1
|
Dalberg K, Liedberg A, Johansson U, Rutqvist LE. Uncontrolled local disease after salvage treatment for ipsilateral breast tumour recurrence. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:143-54. [PMID: 12633557 DOI: 10.1053/ejso.2002.1306] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM Uncontrolled local disease (ULD) following breast conservation constitutes a clinical problem with a major impact on quality of life. The current study analysed the outcome following treatment of ipsilateral breast tumour recurrence (IBTR) and the risk for ULD with the aim to identify risk factors for ULD. METHODS In a cohort of 5502 patients treated for invasive breast cancer Stage I-II with breast-conserving surgery 1976-1998 in Stockholm, 307 patients with subsequent IBTR were identified. The majority (n = 219) had received postoperative radiotherapy. Twenty-six per cent of the patients received adjuvant tamoxifen, for 2 or 5 years, and 9% received adjuvant polychemotherapy. Median follow-up time was 11(2-23) years. 50/307 patients developed ULD, defined as the appearance of clinically manifest invasive adenocarcinoma in the remaining breast or on the ipsilateral chest wall which could not be eradicated within 3 months of detection. Multivariate linear logistic regression was used in the statistical analysis to identify prognostic factors for ULD. RESULTS Five years following the diagnosis of IBTR the cumulative incidence of ULD was 13%. Five independent risk factors for ULD were identified; non-surgical treatment of IBTR, disseminated disease concurrent with IBTR, axillary lymph node metastases (at primary breast conservation), time < 3 years between breast conservation and IBTR, no adjuvant endocrine therapy. Eighty-eight per cent of the patients were treated with salvage mastectomy (n = 207) or re-excision (n = 62). The cumulative incidence at 5 years of ULD following salvage mastectomy and salvage re-excision were 10% and 16% respectively compared to 32% among patients treated non-surgically. Following IBTR, the 5-year overall survival among patients with local control was 78% in contrast to 21% among patients with ULD. CONCLUSION Uncontrolled local disease is an infrequent but important outcome following breast-conserving surgery. Primary postoperative radiotherapy reduces the risk for IBTR and is therefore recommended as part of the primary treatment to avoid both IBTR and ULD. In addition to radiotherapy, adjuvant therapy reduces the risk for IBTR and thereby the risk for subsequent ULD. Patients with IBTR, independent of concurrent distant metastases, should when feasible be recommended for salvage surgery as it provides superior local control compared to salvage systemic therapy alone.
Collapse
Affiliation(s)
- Kristina Dalberg
- Department of Surgery, Uppsala University Hospital and Karolinska Hospital, Stockholm, Sweden
| | | | | | | |
Collapse
|
2
|
Marret H, Perrotin F, Bougnoux P, Giraudeau B, Hubert B, Fetissof F, Le Floch O, Lansac J, Body G. Histologic multifocality is predictive of skin recurrences after conserving treatment of stage I and II breast cancers. Breast Cancer Res Treat 2001; 68:1-8. [PMID: 11678304 DOI: 10.1023/a:1017999507338] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To distinguish various types of local recurrence after conserving treatment of breast cancer and to evaluate their predictive value. MATERIALS AND METHODS We first researched the pronostic factors after local recurrence and second evaluated the predictive factors of skin and inflammatory recurrences out of a series of 605 cases of stage I and stage II breast cancer of less than 4 cm in diameter that occurred after conserving treatment. RESULTS Multivariate analysis revealed two major predictors of poor prognosis associated with recurrence: early appearance Hazard ratio 3.0 (1.28-7.00) (p = 0.011) and inflammatory or skin involvement Hazard ratio 3.38 (1.36-8.45) (p = 0.009). A local recurrence multiplied the relative risk for metastasis by 2.6. This result depended on the type of recurrence: when those with inflammatory and cutaneous types were excluded, local recurrence was no longer a poor prognostic factor. Patients who experienced primary invasive tumor with histologic multifocality have a 4.08 (1.44-11.59) (p < 0.004) times greater risk of developing cutaneous or inflammatory recurrences compared with patients who experienced breast cancer unique localization. CONCLUSION As histologic multifocality is the only factor predictive of dark prognosis local breast cancer recurrences, aggressive therapy at the time of the primary treatment could be the therapeutic implications of such finding on the original tumor.
Collapse
Affiliation(s)
- H Marret
- Department of Gynaecology and Obstetrics, Hopital Bretonneau, Tours, France
| | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Clemons M, Hamilton T, Goss P. Does treatment at the time of locoregional failure of breast cancer alter prognosis? Cancer Treat Rev 2001; 27:83-97. [PMID: 11319847 DOI: 10.1053/ctrv.2001.0205] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer local consequences such as bleeding, ulceration, pain and arm oedema or symptoms of metastases. Unlike existing treatment guidelines for primary tumours, both local (surgical and radiation) and systemic treatment recommendations are less well defined after LRR. The purpose of this review was to assess whether or not treatment at the time of locoregional failure ultimately alters a patient's prognosis. Unfortunately, the data from both retrospective and prospective studies are inconclusive and therefore the treatment of patients with LRR will continue to be recommended using guidelines similar to those for primary breast cancer. Future studies of factors predicting LRR and metastatic spread may allow better prognostication of patients with LRR which may in turn effect both local and systemic treatment decisions.
Collapse
Affiliation(s)
- M Clemons
- Department of Medical Oncology, Princess Margaret Hospital, Toronto, Canada.
| | | | | |
Collapse
|
4
|
Clemons M, Danson S, Hamilton T, Goss P. Locoregionally recurrent breast cancer: incidence, risk factors and survival. Cancer Treat Rev 2001; 27:67-82. [PMID: 11319846 DOI: 10.1053/ctrv.2000.0204] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer both local consequences and symptoms of metastatic disease, as LRR is an independent predictor of subsequent distant metastases. Much of the available data on LRR is derived from small, single institution, retrospective studies, so marked differences in the incidence rates for LRR, it's risk factors and subsequent systemic recurrence are reported. The purpose of this review was to try and collate this data in a format that would be useful for both clinicians and their patients.
Collapse
Affiliation(s)
- M Clemons
- Department of Medical Oncology, Christie Hospital, Wilmslow Road, Manchester, UK.
| | | | | | | |
Collapse
|
5
|
Newman LA, Kuerer HM, Hunt KK, Singh G, Ames FC, Feig BW, Ross MI, Taylor S, Singletary SE. Local recurrence and survival among black women with early-stage breast cancer treated with breast-conservation therapy or mastectomy. Ann Surg Oncol 1999; 6:241-8. [PMID: 10340882 DOI: 10.1007/s10434-999-0241-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer. METHODS The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed. RESULTS Fifty-eight percent of patients (n = 211) had tumors < or = 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year disease-specific survival rates were similar for patients <50 years of age and patients > or = 50 years of age, regardless of treatment. CONCLUSIONS LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.
Collapse
Affiliation(s)
- L A Newman
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
6
|
Dalberg K, Mattsson A, Sandelin K, Rutqvist LE. Outcome of treatment for ipsilateral breast tumor recurrence in early-stage breast cancer. Breast Cancer Res Treat 1998; 49:69-78. [PMID: 9694613 DOI: 10.1023/a:1005934513072] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The aims of the study were to assess the outcome among patients with early breast cancer operated on with wide local excision who developed a subsequent ipsilateral breast tumor recurrence, and to identify risk factors for uncontrolled local disease. Uncontrolled local disease (ULD) was defined as the appearance of clinically manifest invasive adenocarcinoma in the remaining breast or on the ipsilateral chest wall which could not be eradicated with salvage treatment during the period of follow-up (2-18 years). PATIENTS AND METHODS Eighty-five patients in a cohort of 759 patients, treated for invasive Stage I-II breast cancer with breast-conserving surgery 1976-1985 in Stockholm, with a subsequent ipsilateral breast tumor recurrence (IBTR) were reviewed retrospectively. The majority of the patients were premenopausal (58%), node negative (72%), and had received postoperative radiotherapy (79%). Median follow-up time following breast-conserving surgery was 13 (9-19) years. Multivariate Cox's hazard regression was used in the statistical analysis to identify prognostic factors for ULD. RESULTS The majority (n = 61) of the IBTR's were located in the original tumor quadrant and showed the same histopathological features as the primary tumor. Salvage mastectomy (n = 65) or reexcision (n = 14) were performed in 79 (93%) of the patients. Twenty-one patients developed ULD. Five years following the diagnosis of IBTR the disease-free survival was 59%, the cumulative incidence for ULD was 24%, and for death in breast cancer 34%. In the cohort of 759 patients, patients who received radiotherapy following the primary breast-conserving surgery had 1% cumulative incidence of ULD following the diagnosis of IBTR compared to 4% among patients that received no postoperative radiotherapy. The cumulative incidence at 5 years of ULD following salvage mastectomy was 12% compared to 33% after salvage reexcision. Patients operated on with breast-conserving surgery with an original tumor size < 15 mm, who were treated with salvage mastectomy for IBTR, had in multivariate analysis the lowest relative risk for ULD. Adjuvant chemotherapy following IBTR treatment did not seem to improve local tumor control. Following the diagnosis of IBTR, 78% (n = 21) of the patients with ULD and/or regional recurrence (n = 27), died of a disseminated breast cancer in contrast to 10% (n = 6) among the remaining 58 patients. CONCLUSION Uncontrolled local disease is an important outcome measure following breast-conserving surgery. In this cohort, salvage mastectomy provided a superior local control rate compared to salvage reexcision. A higher although not statistically significant rate of ULD was also seen in patients who had not received postoperative radiotherapy as part of their primary treatment.
Collapse
Affiliation(s)
- K Dalberg
- Department of Surgery, Karolinska Hospital, Stockholm, Sweden
| | | | | | | |
Collapse
|
7
|
Abstract
BACKGROUND Local recurrence following breast-sparing surgery for breast cancer is no longer considered to be an ominous sign. Why this should be the case is not understood, and it poses a dilemma for the surgical oncologist. When does local recurrence represent an independent threat to survival? DATA SOURCES I reviewed the few studies that have considered the size or tumor burden of locally persistent breast cancer, and the results of the Guy's Hospital Trials. CONCLUSIONS Locally persistent breast cancer is seldom a risk to patient survival. The surgical literature is seriously deficient in its consideration of the tumor volume of locally persistent cancer. All available evidence suggests that a recurrent tumor is a risk only if its volume exceeds that of the original tumor. Patients appear to have a stable level of host defense against metastasizing tumor cells. Those who survive one breast cancer without developing distant disease can be expected to survive the local persistence of a similar volume of tumor. Investigators should compare the size of each persistent lesion to the size of the patient's primary cancer. Excess deaths will occur only among patients whose persistent disease exceeds the volume of the primary.
Collapse
|
8
|
Abstract
Breast-preserving surgery for tumors of limited size or reduced by neoadjuvant chemotherapy has definitely entered into the practice. Distant results of controlled studies demonstrated that conservative methods, when correctly indicated and performed, can provide the same results as mutilating procedures, in terms of overall survival. There is general agreement on the fact that conservation bears a major risk of intrabreast recurrences, whose meaning and impact on prognosis are still open to debate. Inadequate surgery, i.e., too-limited excision, or the lack of radiotherapy, certainly causes a higher rate of local failures. However, analysis of the patient series reported in the literature permits the conclusion that local failures and distant metastasis are events partially independent of each other. In other words, there are factors that are predictive of local recurrence, and not of distant spread, and vice versa, and factors that affect both the risks. Uncertainty about the meaning of local recurrences influences therapeutic attitudes, not only with regard to the choice between total mastectomy and re-resection, when possible, but also with reference to the identification of those local recurrences that merit systemic treatment. As far as the treatment of local failures is concerned, it is too soon to indicate undisputable guidelines. It is necessary to wait for distant results of the many experiences in progress on this issue. On the other hand, since local intrabreast recurrences fortunately are not very frequent (about 10% at 10 years from first treatment), the accrual of patients eligible for clinical trials would take a long time, even for cooperative groups. This is one of the reasons why local failure actually is an open problem.
Collapse
Affiliation(s)
- B Salvadori
- Division of Surgery, National Cancer Institute, Milan, Italy
| |
Collapse
|
9
|
Abstract
Prophylactic lymph node excision has long been recommended for preventing axillary recurrence of primary breast cancer, and has more recently gained support from the finding that adjuvant systemic therapy preferentially benefits patients with axillary node metastases. Despite these justifications, medical opinion in many communities has become deeply polarised over the merits of routine axillary dissection. A factor likely to be contributing to this split is the popularity of prescribing adjuvant systemic therapy (usually tamoxifen) on an expectant basis. Since there has been no controlled assessment of the net benefits of axillary dissection in patients receiving routine adjuvant systemic therapy--followed where necessary by delayed ("salvage") axillary treatment--objective data are urgently needed. If no substantial benefit is lost by replacing routine with delayed dissection, a small but significant improvement in quality of life could be expected for the majority of breast cancer patients.
Collapse
Affiliation(s)
- R J Epstein
- Department of Medical Oncology, Charing Cross Hospital, London, U.K
| |
Collapse
|
10
|
|
11
|
Post-treatment mammography following the breast-conserving treatment of breast cancer: is it of value? Breast 1993. [DOI: 10.1016/0960-9776(93)90011-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
12
|
Affiliation(s)
- E B Mendelson
- Department of Radiology, Western Pennsylvania Hospital, Pittsburgh 15224
| |
Collapse
|
13
|
Blichert-Toft M. Breast-conserving therapy for mammary carcinoma: psychosocial aspects, indications and limitations. Ann Med 1992; 24:445-51. [PMID: 1485936 DOI: 10.3109/07853899209166993] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Breast-conserving therapy (BCT) for invasive cancer comprises complete tumour excision and axillary dissection, followed by irradiation. The object is to perform local treatment and determine the stage of disease on lines similar to those of mastectomy. In selected series of patients the efficacy of BCT has been equivalent to that of mastectomy with a view to distant relapse and survival. On the other hand, it has not been proved whether local relapse pattern is comparable to that of mastectomy, especially in high-risk patients. The advantage of BCT is of psychological nature, since preserving the configuration of the body maintains the sensation of female identity and body image to a better extent than that seen after mastectomy. BCT does not, however, reduce the high frequency of anxiety phenomena, mental instability, and depression. The selection of patients for BCT is based primarily upon a clinical-technical assessment, patient's preference and surgeon's preference, rather than eligibility based on biological risk factors. Demands on surgical technique, radicality of operation, and irradiation are important issues regarding local control. The relation between local recurrence rate and distant relapse will be discussed. The conclusion is that BCT is a method eligible for selected patients and that the increased used of mammography is going to extend the intake of patients for the method. However, it must be an obligation to keep following up the therapeutic results, in order not to lose the advantage of an early diagnosis by altered treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- M Blichert-Toft
- Department of Surgery D, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
14
|
|
15
|
Abstract
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.
Collapse
Affiliation(s)
- M P Osborne
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021
| |
Collapse
|
16
|
Verhoef LC, Stalpers LJ, Verbeek AL, Wobbes T, van Daal WA. Breast-conserving treatment or mastectomy in early breast cancer: a clinical decision analysis with special reference to the risk of local recurrence. Eur J Cancer 1991; 27:1132-7. [PMID: 1835623 DOI: 10.1016/0277-5379(91)90310-a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A clinical decision analysis was performed to judge the impact of local recurrences after breast-conserving treatment (BCT) on the (quality-adjusted) life expectancy of breast cancer patients. A life-long follow-up of two patient groups, one of which had undergone mastectomy and one BCT, was simulated by a Markov model of medical prognosis. Data used in the model originated from the literature. Since results in the source papers were not split according to stage, we performed two analyses: one with data from all source studies (T1 and T2) and one with data from source studies, concerning only T1 patients. In both analyses, the conclusion was that BCT yields better quality-adjusted life expectancy than mastectomy. Sensitivity analysis, however, identified subgroups of patients who should preferably undergo mastectomy. These subgroups are: patients preferring mastectomy to BCT, patients with a high risk of local recurrence, young patients and patients at high age, if they also have a high local recurrence risk. For these groups, patient preferences should play a major role in recommending treatment.
Collapse
Affiliation(s)
- L C Verhoef
- Institute for Radiotherapy, Radboud University Hospital, Nijmegen, The Netherlands
| | | | | | | | | |
Collapse
|
17
|
Van Dierendonck JH, Keijzer R, Cornelisse CJ, Van de Velde CJ. Surgically induced cytokinetic responses in experimental rat mammary tumor models. Cancer 1991; 68:759-67. [PMID: 1855176 DOI: 10.1002/1097-0142(19910815)68:4<759::aid-cncr2820680417>3.0.co;2-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The effect of surgical removal of "primary" tumors on the cytokinetics of local tumor remnants, secondary implants, and metastases was investigated in three different rat tumor models in the Wag/Rij rat: a slow-growing (MCR83) and a fast-growing (EMR86) hormone-dependent mammary tumor and a rapidly, but autonomously growing carcinoma (MCR86). The latter two tumors had metastatic potential. Cell kinetic studies were done using in vivo labeling with 5'-bromodeoxyuridine (BrdUrd). Thirty-three hours after removal of a subcutaneous MCR83 flank tumor, secondary implants showed a significant (P less than 0.05) but transient increase in the BrdUrd labeling index (LI). A more rapid and prolonged increase, lasting for at least 7 days, was observed in EMR86 lymph node and lung metastases. In both models, no effect was observed after sham surgery (consisting of opening and closing of the skin under anesthesia). Removal of MCR86 tumors (growing in the hind leg muscle) also resulted in a rapid, transient LI increase in metastases. Continuous BrdUrd labeling experiments in this tumor model did not favor the hypothesis that the LI increase predominantly resulted from an increase in the growth fraction. Moreover, in this model, the effect was related to operation trauma. A similar increase in LI, although smaller than after tumor removal, was seen after major surgical trauma in MCR83 flank tumors. These results indicate that in the rat, tumor removal and/or major surgical trauma may modulate the cytokinetics of distant metastases significantly. A study of the systemic, possibly endocrine, factors involved in the growth-stimulating effect of surgical trauma in these rat tumor models may help to assess the clinical relevance of these findings for patients with breast cancer.
Collapse
|
18
|
Beerman H, Bonsing BA, van de Vijver MJ, Hermans J, Kluin PM, Caspers RJ, van de Velde CJ, Cornelisse CJ. DNA ploidy of primary breast cancer and local recurrence after breast-conserving therapy. Br J Cancer 1991; 64:139-43. [PMID: 1854613 PMCID: PMC1977293 DOI: 10.1038/bjc.1991.257] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The value of DNA-flow cytometry and clinico-pathological prognostic factors for the prediction of local recurrences after breast-conserving therapy (BCT) were evaluated in a retrospective study. Thirty-one patients with a local recurrence were compared with 31 matched patients without a local recurrence. Morphology and DNA-indices of the local recurrences and their corresponding primary tumours were compared. Ductal carcinoma in situ was present significantly more often in the group with a primary recurring tumour, than in the matched group (P less than 0.001), and the same holds for lobular carcinoma (n = 5). Half of the tumours that recurred had macroscopically positive surgical margins compared to about one-fourth of the matched group. Fifty-six per cent of the DNA-aneuploid stemlines in cases with local recurrence were present in the corresponding primary tumour as well (confidence limits 45%-75%), an indication that the majority of local recurrences are true recurrences and not independently developed tumours. The lack of similarity of DNA stemlines between some primary DNA-aneuploid tumours and their local recurrences indicates that these tumours had developed independently. The percentage of DNA-aneuploid cases in the group with local recurrence (89%) did not differ significantly from that in the matched group (70%). However, the findings suggest a selective recurrence of DNA-diploid stemlines. This might indicate increased resistance of DNA-diploid tumour cells to radiotherapy as compared with the resistance level in DNA-aneuploid cells.
Collapse
Affiliation(s)
- H Beerman
- Department of Pathology, Faculty of Medicine, Leiden University Hospital, University of Leiden, The Netherlands
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Kurtz JM, Jacquemier J, Amalric R, Brandone H, Ayme Y, Hans D, Bressac C, Spitalier JM. Is breast conservation after local recurrence feasible? Eur J Cancer 1991; 27:240-4. [PMID: 1827303 DOI: 10.1016/0277-5379(91)90505-8] [Citation(s) in RCA: 100] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The feasibility of conservative salvage surgery was addressed in a clinicopathologic study of the results of wide excision for 50 selected parenchymal intramammary recurrences after standard breast conserving treatment. After median follow-up of 51 months, 16 (32%) second local failures were observed (5-year local control 62%). Cox multivariate analysis of 18 parameters indicated that only disease-free interval and resection margins significantly influenced local control. 5-year local control was 92% for recurrences occurring after 5 years vs. 49% for shorter intervals, and 73% for negative vs. 36% for positive or indeterminate margins. Local control appeared independent of morphologic features, initial tumour stage, patient age, recurrent tumour size and location. Median survival after second local failure was 33 months; tertiary therapy obtained ultimate local-regional control in 8 of 16 cases. The authors conclude that wide excision is a particularly satisfactory alternative to salvage mastectomy for late recurrences. Negative margins are essential. Further study will be required to establish additional guidelines allowing improved patient selection.
Collapse
Affiliation(s)
- J M Kurtz
- Radiation Oncology Division, University Hospital, Geneva, Switzerland
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Cady B, Stone MD. Selection of breast-preservation therapy for primary invasive breast carcinoma. Surg Clin North Am 1990; 70:1047-59. [PMID: 2218818 DOI: 10.1016/s0039-6109(16)45229-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
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)
Collapse
Affiliation(s)
- B Cady
- Department of Surgery, New England Deaconess Hospital, Boston, Massachusetts
| | | |
Collapse
|
21
|
Abstract
For stage I or II breast cancer, conservative surgery and radiation therapy are as effective as modified radical or radical mastectomy. In most cases, cosmetic considerations and the availability of therapy are the primary concerns. The extent of a surgical resection less than a mastectomy has not been a subject of a randomized trial and is controversial. It appears that removal of a quadrant of the breast for small lesions is safe but excessive. Using histologic findings in the biopsy as a guide, it may be possible to limit the breast resection to gross tumor removal for most patients while using wider resections for patients with an extensive intraductal component or for invasive lobular carcinoma. It also appears that excluding patients from breast conservation on the basis of positive margins on the first attempt at tumor excision may be unnecessarily restrictive. Although patients with an extensive intraductal component or invasive lobular carcinoma should have negative margins, it appears that a patient with predominantly invasive ductal carcinoma can be treated without re-excision if all gross tumor has been resected and there is no reason to suspect extensive microscopic disease. Patients with indeterminate margins should have a re-excision. Axillary dissection provides prognostic information and prevents progression of the disease within the axilla. Axillary dissections limited to level I will accurately identify a substantial number of patients who have pathologically positive but clinically negative nodes. When combined with radiation therapy to the axilla, a level I dissection results in a limited number of patients with progressive axillary disease. Patients with pathologically positive axillas and patients at particularly high risk for systemic disease because of the extent of axillary node involvement can be identified by dissections of levels I and II. Radiation therapy can be avoided safely in patients who have pathologically negative axillas by level I and II dissection. There appears to be no advantage to routine dissection of level III lymph nodes. Lymphedema of the arm and breast increases with more extensive dissections and with radiation therapy.
Collapse
Affiliation(s)
- R T Osteen
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
22
|
Kurtz JM, Spitalier JM. Local recurrence after breast-conserving surgery and radiotherapy: what have we learned? Int J Radiat Oncol Biol Phys 1990; 19:1087-9. [PMID: 2211247 DOI: 10.1016/0360-3016(90)90038-l] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
23
|
Nicholson S. Advertising for medical research funds. Lancet 1990; 335:1285. [PMID: 1971358 DOI: 10.1016/0140-6736(90)91356-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|