reports have suggested an even more favorable prognosis for this group. However, consensus statements advise selecting some of these women for treatment, and many do receive adjuvant chemotherapy.

METHODS

Sequential patients with breast cancer at the Emory Clinic were prospectively staged and followed up for outcome. The records of patients with T1a and T1b N0 tumors were reviewed for exact tumor diameter, grade, receptor status, adjuvant therapy, and outcome. A corrected data set was stripped of patient identifiers and analyzed by Kaplan-Meier methods. Subgroups were formed based on tumor grade (1 vs. 3), adjuvant chemotherapy (use vs. no use), and adjuvant tamoxifen (use vs. no use) and were compared via log-rank tests.

RESULTS

Two hundred eighty-two women were identified. Two developed metastatic disease and one experienced a local failure after breast-conserving treatment. The estimated disease-free survival rate at 10 years was 98.7%. With only two distant failures and one local failure, there was no significant difference by grade, receptor status, or use of adjuvant chemotherapy or tamoxifen.

CONCLUSIONS

The risk of systemic failure from such tumors barely exceeded 1% at 10 years. Unless future studies can identify a subgroup at higher risk, the cognitive changes associated with cytotoxic chemotherapy or the loss of estrogen involved do not appear to have sufficient offsetting benefit to warrant chemotherapy for this group of women.