Segmental mastectomy without radiotherapy. Short-term follow-up

Partial breast irradiation versus whole breast radiotherapy for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

On 27 August 2020, we searched the Cochrane Breast Cancer Group Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and three trial databases. We searched for grey literature: OpenGrey (September 2020), reference lists of articles, conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction, used Cochrane's risk of bias tool and resolved any disagreements through discussion, and assessed the certainty of the evidence for main outcomes using GRADE. Main outcomes were local recurrence-free survival, cosmesis, overall survival, toxicity (subcutaneous fibrosis), cause-specific survival, distant metastasis-free survival and subsequent mastectomy. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included nine RCTs that enrolled 15,187 women who had invasive breast cancer or ductal carcinoma in-situ (6.3%) with T1-2N0-1M0 Grade I or II unifocal tumours (less than 2 cm or 3 cm or less) treated with breast-conserving therapy with negative margins. This is the second update of the review and includes two new studies and 4432 more participants. Local recurrence-free survival is probably slightly reduced (by 3/1000, 95% CI 6 fewer to 0 fewer) with the use of PBI/APBI compared to WBRT (hazard ratio (HR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 8 studies, 13,168 participants; moderate-certainty evidence). Cosmesis (physician/nurse-reported) is probably worse (by 63/1000, 95% CI 35 more to 92 more) with the use of PBI/APBI (odds ratio (OR) 1.57, 95% CI 1.31 to 1.87; 6 studies, 3652 participants; moderate-certainty evidence). Overall survival is similar (0/1000 fewer, 95% CI 6 fewer to 6 more) with PBI/APBI and WBRT (HR 0.99, 95% CI 0.88 to 1.12; 8 studies, 13,175 participants; high-certainty evidence). Late radiation toxicity (subcutaneous fibrosis) is probably increased (by 14/1000 more, 95% CI 102 more to 188 more) with PBI/APBI (OR 5.07, 95% CI 3.81 to 6.74; 2 studies, 3011 participants; moderate-certainty evidence). The use of PBI/APBI probably makes little difference (1/1000 less, 95% CI 6 fewer to 3 more) to cause-specific survival (HR 1.06, 95% CI 0.83 to 1.36; 7 studies, 9865 participants; moderate-certainty evidence). We found the use of PBI/APBI compared with WBRT probably makes little or no difference (1/1000 fewer (95% CI 4 fewer to 6 more)) to distant metastasis-free survival (HR 0.95, 95% CI 0.80 to 1.13; 7 studies, 11,033 participants; moderate-certainty evidence). We found the use of PBI/APBI in comparison with WBRT makes little or no difference (2/1000 fewer, 95% CI 20 fewer to 20 more) to mastectomy rates (OR 0.98, 95% CI 0.78 to 1.23; 3 studies, 3740 participants, high-certainty evidence).

AUTHORS' CONCLUSIONS

It appeared that local recurrence-free survival is probably worse with PBI/APBI; however, the difference was small and nearly all women remain free of local recurrence. Overall survival is similar with PBI/APBI and WBRT, and we found little to no difference in other oncological outcomes. Some late effects (subcutaneous fibrosis) may be worse with PBI/APBI and its use is probably associated with worse cosmetic outcomes. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver PBI/APBI. We await completion of ongoing trials.

Partial breast irradiation for early breast cancer

BACKGROUND

Breast-conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiotherapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast radiotherapy (WBRT) may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane review, we investigated the delivery of radiation to a limited volume of the breast around the tumour bed (partial breast irradiation (PBI)) sometimes with a shortened treatment duration (accelerated partial breast irradiation (APBI)).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypo-fractionated WBRT after breast-conserving therapy for early-stage breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialized Register (4 May 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 5), MEDLINE (January 1966 to 4 May 2015), EMBASE (1980 to 4 May 2015), CINAHL (4 May 2015) and Current Contents (4 May 2015). We searched the International Standard Randomised Controlled Trial Number Register (5 May 2015), the World Health Organization's International Clinical Trials Registry Platform (4 May 2015) and ClinicalTrials.gov (17 June 2015). We searched for grey literature: OpenGrey (17 June 2015), reference lists of articles, several conference proceedings and published abstracts, and applied no language restrictions.

SELECTION CRITERIA

Randomized controlled trials (RCTs) without confounding, that evaluated conservative surgery plus PBI/APBI versus conservative surgery plus WBRT. Published and unpublished trials were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors (BH and ML) performed data extraction and used Cochrane's 'Risk of bias' tool, and resolved any disagreements through discussion. We entered data into Review Manager 5 for analysis.

MAIN RESULTS

We included seven RCTs and studied 7586 women of the 8955 enrolled.Local recurrence-free survival appeared worse for women receiving PBI/APBI compared to WBRT (hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.11 to 2.35; six studies, 6820 participants, low-quality evidence). Cosmesis (physician-reported) appeared worse with PBI/APBI (odds ratio (OR) 1.51, 95% CI 1.17 to 1.95, five studies, 1720 participants, low-quality evidence). Overall survival did not differ with PBI/APBI (HR 0.90, 95% CI 0.74 to 1.09, five studies, 6718 participants, high-quality evidence).Late radiation toxicity (subcutaneous fibrosis) appeared worse with PBI/APBI (OR 6.58, 95% CI 3.08 to 14.06, one study, 766 participants, moderate-quality evidence). Acute skin toxicity appeared reduced with PBI/APBI (OR 0.04, 95% CI 0.02 to 0.09, two studies, 608 participants). Telangiectasia (OR 26.56, 95% CI 3.59 to 196.51, 1 study, 766 participants) and radiological fat necrosis (OR 1.58, 95% CI 1.02 to 2.43, three studies, 1319 participants) appeared worse with PBI/APBI. Late skin toxicity (OR 0.21, 95% CI 0.01 to 4.39, two studies, 608 participants) and breast pain (OR 2.17, 95% CI 0.56 to 8.44, one study, 766 participants) appeared not to differ with PBI/APBI.'Elsewhere primaries' (new primaries in the ipsilateral breast) appeared more frequent with PBI/APBI (OR 3.97, 95% CI 1.51 to 10.41, three studies, 3009 participants).We found no clear evidence of a difference for the comparison of PBI/APBI with WBRT for the outcomes of: cause-specific survival (HR 1.08, 95% CI 0.73 to 1.58, five studies, 6718 participants, moderate-quality evidence), distant metastasis-free survival (HR 0.94, 95% CI 0.65 to 1.37, four studies, 3267 participants, moderate-quality evidence), relapse-free survival (HR 1.36, 95% CI 0.88 to 2.09, three studies, 3811 participants), loco-regional recurrence-free survival (HR 1.80, 95% CI 1.00 to 3.25, two studies, 3553 participants) or mastectomy rates (OR 1.20, 95% CI 0.77 to 1.87, three studies, 4817 participants, low-quality evidence). Compliance was met: more than 90% of the women in all studies received the RT they were assigned to receive. We found no data for the outcomes of costs, quality of life or consumer preference.

AUTHORS' CONCLUSIONS

It appeared that local recurrence and 'elsewhere primaries' (new primaries in the ipsilateral breast) are increased with PBI/APBI (the difference was small), but we found no evidence of detriment to other oncological outcomes. It appeared that cosmetic outcomes and some late effects were worse with PBI/APBI but its use was associated with less acute skin toxicity. The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.

Partial breast irradiation for early breast cancer

BACKGROUND

Breast conserving therapy for women with breast cancer consists of local excision of the tumour (achieving clear margins) followed by radiation therapy (RT). RT is given to sterilize tumour cells that may remain after surgery to decrease the risk of local tumour recurrence. Most true recurrences occur in the same quadrant as the original tumour. Whole breast RT may not protect against the development of a new primary cancer developing in other quadrants of the breast. In this Cochrane Review, we investigated the role of delivering radiation to a limited volume of the breast around the tumour bed (partial breast irradiation: PBI) sometimes with a shortened treatment duration (accelerated partial breast irradiation: APBI).

OBJECTIVES

To determine whether PBI/APBI is equivalent to or better than conventional or hypofractionated WBRT after breast conservation therapy for early-stage breast cancer.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group Specialised Register (07 November 2013), CENTRAL (2014, Issue 3), MEDLINE (January 1966 to 11 April 2014), EMBASE (1980 to 11 April 2014), CINAHL (11 April 2014) and Current Contents (11 April 2014). Also we searched the International Standard Randomised Controlled Trial Number Register, the World Health Organization's International Clinical Trials Registry Platform (07 November 2013) and US clinical trials registry (www.clinicaltrials.gov) (22 April 2014). We searched for grey literature: Open Grey (23 April 2014), reference lists of articles, a number of conference proceedings and published abstracts, and did not apply any language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) without confounding and evaluating conservative surgery plus PBI/APBI versus conservative surgery plus whole breast RT. We included both published and unpublished trials.

DATA COLLECTION AND ANALYSIS

Three review authors (ML, DF and BH) performed data extraction and resolved any disagreements through discussion. We entered data into Review Manager for analysis. BH and ML assessed trials, graded the methodological quality using Cochrane's Risk of Bias tool and resolved any disagreements through discussion.

MAIN RESULTS

We included four RCTs that had 2253 women. Two older trials examined RT techniques which do not reflect current practice and one trial had a short follow-up. We downgraded the quality of the evidence for our key outcomes due to risk of bias. Taken together with other GRADE recommendations, the quality of evidence for our outcomes was very low to low. For the comparison of partial breast irradiation/accelerated breast irradiation (PBI/APBI) with whole breast irradiation (WBRT), local recurrence-free survival appeared worse (Hazard Ratio (HR) 1.74, 95% confidence interval (CI) 1.23 to 2.45; three trials, 1140 participants, very low quality evidence). Cosmesis appeared improved with PBI/APBI in a single trial (OR 0.40, 95% CI 0.23 to 0.72; one trial, 241 participants, very low quality evidence), but late toxicity (telangiectasia OR 4.41, 95% CI 3.21 to 6.05; very low quality evidence, 708 participants) and subcutaneous fibrosis (OR 4.27, 95% CI 3.04 to 6.01; one trial, 710 participants, very low quality evidence) appeared increased in another trial. We found no clear evidence of a difference for the comparison of PBI/APBI versus WBRT for the outcomes of: overall survival (HR 0.99, 95% CI 0.83 to 1.18; three trials, 1140 participants, very low quality evidence), cause-specific survival (HR 0.95, 95% CI 0.74 to 1.22; two trials, 966 participants, low evidence quality), distant metastasis-free survival (HR 1.02, 95% CI 0.81 to 1.28; 1140 participants, low quality evidence), subsequent mastectomy rate (OR 0.20, 95% CI 0.01 to 4.21; 258 participants, low quality evidence) and relapse-free survival (HR 0.99, 95% CI 0.53 to 1.85; 258 participants, low quality evidence). We found no data for the outcomes of acute toxicity, new ipsilateral breast primaries, costs, quality of life or consumer preference.

AUTHORS' CONCLUSIONS

The limitations of the data currently available mean that we cannot make definitive conclusions about the efficacy and safety or ways to deliver of PBI/APBI. We await completion of ongoing trials.

Are mastectomy resection margins of clinical relevance? A systematic review

Although some guidelines support the use of post-mastectomy radiotherapy where the resection margin is involved or close, the scientific basis of this practice is not established. This systematic review explores the relationship between margin status and subsequent relapse. Pooled data from 22 studies (18,863 women) identified an involved post-mastectomy margin in 2.5%, a close margin in 8.0% and muscle or fascia invasion in 7.2% of patients. In a meta-analysis of five studies of non-inflammatory breast cancer without radiotherapy, local recurrence was increased by an involved or close margin (relative risk 2.6; P<0.00001). The effect of muscle or fascia invasion was of borderline significance (relative risk 1.7; P=0.04). In two separate meta-analyses, risk of relapse was related to margin status in women with inflammatory breast cancer (relative risk 3.1; P<0.0001) but not in those undergoing skin-sparing mastectomy (relative risk 2.1; P=0.16).

Contrast-enhanced MR imaging of breast lesions and effect on treatment

PURPOSE

To assess the value of local staging with preoperative magnetic resonance imaging (MRI) in patients with suspect breast lesions and the effect on therapeutic approach.

MATERIALS AND METHODS

Two hundred and four consecutive women with suspect breast lesions on clinical examination (CE) and/or mammography (MX) and/or ultrasound (US) underwent preoperative contrast-enhanced MRI. Detection of multifocal, multicentric and bilateral breast cancer by all three imaging modalities was evaluated. Results of preoperative breast MRI were discussed with the treating surgeons. The type of therapeutic change after preoperative MRI was marked on a questionnaire (none, additional fine needle aspiration, core biopsy, open biopsy, wider excision, mastectomy) and considered 'necessary' or 'unnecessary' using final histopathological results as gold standard.

RESULTS

In 170 patients, breast cancer was diagnosed. MRI detected 96% of multifocal disease and 95% of multicentric disease, whereas MX depicted 37 and 18%, and US 41 and 9% of them, respectively. All bilateral breast cancers were seen on MRI; both MX and US detected 56%. Findings of more extensive disease and unsuspected multiple breast cancer foci identified on MRI only, changed the therapeutic approach correctly in 30.6% of breast cancer patients. Nine unnecessary wider excisions and three unnecessary FNA/core biopsies were performed because MRI overestimated the number or size of malignant lesions.

CONCLUSION

Preoperative breast MRI is an important adjunct to conventional imaging in the loco-regional staging of breast cancer and a useful tool in treatment planning.

Preoperative assessment of breast cancer: sonography versus MR imaging

OBJECTIVE

The purposes of our study were to compare the diagnostic value of whole-breast sonography and MR imaging as adjunctive techniques to mammography and to determine whether MR imaging should be used routinely in the preoperative assessment of patients with suspected breast cancer.

SUBJECTS AND METHODS

. One hundred four women (age range, 34-84 years; mean age, 60 years) with findings highly suggestive of malignancy in the breast were examined with mammography, sonography, and dynamic MR imaging before undergoing surgery. All visualized suspicious lesions were correlated histologically. The diagnostic relevance of sonographic and MR imaging findings was compared with the diagnostic value of the findings of clinical examination and mammography alone.

RESULTS

. Twenty-seven tumors showed multifocal or multicentric invasive growth at pathology. Of these 27, 48% were correctly diagnosed via mammography alone; 63%, via the combination of mammography and sonography; and 81%, via MR imaging. Nine of the index tumors were invisible on mammography but were detected on sonography. Use of sonography benefited 13 patients and produced two studies with false-positive findings. Use of MR imaging benefited seven patients and produced eight studies with false-positive findings. In summary, 93% of all patients gained no advantage from MR imaging. Relevant additional findings were significantly more frequent in patients with dense breasts.

CONCLUSION

Although MR imaging is most sensitive for the detection of small tumors, routine preoperative MR imaging appears to be unnecessary for most patients if a combination of mammography and whole-breast sonography is used. Additional MR imaging can be restricted to problematic cases in women with dense breast parenchyma.

Magnetic resonance imaging-guided biopsy of mammographically and clinically occult breast lesions

BACKGROUND

Breast magnetic resonance imaging (MRI) is a very sensitive technique for detection of breast cancer. We report on MRI-guided needle localization for biopsy of abnormalities seen only on MRI.

METHODS

A retrospective review was performed of 231 patients with invasive breast cancer or ductal carcinoma-in-situ who had MRI as part of their evaluation and treatment at the University of Pennsylvania between 1992 and 1998. Clinical, radiological, and pathologic data were examined.

RESULTS

MRI needle localization was performed in 41 (18%) patients. MRI needle localization was required for a finding of a mammographically or clinically occult lesion in 31 patients, better MRI definition of tumor in 5 patients, and surgeon's choice in 5 patients. In all cases, MRI localization and excisional biopsy were successfully completed. Nineteen of 31 patients were found to have additional mammographically and clinically occult tumors. There were 12 (29%) false-positive MRI scans.

CONCLUSIONS

MRI has a high sensitivity for detection of breast cancer; additional mammographically and clinically occult sites of tumor are detected in approximately 1 (15%) of 7 breast cancer patients. These otherwise occult sites of disease can be appropriately biopsied with MRI needle-localization techniques.

MRI: a role in clinical trials

The diagnosis and treatment of breast cancer has evolved significantly over the last 20 years. Breast-conserving therapy is replacing the Halstedian concept of "en bloc" resection. Difficulties in detection, pre- and postoperative planning and follow up continue to challenge the clinician. Women at high risk present a significant clinical dilemma. MRI technology in many of these areas is providing more information about detection, tumor size, extent, and response to treatment. The careful and thoughtful inclusion of MRI in clinical trials may help continue the advancement of breast cancer care. J. Magn. Reson. Imaging 2001;13:837-841.

Breast cancer surgery--historical evolution, current status and future perspectives

The diagnosis and management of breast cancer have changed dramatically over the past two decades in response not only to new technologies but also to cultural and social aspects of the discase. Mastectomy (either radical or modified radical) was the historical mainstay of the treatment of breast cancer for decades. Although mastectomy continues to be appropriate for some patients, breast conservation has become the preferred method of treatment for many patients. Meeting the dual goal of optimum cosmesis and minimal rates of in-breast recurrences after breast-conservation therapy requires the selection and integration of appropriate diagnostic methods (including breast imaging techniques and breast biopsy techniques) its well as therapeutic methods (breast irradiation techniques, and systemic cytotoxic and hormonal therapy). To achieve optimal breast-conservation treatment, a multidisciplinary approach is neccessary. Mastectomy followed by breast reconstruction is a valuable alternative for patients who require or choose mastectomy. After tumor downstaging with induction chemotherapy, a large percentage of patients with large or locally advanced tumors will be able to undergo breast-conservation therapy Partial (levels I and II) axillary lymph node dissection remains the standard of care in the surgical management of patients with invasive breast cancer. Recently there has been intense interest in selective axillary lymph node dissection, focused mainly on the identification of patients who are likely to benefit from axillary lymph node dissection, using sentinel lymph node biopsy.

Breast carcinomas of limited extent: frequency, radiologic-pathologic characteristics, and surgical margin requirements

BACKGROUND

Clinical trials established the value of breast-conserving treatment (BCT) including the macroscopic removal of the tumor followed by local radiation therapy (RT) for Stage I and II invasive carcinomas. The occurrence of local tumor recurrence is related to the extent and multifocality of the tumor. Various studies aim to identify those tumors that could be proper candidates for conventional BCT. Furthermore, recent studies have focused on the identification of tumors that may be treated by breast-conserving surgery alone without RT. Small, localized tumors theoretically should be the potential candidates for this type of treatment. The mammographic and pathologic criteria for the identification of tumors with limited extent are not yet established; furthermore, the optimal extent of the surgical excision and the method for margin examination are controversial.

METHODS

Surgical breast-conserving procedures were simulated in a review of 135 mastectomy specimens of patients treated for an invasive carcinoma (> or = 4 cm in size, all pathologic types except invasive lobular carcinoma) who were theoretically eligible for conservative treatment. Tumor spread including possible multifocality and multicentricity was studied by the technique of correlated specimen radiography and pathology. Breast carcinoma of limited extent (BCLE), the proper tumor profile for BCT, was defined as having no invasive carcinoma, ductal carcinoma in situ, and lymphatic emboli foci beyond 1 cm from the edge of the dominant mass.

RESULTS

Fifty-three percent of the patients in this series had a BCLE. No statistically significant relation was found between BCLE and patient age, pathologic size, type and grade of the tumor, lymph node status, mode of detection, and mammographic aspect of the index tumor. Based on mammography, the absence of calcification or tumor density beyond the edge of index tumor appears to be the best predictor for BCLE (P < 0.0001). A 1-cm microscopically tumor free margin as the outer rim of a macroscopic surgical margin of 2 cm gives the best positive predictive value based on pathology (P < 0.0001). By applying the above conditions, 72 of the 135 cancers were identified as being potential BCLE cases in this series. However, whereas 64 of these 72 tumors (89%) were correctly identified as being true BCLE, 8 (11%) were erroneously identified as such (non-BCLE cases), having "residual" tumor foci beyond 2 cm from the edge of the dominant tumor.

CONCLUSIONS

We conclude, that approximately 50% of invasive ductal carcinomas may have limited extent. The accuracy of identifying this group of cancers, the proper candidates for BCT, by applying state-of-the-art mammography and pathology may be as high as 90%. A subset of these tumors might represent the potential candidates for treatment with surgery alone without RT. As a result, the routine application of BCT complemented by RT would have led to the overtreatment of 89% of the patients with a BCLE in this series; conversely, 11% of the tumors may have recurred without the use of RT. Considering that these conclusions are based on a theoretic morphologic model, further clinical studies with facilities for high quality team approach in diagnosis and therapy are needed to evaluate the impact of BCLE on BCT strategies. The results of this study should not justify the withholding of RT outside the context of clinical trials.

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

BACKGROUND AND OBJECTIVES

Breast-conserving treatment (BCT) is the elective approach to early stage breast cancer. We report on our 24 years of experience.

METHODS

Between 1975 and 1998, 980 conservative surgical procedures in 962 patients for limited-sized infiltrating breast cancer (T1 to "small" T2, N0-N1, M0) were performed. BCT consisted of a local wide excision, axillary dissection and postoperative radiation therapy to the entire breast (50 Gy). An adjuvant systemic treatment (chemo- and/or hormonotherapy) was administered to the large majority of patients. Data on age, menopausal status, histologic subtype of tumor, quadrant site of cancer, tumor size (Tla, T1b, T1c, or T2), axillary nodal status (N- or N+, with involvement of 1-3 nodes, or more), and follow-up were stored for each patient. Overall, N+ patients constituted 29.2% of the total number. Survival data were analyzed using the Berkson-Gage actuarial method.

RESULTS

The 15-year overall and disease-free survival rates were 72% and 67%, respectively. Nevertheless, the more interesting results concern survival rates in relation to T and N parameters. T-related survival showed a sharp distinction among the subgroups T1a + T1b and T1c, with values of 90% for the former versus 62% for the latter. Even more significative results were achieved by comparing N with survival. In fact, it was 84% for N-patients and 31% for N+ patients; for N+ patients, outcome was poor for the subgroup showing an involvement of more than 3 nodes, with no patient surviving at 15 years. None of the other evaluated parameters proved to be related to survival. The validity of our protocol is confirmed by the low number of local relapses: only 33 (3.4%) of 980 total treated cases. Cosmetic results were excellent or good in a high percentage of patients (>80%).

CONCLUSIONS

These results unquestionably confirm the validity of BCT, provided certain prerequisites are fulfilled.

A Retrospective Study of Breast Cancer Patients Treated with Quadrantectomy without Radiation Therapy

BACKGROUND: Radiation therapy after breast-conserving surgery (BCS) reduces the risk of local recurrence. However, whether radiation therapy is necessary forall patients undergoing BCS remains unclear. METHODS: In order to determine the selection criteria for patients who can safely omit radiation therapy and to confirm the survival benefit of quadrantectomy without radiation therapy, we reviewed 107 patients who underwent quadrantectomy without radiation therapy between February 1988 and July 1995. RESULTS: The 5-year overall survival, disease-free survival and cumulative local recurrence rates were 93.7%, 80.7% and 12.1% respectively. There were no significant differences of 5-year overall survival (94.0% vs 94.1%) and disease-free survival rates (83.1% vs 70.0%) between patients with or without tamoxifen. The 5-year cumulative local recurrence rate of patients with tamoxifen, however, tended to be lower (p = 0.0810) than that of patients without tamoxifen. The 5-year cumulative local recurrence rate of the patients aged 45 or less was significantly higher than that of patients aged from 45 to 55 years and those over 55 (p= 0.0090 and 0.0089, respectively). In ER positive patients, the 5-year cumulative local recurrence rate of patients with tamoxifen tended to be lower (p= 0.0791) than that of patients without tamoxifen. CONCLUSION: The survival rate of quadrantectomy without radiation therapy wasacceptable. While the risk of local recurrence following quadrantectomy withoutradiation therapy is substantial, radiation therapy following quadrantectomy might not be necessary in elderly ER positive women receiving adjuvant tamoxifen therapy.

Rapid Intraoperative Scrape Cytology Assessment of Surgical Margins in Breast Conservation Surgery

Rapid intraoperative scrape cytologic examination for diagnosing surgical margin involvement of specimens obtained by breast conservation surgery was evaluated. Four surgical margins(nipple side, two lateral sides and distal side)of the removed breast tissue were cytologically examined and histologically compared following segmentectomy in 50 breast cancer patients(200 margins). Intraductal carcinoma had a tendency to spread most extensively to the nipple, compared with other margins. The margin positive rate of tumors with ductal spread(DS)of over 20mm was significantly higher than in tumors with a DS under 20 mm(52.2% vs 7.4%)(P < 0.001). of 50 canditates 10 patients underwent total mastectomy due to positive margins on repeat cytologic examination after re-excision. Four of the 10 patients had an extensive intraductal component on microscopy. The sensitivity, specificity and accuracy of cytology were 96.4 %, 90.7% and 91.5%, respectively.Scrape cytology is useful to determine surgical margin involvement after segmentectomy for breast cancer, although overestimation of involvement will tend to result.

MRI of histologically confirmed mammary carcinoma: clinical relevance of diagnostic procedures for detection of multifocal or contralateral secondary carcinoma

PURPOSE

MR mammography (MRM) is a sensitive diagnostic method for the detection of mammary carcinomas. The present study evaluates whether MRM can yield additional relevant data in cases of histologically confirmed mammary carcinoma.

METHOD

Thirty-four patients with histologically confirmed mammary carcinoma were examined at MRM using a T1-weighted GE sequence and a T2-weighted SE sequence. Morphologic criteria and the dynamic contrast medium behavior of the tumors were evaluated.

RESULTS

MRM showed a 100% sensitivity and diagnostic accuracy in the detection of mammary carcinomas. Additionally, three unexpected contralateral carcinomas were discovered. In 26 patients, there was a multifocal or multicentric tumor process. In 24 patients, peritumoral edema was visualized, which corresponded histologically in 21 patients with lymphangiosis and in 3 with an inflammatory peritumoral reaction.

CONCLUSION

Because of its high sensitivity in the diagnosis of multifocal disease and of contralateral carcinomas, MRM would seem to represent a useful addition to preoperative diagnostic procedures. The potential benefit to the patient and its cost efficiency, however, remain to be clarified.

Frozen-section-guided breast-conserving surgery: implications of diagnosis by frozen section as a guide to determining the extent of resection

This study was conducted to analyze retrospectively the results of performing sector resection on 56 breasts in 54 patients with breast cancer. The glands were resected with a 2-cm tumor-free margin on both lateral sides and the distal side, and with more than a 3-cm tumor-free margin on the nipple side. The frequency of positive resection margins for the cancer cells was 7/56 (12.5%) on the nipple side and 12/46 (26.1%) on the lateral sides, with an overall frequency of 15/56 (26.8%). There were positive resected margins for cancer cells on both the nipple and lateral sides in 4/46 patients (9%). Assuming the equivocal margins were positive for cancer cells, an accurate diagnosis by frozen section examination was made in 51 of the 56 operations (91.1%). Additional resection of the margins was performed in all 20 cases of a positive resected margin for cancer cells according to the diagnosis by frozen section. Thereafter, the resected margins became negative in 13 cases (65%), but remained positive in 7 cases (35%). These results show that performing diagnosis by frozen section of the surgical margins is an effective guide to resecting tumors adequately.

MRI in breast cancer diagnosis and treatment

Breast cancer diagnosis and treatment are important health care issues in the Industrialized World. About 180,000 new breast cancers are discovered annually in the United States. Because this cancer often occurs in premenopausal women, breast cancer is a leading cause of potential life years lost. Breast magnetic resonance imaging (MRI) is capable of producing detailed information concerning the extent and character of breast lesions. The technique and alternatives for generating high-resolution breast MR images are reviewed. Characteristic features of a pulse sequence for breast imaging includes heavy T1 weighting and magnetization transfer weighting for more effective gadolinium contrast, fat suppression, and rapid acquisition time. MRI is best employed for breast cancer diagnosis as a supplement to conventional breast imaging. Diagnostic groups particularly well suited to breast MRI include women with radiographically dense breasts, silicone augmentation, and postoperative scar. The capacity of breast MRI to show disease extent is employed to plan and localize for breast-conservation therapy. Tumor size and multiple tumors can be characterized for more-effective surgical management. Ductal carcinoma in situ can be imaged and staged for tailored therapy. MRI-directed biopsy and localization can be used to optimize lumpectomy surgery and reduce the potential for histologically positive margins. MRI can define the effectiveness of radiation therapy and chemotherapy to provide improved information on nonsurgical treatment of breast cancer. The clinical implementation of breast MRI in the future depends on the careful coordination of quality MRI images and interpretations with skillful therapeutic management.

Breast-conserving treatment: controversies and consensus

Although breast-conserving therapy (BCT) is an accepted alternative for the treatment of breast cancer, numerous controversies surround the selection criteria and the treatment details. A review of the literature revealed that patient selection is of critical importance. However, there is disagreement over the relative importance of some of the criteria for patient selection. A wide excision is preferable to a less complete excision (tumorectomy) or a more radical excision (quadrantectomy). Accurate assessment of surgical margins is important. The risk of local recurrence may be diminished if a re-excision is performed to obtain tumor-free margins. However, the suitability and practicality of the techniques used to assess the resection margins have been questioned. Radiotherapy is an integral part of BCT. Surgery alone remains an investigational approach. Axillary dissection remains a reliable method of assessing nodal status and treating regional disease.

The importance of the resection margin in conservative surgery for breast cancer

Eradication of breast cancer by wide local excision alone is not possible unless the clinical margins of excision exceeds 5 cm or a segmental mastectomy is performed, though recurrences may still occur after a segmental mastectomy. With inadequate excision radiotherapy to the breast is essential, but will not prevent local recurrence. In a prospective trial (1981 to 1990) to assess the value of radiotherapy to the breast when adjuvant therapy was administered, 418 patients treated by wide local excision and adjuvant chemotherapy (tamoxifen if oestrogen receptor-positive and CMF chemotherapy if oestrogen receptor-negative) were randomized to have loco-regional radiotherapy to the breast or not. At a minimum 5-year follow-up, the local recurrence rate in patients receiving radiotherapy was 13% compared to 35% in those not so treated. Local recurrence was strictly related to microscopic clearance in millimetres irrespective of clinical wide local excision, nodal, or menopausal status. Where, histologically, local excision was incomplete and patients received radiotherapy, the local recurrence rate was 17%. The criteria for wide local excision need to be strictly defined and histologically proven if post-operative radiotherapy is to achieve its effective function, that is the prevention of local recurrence. Radiotherapy cannot compensate for inadequate surgery.

Tumour bed biopsy detects the presence of multifocal disease in patients undergoing breast conservation therapy for primary breast carcinoma

This study prospectively examined tumour bed biopsies in 135 consecutive patients undergoing conservative surgery for breast carcinoma. All had wide resection of the primary tumour and histologically clear margins. Twelve patients (9%) had positive tumour bed biopsies. Two subgroups of patients had positive bed biopsies; those with ductal carcinoma in situ, and a second group with more aggressive disease characterized by lymph node involvement, vascular invasion and a higher grade and mitotic count. As the majority of recurrences from breast carcinoma occur in the region of the primary tumour, bed biopsy may aid in the identification of a group of patients with multifocal or aggressive disease who are at increased risk of local recurrence.

Local and regional therapy for primary breast tumors

Preview Few subjects in modern medicine stir the emotions and invite such scrutiny as breast cancer does. Important questions must be answered in its primary treatment: Can the breast be preserved, or is a complete mastectomy necessary? Should axillary node dissection be done? Will radiation therapy be useful? Should reconstruction be part of initial treatment? In this article, the authors first discuss issues that most directly affect the primary care physician and then review management from the perspective of the surgical oncologist.

Conservative surgery without radiotherapy in the treatment of patients with early-stage invasive breast cancer. A review

OBJECTIVE

The authors determined whether some patients with clinical stage I or II invasive breast cancer can be adequately treated by conservative surgery without radiotherapy.

SUMMARY BACKGROUND DATA

Currently, there are many patients who are being treated in this manner in both academic and community hospitals. This approach is not as effective as either mastectomy or conservative surgery followed by radiotherapy in preventing local recurrence. However, there may be subsets of patients who might be adequately treated by surgery alone with acceptably low recurrence rates.

METHODS

The authors reviewed retrospective studies of conservative surgery alone and of randomized trials comparing the results of treatment with and without postoperative radiotherapy.

RESULTS

The local recurrence rate is unacceptably high when random patients are treated with conservative surgery without radiotherapy. More favorable results may be possible when relatively wide excisions are performed on selected postmenopausal patients with small lesions without an extensive intraductal component, lymphatic or blood-vessel invasion, and histologically negative axillary nodes. The role of tamoxifen in reducing the risk of breast recurrence is uncertain. Despite salvage therapy, some individuals may develop disseminated disease as a result of local recurrence.

CONCLUSIONS

The authors believe that conducting carefully designed prospective studies of conservative surgery alone is reasonable for patients who are adequately informed of the potential risks of omitting radiation therapy. However, currently, patients should not be treated with conservative surgery alone (without radiotherapy) without such stringent guidelines.

Analysis of residual cancer after diagnostic breast biopsy: an argument for fine-needle aspiration cytology

BACKGROUND

Diagnostic breast biopsy (DxBx) requires an effective strategy for successful treatment of breast cancer by lumpectomy or mastectomy. Clearance of margins is required to achieve local control.

METHODS

We reviewed 844 malignant diagnostic biopsies. The strategy was to perform DxBx on all nonpalpable lesions and fine-needle aspiration (FNA) on all palpable lesions. When FNA was equivocal, DxBx was performed. After positive DxBx, either the biopsy cavity or FNA-positive breast mass was excised, and margins were documented with touch preparation cytology analysis (TPC) and frozen section (FS) as necessary to achieve negative margins.

RESULTS

Outside institutions referred 430 excisional biopsies. Two hundred twenty-five (52.3%) were found to have residual cancer at surgical excision. Our institution performed 414 biopsies: 169 were performed on nonpalpable lesions in which 58% had residual tumor at resection; 245 were diagnosed by FNA of palpable lesions. Residual disease was found in 12 (5%).

CONCLUSIONS

Of patients who undergo DxBx, > 50% have residual breast cancer. It is recommended that (a) FNA be performed on all palpable masses or DxBx of nonpalpable masses; when cancer is diagnosed, proceed to surgical excision. (b) When lumpectomy is the option, margins should be reexcised and intraoperatively evaluated with TPC and FS at the time of axillary dissection.

Should multicentric disease be an absolute contraindication to the use of breast-conserving therapy?

PURPOSE

Multicentric cancer is present in a large proportion of mastectomies performed as treatment of breast cancer; it has been considered a contraindication to breast conservation.

METHODS AND MATERIALS

We reviewed the records of our patients with Stage I or II breast cancer treated with breast conserving surgery and radiation therapy over a 13-year period. Twenty-seven patients had two or more nodules of grossly visible cancer separated by histologically normal breast tissue. All patients had grossly negative margins of excision; however, four patients had microscopically positive margins. Nine patients had positive axillary nodes. All patients received radiation therapy to the breast postoperatively, with a median dose of 50.4 Gy in 28 fractions; 11 patients also received a boost dose of 6-20 Gy to the tumor bed. Eleven patients were given adjuvant chemotherapy and one patient was given adjuvant tamoxifen.

RESULTS

With a median follow-up of 53 months, only one patient has relapsed in the breast (3.7%); that patient relapsed in multiple distant sites at the same time. Three patients have died of disseminated disease; the actuarial survival and disease-free survival rates at 4 years are 89%.

CONCLUSION

Breast conservation may be considered for patients with multicentric breast cancer discovered at the time of histologic examination. For patients with multicentric disease detected prior to surgery, breast conserving therapy may be appropriate as long as: (1) all clinically and radiographically apparent abnormalities are removed, (2) clear margins of resection are achieved, and (3) there is no extensive intraductal component.

Characteristics of local recurrence following lumpectomy for breast cancer

We report the clinical characteristics and treatment of local breast relapse in our breast cancer patients who were initially managed with breast conservation surgery (lumpectomy) alone. A retrospective study was conducted of 366 patients who were treated since 1977. The clinical, pathological, and treatment data regarding the primary tumor and the recurrences (91) were reviewed. The actuarial rate of local breast relapse in this group was 31% at 10 years. Breast relapse was significantly less in those patients 65 years old or greater. Acceptable treatment of the breast relapse included total mastectomy or repeat lumpectomy plus radiotherapy. Most relapses were small and occurred in the same area as the original tumor and had similar histology and estrogen and progesterone receptor values. About one-third of patients will have isolated relapses after conservation surgery alone, but in the older age group, isolated breast relapse occurs less frequently. The recurrences are usually surgically resectable, and acceptable results can be achieved with salvage surgery.

Controversies in primary breast cancer management

Adequate locoregional treatment of patients with primary operable breast cancer involves the control of multicentric disease in the breast and axillary dissection to stage the disease and control it in the axilla, when present. Two options, having equal survival rates in prospective, randomized studies, are breast preservation and mastectomy. In breast preservation, adequate tumor excision with clear histologic margins and axillary dissection is followed by breast irradiation. The mastectomy option involves no radiotherapy and can be followed by reconstruction. Careful selection of patients and a detailed description of the pros and cons of each approach should be undertaken on an individual basis.

Breast cancer: the role of radiation therapy after treatment by conservative surgery

The role of conservative surgery (CS) as definitive treatment of invasive breast cancer has not been established. Previous studies have demonstrated high rates of local tumour recurrence if CS is not followed by radiotherapy (RT). At present, it is impossible to identify subsets of patients who may be at acceptably low risk of recurrence after CS. The treatment of breast cancer by CS alone remains an important research question as this may avoid over-treatment by radiation for some patients. In Australia, a trial has been proposed by the ANZ Breast Cancer Trials Group, comparing CS alone to CS+RT. This paper reviews all available data on CS alone in order to stimulate debate as to the appropriateness of the trial and its end-points. Given that all prospective randomized trials have failed to show a survival disadvantage for CS alone it is essential to consider the value of all outcomes after CS or CS+RT. The conventional end-points proposed in the Australian study (mastectomy rate, disease-free survival (DFS) and overall survival (OS)) are selective. Without the addition of quality of life measures, the utilities of the strategies addressed in the trial cannot be evaluated. Data are presented on the desirability (utility) of the alternative approaches of CS or CS+RT based on data obtained from a questionnaire completed by Westmead Hospital staff. This preliminary study indicates that the majority of respondents to the questionnaire perceived that the strategy of CS+RT to have a higher utility than the strategy of CS alone.

Salvage mastectomy

Local-regional relapse after breast-conserving surgery and radiation therapy is operable and not associated with concurrent distant metastases in most cases. Salvage mastectomy results in local-regional control for most patients. The extent of the surgery relates to the extent of the local-regional recurrence and does not carry an increased complication rate. The outcome of salvage mastectomy depends on the disease-free interval from initial breast-conserving surgery and radiation therapy to local-regional recurrence. Additional factors, such as the extent and histologic type of the recurrence, as well as the axillary lymph node status, either at the time of initial breast conservation or at salvage mastectomy, may influence outcome and require further study. Prospective trials are required to determine the safety of further breast-conserving surgery after local-regional relapse and the role of systemic therapy in improving postsalvage survival.

Primary treatment for breast cancer

Adequate local-regional treatment of patients with primary operable breast cancer involves controlling multicentric disease in the breast, and axillary dissection to stage the disease and control it in the axilla, when present. Two options, showing equal survival rates in prospective, randomized studies, are breast preservation and mastectomy. In breast preservation, adequate tumor excision with clear histologic margins and axillary dissection is followed by breast irradiation. The mastectomy option involves no radiation therapy and can be followed by reconstruction. Careful selection of patients and detailed description of the pros and cons of each approach should be undertaken on an individual basis.

Radiotherapy after conservative surgery for breast cancer: selective use of iridium-192 wire boost to tumour bed in high risk patients

The results of treatment for 51 patients referred for radiotherapy after local excision of an 'early' breast carcinoma are reviewed. The patients were considered to be at particularly high risk of local recurrence due to the presence of one or more adverse histological features, most commonly microscopic involvement of resection margins. The patients received a course of whole-breast irradiation (40 Gy in 15 fractions over 3 weeks) but instead of following this with a routine photon or electron tumour-bed boost (15 Gy in five fractions) these patients received an iridium-192 wire implant, giving a tumour-bed boost of 25 Gy over approximately 3 days. After a median follow-up of 38 months, five patients have recurred locally within the breast, giving an actuarial breast recurrence-free survival of 87.8% at 8 years. Four patients have died of metastatic breast cancer, none of whom had uncontrolled local disease. Cosmesis was good or excellent in 76% of cases. The presence of microscopic tumour at resection margins or other adverse histological features is not, therefore, necessarily an indication for further surgery, as a good level of local control can still be achieved with radiotherapy providing a relatively high-dose tumour-bed boost is employed using an iridium-192 wire implant.

The significance of the pathology margins of the tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer

To evaluate the significance of the pathology margins of the tumor excision on the outcome of treatment, an analysis was performed of 697 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive irradiation. Complete gross excision of the primary tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 697 patients were divided into four groups based on the final pathology margin from the primary tumor excision or from the re-excision if performed. These four groups were: (a) 257 patients with a negative margin (greater than 2 mm), (b) 57 patients with a positive margin, (c) 37 patients with a close margin (less than or equal to 2 mm), and (d) 346 patients with an unknown margin. The patients with positive final pathology margins were focally positive on microscopic examination. Patients with grossly positive margins or with diffusely positive microscopic margins were treated with conversion to mastectomy. There was a significant difference in the total radiation dose for the four groups (median dose of 6000 vs 6500 vs 6400 vs 6240 cGy, respectively; p less than .0001). There was no significant difference among the four groups for 5-year actuarial overall survival (p = .19), no evidence of disease (NED) survival (p = .95), or relapse-free survival (p = .80). There was no significant difference among the four groups for five year actuarial local or regional control (all p greater than or equal to .29). Subset analyses did not identify any poor outcome subgroups. These results have demonstrated that selected patients with focally positive or close microscopic pathology margins can be adequately treated with definitive breast irradiation. Patient selection and the technical delivery of radiation treatment including a boost may have been important contributing factors to the good outcome in these patients.

Treatment of early breast cancer with conservation of the breast. A review

This paper reviews the current status of conservative treatment for early breast cancer. While the first patients were treated with such techniques more than 60 years ago, it is during the last decade that randomized trials have confirmed that such treatment is comparable to mastectomy in preventing breast cancer death. Radiotherapy to the breast after local tumour excision is important to prevent local breast relapse, but it is not clear whether it has any influence on the risk of distant metastases. Several questions remain to be answered. While most investigators agree that the breast should receive a radiation dose of about 50 Gy in 5 weeks, there is no general agreement about the need for a tumour bed booster dose. Considering patients with tumour infiltration at the surgical resection line for whom it is not possible for cosmetic reasons to perform re-resection, it is not clear whether an acceptable local control rate can be achieved through application of a high booster dose in the tumour bed. More trials are needed to show whether certain patients with small invasive carcinomas should be treated with wide local excision without radiotherapy. The need for radiotherapy after local excision for small intraductal (ductal carcinoma in situ) cancers is being addressed in ongoing trials.

Prognostic factors associated with survival after breast cancer recurrence

Factors associated with disease-free interval after the primary treatment and survival after a recurrence of breast cancer were studied in 331 female breast cancer patients treated in 1976-1980. Within five years after the primary treatment, recurrence occurred in 131 patients. The observation time of these patients after recurrence was from few weeks to twelve years. Twenty-nine patients were alive at the end of the follow-up. The average disease-free time was 2 years. The clinical stage of the disease in this material was not significantly associated with the disease-free interval. The median survival time after recurrence was 2.7 years when only breast cancer related deaths were included. Survival was significantly better for patients with primarily stage I disease than for patients with primarily stage II-IV disease. The size of the primary tumour was not significantly associated with survival after recurrence. The patients with loco-regional recurrence survived almost significantly better than those with distant recurrence. The disease-free time correlated positively with survival after a recurrence. The present study confirms the view that breast cancer includes several subgroups with a different type of clinical course.

Selection of breast-preservation therapy for primary invasive breast carcinoma

Breast-preservation treatment for primary breast cancer should not be used for all women. Women frequently excluded from consideration for such treatment or who choose not to have it may be elderly and not concerned about cosmetic appearance or live at a distance so that 6 weeks of daily trips to radiotherapy would be inconvenient or even impossible. Also, if radiotherapeutic expertise or facilities are not available, a breast-preservation program is difficult. In Massachusetts, a full course of just over 6000 cGy (4500 cGy to the whole breast and a 1600-cGy local boost) costs roughly $6000. Thus, breast preservation is more expensive than mastectomy even with reconstruction, as patients still frequently require a hospital admission with general anesthesia for an axillary dissection. Although insurance policies cover such expenses, patients who do not have insurance or have inadequate coverage may find the extra expense of the breast-preservation technique burdensome or impossible. Women with a small breast and a proportionately large cancer may have an unsatisfactory cosmetic outcome after appropriate lumpectomy. The cosmetic result in such patients frequently cannot be predicted beforehand; this fact adds emphasis to the need for a two-step process of lumpectomy and then re-evaluation of the cosmetic outcome as well as pathologic features for decisions regarding breast preservation. Finally, women may have strikingly different attitudes toward breast preservation than expected by the surgeon. For some women, the urge to preserve the breast is so strong that they will accept virtually any risk to achieve this option, whereas for other women, the constant anxiety about a recurrence or undergoing radiation therapy is traumatic enough that they readily accept mastectomy. In our referral surgical oncology practice, roughly 60% of patients are currently treated with breast-preservation techniques; the remainder undergo mastectomy, with immediate reconstruction in approximately three fourths of the cases. The proportion of patients who elect to have breast preservation depends greatly on local medical customs and attitudes; the radiotherapeutic skills available; women's attitudes, which frequently are dependent on the local press and publicity; and the surgeon's interest and enthusiasm for such a program. There is no appropriate proportion of patients who should be treated by breast-preservation techniques, but clearly, the proportion of patients so treated increases with experience, acceptability, publicity, and availability. Thus, the selection of breast-preserving therapy for individual patients is a result of an extraordinary array of factors that need to be considered in each patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Conservative surgery and radiotherapy for early breast cancer

In 1984, as part of a prior American Cancer Society National Conference on Breast Cancer, the authors reported on the status of conservative surgery (CS) and radiotherapy (RT) as primary local treatment for women with early stage breast cancer. Since that time, additional data have become available regarding the use of this approach and its comparability to mastectomy. In general, these data support the use of CS and RT and, as a result, this approach is now more widely employed in the United States and abroad than it was in 1984. The current focus of inquiry has shifted from whether or not CS and RT is an acceptable option for patients with early stage breast cancer to the following questions. For which patients are CS and RT suitable? What are the best techniques of surgery and RT? Are there any patients who can be treated safely with CS without RT? How should RT and systemic therapy be integrated when both are to be used? In this report, recent results on the use of CS and RT from both retrospective and prospective trials are summarized, and these current areas of inquiry are addressed.

Duct carcinoma in situ. Pathology and treatment

Duct carcinoma in situ is now being detected with a frequency and at a size unknown prior to mammography. The majority of currently detected lesions are of limited extent and not associated with either occult invasion or axillary metastasis. For such limited duct carcinoma in situ, attempts at adequate local excision appear appropriate. Duct carcinoma in situ represents a number of biologically different processes that exhibit different frequencies of occult invasion and different risks for local recurrence after attempts at excision biopsy. The risks of local recurrence after a breast-conserving procedure without irradiation observing the selection criteria we employ can be estimated on the basis of the histologic subtype of the in situ carcinoma, the extent of disease, and the adequacy of the resection margins. In our prospective series, these risks ranged from 0 to 25 per cent for specific histologic subtypes at a median of 68 months of follow-up, with an overall frequency of recurrence of 12.6 per cent. All recurrences were local in the breast. Half were noninvasive disease, and all of the latter were initially treated by re-excision only. Other investigators report a similar experience. Invasive recurrences have been of minimal size, and all but one was free of nodal metastases. All patients are well at present. Three deaths have occurred secondary to cardiac disease.

New diagnostic, staging, and therapeutic aspects of early breast cancer

Many advances have occurred in breast cancer through research and clinical trials. More confidence in new biological consumptions about invasive breast cancer indicate that: (1) details of the primary breast cancer do not control survival; (2) breast-only failures after local excision do not bias against survival; and (3) cancer cell dissemination occurs at the same time via both lymphatic and hematogenous routes. Early detection with mammographic screening has indicated a greater number of smaller breast cancers, including sharp increases in ductal carcinoma in situ (DCIS). With proper analysis and control, DCIS of limited extent can be treated by local excision with or without radiation. Invasive breast cancer of limited extent can frequently be managed by lumpectomy and radiation therapy with survival rates equivalent to the more traditional mastectomy. Patient desires regarding breast preservation and quality of life are paramount. Risk: benefit analyses for individual patients need to be emphasized in issues of breast preservation and in selecting adjuvant therapy, both regional (radiotherapy) and systemic (chemotherapy) and hormonal therapy). We are entering an era of highly selective therapy based on more sophisticated analysis of the primary cancer. In the future, not only statistical predictions of outcome as achieved by flow cytometry, for example, will be more widely used, but individual prognostic factors may be developed such as with oncogene expression. Such individual prognostic factors will enable more selective therapy.

Neoplastic involvement of nipple-areolar complex in invasive breast cancer

The neoplastic involvement of the nipple-areolar complex was histologically studied in 1,291 available consecutive mastectomy specimens with primary invasive breast carcinoma. Tumor involvement of the nipple-areolar complex was found in 150 specimens (12 percent) and was not suspected on gross examination in 99 patients (8 percent). A significant finding of our study was the relatively high rate of tumor foci in the nipple-areolar complex (7 percent) in those patients with early invasive stage I or II breast carcinoma eligible for conservative therapy. Analysis of nipple-areolar complex involvement with consideration of different clinico-morphologic variables indicates that it was directly associated with tumor size. No significant correlation was found with axillary metastases, tumor histologic type, or with the presence of noninvasive cancer in the vicinity of the dominant tumor. Our estimate of the significant change of finding tumor in the nipple-areolar complex, especially in the patient group eligible for conservative therapy, underlines the need for postoperative radiation.

Patterns of breast relapse after local excision +/- radiotherapy for early stage breast cancer

One hundred patients with breast recurrence have been identified from patients at the Royal Marsden Hospital, treated by local excision +/- radiotherapy for early stage primary invasive breast cancer between 1961 and 1985. The mean follow-up was 58 months (range 1 month - 19 years). In 74/100 patients, breast recurrence occurred within the breast parenchyma, was not associated with systemic relapse and carried a relatively good prognosis with a median survival of 77 months from the time of breast relapse. In 67 patients with parenchymal relapse in whom the site of relapse could be reliably compared with that of the original tumour, 60 (90%) patients developed recurrent tumours at or close to the primary site. In 24/100 patients, breast recurrence occurred in the overlying skin and in only two of these patients (2% of total) did recurrence actually occur within the scar tissue. Skin relapse was associated with systemic relapse and carried a relatively poor prognosis with a median survival of 36 months from the time of recurrence. The pattern of breast relapse was similar in irradiated and unirradiated patients. Skin relapse appears to be a manifestation of metastatic disease while parenchymal relapse may represent regrowth of primary tumour. This pattern of breast relapse questions the requirement for radiotherapy to the whole breast after local excision for early stage breast cancer.