Bilaterality and recurrence rates for lobular breast cancer: considerations for treatment

Recurrence in lobular carcinoma of the breast: A 14-year review

INTRODUCTION

The two most common types of breast cancer are invasive or infiltrating ductal carcinoma (IDC) and invasive or infiltrating lobular carcinoma (ILC) (Pestalozzi et al., J. Clin. Oncol., 26, 2008, 3006). Between 5% and 15% of invasive breast carcinomas are lobular carcinomas (Pestalozzi et al., J. Clin. Oncol., 26, 2008, 3006; Dossus and Benusiglio, Breast Cancer Res., 17, 2015, 37; Braunstein et al., Breast Cancer Res. Treat., 149, 2015, 555). The paucity of data relating to recurrence rates of lobular cancers prompted this study.

METHODS

A retrospective cohort study of all cases of lobular breast carcinoma reported to the Western Australia Cancer Registry with the clinical and pathological details between 2000 and 2014.

RESULTS

Overall, 2463 subjects with a total of 2526 events of invasive lobular carcinoma of the breast. 11/2463 (0.45%) subjects met criteria for local recurrence of invasive lobular breast cancer, with an incidence of 1 in 224.

CONCLUSION

There are clinical implications for the management and follow-up for patients with a diagnosis of lobular cancer of the breast. Due to the low recurrence rate, now, the standard practice in our institution does not offer magnetic resonance imaging (MRI) as part of the follow-up for ILC patients. Other centres should establish local recurrence rates to aid development of appropriate management protocols.

Histologic tumor type as a determinant of survival in hormone receptor-positive, HER2-negative, pT1-3 invasive ductal and lobular breast cancer

PURPOSE

The aim of the study was to compare the difference in survival between invasive ductal (IDC) and lobular carcinoma (ILC).

METHODS

Data of patients (n = 1843) with a hormone receptor-positive, HER2-negative, pT1-3 IDC or ILC cancer without distant metastasis, treated at the Ghent University Hospital over the time period 2001-2015, were analyzed.

RESULTS

ILC represented 13.9% of the tumors, had a higher percentage of pT3 and pN3 stages than IDC, lymphovascular space invasion (LVSI) was less present and Ki-67 was mostly low. 73.9% of ILCs were grade 2, whereas IDC had more grade 1 and grade 3 tumors. Kaplan-Meier curves and log-rank testing showed a significant worse DFS for ILC with pN ≥ 1 than for their IDC counterpart. In a multivariable Cox regression analysis the histologic tumor type, ductal or lobular, was a determinant of DFS over 120 months (IDC as reference; hazard ratio for ILC 1.77, 95% CI 1.08-2.90) just as the ER Allred score (hazard ratio 0.84, 95% CI 0.78-0.91), LVSI (hazard ratio 1.75, 95% CI 1.12-2.74) and pN3 (hazard ratio 2.29, 95% CI 1.03-5.09). Determinants of OS over ten years were age (hazard ratio 1.05, 95% CI 1.02-1.07), LVSI (hazard ratio 3.62, 95% CI 1.92-6.82) and the ER Allred score (hazard ratio 0.80, 95% CI 0.73-0.89).

CONCLUSION

The histologic tumor type, ductal or lobular, determines DFS in hormone receptor-positive, HER2-negative, pT1-3 breast cancer besides the ER Allred score, LVSI and pN3.

Personalizing Decision-Making for Patients Choosing Contralateral Prophylactic Mastectomy: A Utility Analysis of Genetic Factors and the Relative Risk of Breast Cancer

Introduction

There has been an increasing trend of patients with breast cancer electing to undergo contralateral prophylactic mastectomy (CPM), despite the lack of evidence showing long-term survival benefit. We aim to quantify the tiered amount of genetic and surgical complication risk deemed necessary to justify CPM.

Methods

A review of breast cancer-affiliated genetic mutations and morbidity rates of breast cancer surgery from a single institution was compiled. A survey using a utility analysis was created. Severity of breast cancer genetic risk and morbidity risk warranting CPM was quantified and evaluated.

Results

A total of 143 surveys were submitted by women of the general population. Data analysis confirmed previous predictions that at a hypothetical increased risk of contralateral breast cancer (CBC), about twice the proportion of women will elect CPM. With over 10 times the baseline risk and no surgical complications, 98.6% of women chose CPM. There was a decrease in affirmative responses with increasing morbidity. This decrease was least prominent at higher genetic risk, illustrating that when women are at a higher risk of CBC, the surgical morbidity rate has less of an impact on their decision for CPM.

Conclusion

At increased risk of CBC, women are likely to elect for CPM. We anticipate that these findings will encourage the growing use of personalized medicine, with the potential to tailor breast cancer treatment plans for each patient's personal genetic profile.

Assessing the additional surgical risk of contralateral prophylactic mastectomy and immediate breast implant reconstruction

INTRODUCTION

There has been a sharp rise in the rate of contralateral prophylactic mastectomy over the last decade, despite the low incidence of new primary cancers predicted for the contralateral breast. This study compares the postoperative complication rates between the diseased breast treated with mastectomy and the contralateral breast that underwent prophylactic mastectomy, followed by immediate bilateral breast implant reconstruction. We hypothesized that there will be no difference in postoperative outcomes between prophylactic and diseased groups, as the surgical approach would be comparable.

METHODS

After IRB approval, a retrospective chart review identified consecutive unilateral breast cancer patients who underwent bilateral mastectomy and immediate breast reconstruction between May 2008 and May 2018 at a tertiary academic medical center. A paired sample t-test and a penalized logic regression model were constructed to identify relationships between breast laterality and outcomes.

RESULTS

A total of 1117 patients with unilateral breast cancer who underwent bilateral mastectomy and immediate breast implant reconstruction were identified. Rates of capsular contracture and infection were significantly greater in the diseased breast, while rates of revision were significantly greater in the contralateral prophylactic breast. There were no statistically significant differences between breasts in rates of explant, skin flap necrosis or hematoma. When adjusted for confounding variables, a higher infection rate was observed in the diseased breast.

CONCLUSION

This study detected significant differences in postoperative complication rates between the diseased and prophylactic breasts following bilateral mastectomy and immediate breast implant reconstruction. Postoperative complications occurred more frequently in the diseased breast compared with low rates of complications in the contralateral prophylactic breast. This information is helpful for preoperative decision making, as surgeons and patients carefully weigh the additional risks of contralateral prophylactic procedure.

Indications for Contralateral Prophylactic Mastectomy: A Consensus Statement Using Modified Delphi Methodology

OBJECTIVE

To reach a consensus about contralateral prophylactic mastectomy in unilateral breast cancer.

SUMMARY BACKGROUND DATA

There has been a substantial increase in the number of North American women with unilateral breast cancer undergoing a therapeutic mastectomy and a contralateral prophylactic mastectomy (CPM) either simultaneously or sequentially. The purpose of this project was to create a nationally endorsed consensus statement for CPM in women with unilateral breast cancer using modified Delphi consensus methodology.

METHODS

A nationally representative expert panel of 19 general surgeons, 2 plastic surgeons, 2 medical oncologists, 2 radiation oncologists, and 1 psychologist was invited to participate in the generation of a consensus statement. Thirty-nine statements were created in 5 topic domains: predisposing risk factors for breast cancer, tumor factors, reconstruction/symmetry issues, patient factors, and miscellaneous factors. Panelists were asked to rate statements on a 7-point Likert scale. Two electronic rounds of iterative rating and feedback were anonymously completed, followed by an in-person meeting. Consensus was reached when there was at least 80% agreement.

RESULTS

Our panelists did not recommend for average risk women with unilateral breast cancer. The panel recommended CPM for women with a unilateral breast cancer and previous Mantle field radiation or a BrCa1/2 gene mutation. The panel agreed that CPM could be considered by the surgeon on an individual basis for: women with unilateral breast cancer and a genetic mutation in the CHEK2/PTEN/p53/PALB2/CDH1 gene, and in women who may have significant difficulty achieving symmetry after unilateral mastectomy.

CONCLUSION

Contralateral prophylactic mastectomy is rarely recommended for women with unilateral breast cancer.

An Analysis of the Decisions Made for Contralateral Prophylactic Mastectomy and Breast Reconstruction

BACKGROUND

Little is known about the role breast reconstruction plays in decisions made for contralateral prophylactic mastectomy. This study explores factors critical to patient medical decision-making for contralateral prophylactic mastectomy and reconstruction among women with early stage, unilateral breast cancer.

METHODS

A mixed methods approach was used to gain an understanding of patients' choices and experiences. Patients with stage 0 to III unilateral breast cancer who underwent reconstruction were recruited, and semistructured interviews were conducted. Patient-reported outcomes were evaluated using the Concerns About Recurrence Scale and the BREAST-Q.

RESULTS

Thirty patients were enrolled; 13 (43 percent) underwent unilateral mastectomy and 17 (57 percent) underwent contralateral prophylactic mastectomy. Three broad categories emerged from patient interviews: medical decision-making, quality of life after mastectomy, and breast reconstruction expectations. Patients who chose contralateral prophylactic mastectomy made the decision for mastectomy based primarily on worry about recurrence. Quality of life after mastectomy was characterized by relief of worry, especially in patients who chose contralateral prophylactic mastectomy [n = 14 (82.4 percent)]. Patients' desires for symmetry, although not the primary reason for contralateral prophylactic mastectomy, played a role in supporting decisions made. Levels of worry after treatment were similar in both groups (72.7 percent). Patients with contralateral prophylactic mastectomy had higher mean scores for satisfaction with breast (82.4 versus 70.6) and satisfaction with outcome (89.9 versus 75.2).

CONCLUSIONS

The choice for contralateral prophylactic mastectomy is greatly influenced by fear of recurrence, with desires for symmetry playing a secondary role in decisions made.

Synchronous and metachronous breast malignancies: a cross-sectional retrospective study and review of the literature

Objective. There is increasing interest in patients with metachronous (MBC) and synchronous breast cancer (SBC). The objective of this study was to evaluate the occurrence and outcome of MBCs and SBCs. Methods. A retrospective study on women operated in our department for breast cancer between 2002 and 2005 was carried out. Patients were divided into three groups: women with MBC, SBC, and unilateral breast cancer (UBC). Moreover, we performed a meta-analysis of the English literature about multiple breast cancers between 2000 and 2011 taking into consideration their prevalence and overall survival (OS). Results. We identified 584 breast cancer patients: 16 women (3%) presented SBC and 40 MBC (7%, second cancer after 72-month follow-up IQR 40–145). Although the meta-analysis showed significant OS differences between MBC or SBC and UBC, we did not observe any significant OS difference among the three groups of our population. Anyway, we found a significant worse disease-free survival in MBC than UBC and a significant higher prevalence of radical surgery in MBC and SBC than UBC. Conclusions. Despite the low prevalence of MBC and SBC, the presence of a long time risk of MBC confirms the crucial role of ipsi- and contralateral mammographies in the postoperative follow-up.

Contralateral prophylactic mastectomy: clinical and pathological features from a prospective database

INTRODUCTION

In keeping with recently documented national trends, a significant and increasing number of patients will have chosen contralateral prophylactic mastectomy (CPM) based on personal preference, without traditional clinical or pathological indication.

METHODS

Women who underwent CPM at the University of Louisville from 2003 to 2009 were selected for this study. Descriptive factors were evaluated such as age, race, family history of breast cancer, laterality, hormone receptor status, stage, grade and histology of the index breast lesion. Statistical analysis was used to compute predictive factors for occult contralateral pathology.

RESULTS

A total of 107 patients underwent CPM and had adequate medical information to be included in this study. The median age was 48 years, with 88% being white and 12% being African American. Seventy-six percent of the index breast cancers were infiltrating ductal carcinoma and 12% were infiltrating lobular carcinoma. Five "significant" occult pathologies were found in the prophylactically removed breast. Two of the lesions were ductal carcinoma in situ, 2 were lobular carcinoma in situ and 1 was an invasive mucinous carcinoma. On bivariate analysis, there were no factors identified predictive for occult contralateral pathology.

CONCLUSIONS

In line with previously reported data, we noted that fewer than 5% of patients who underwent CPM had pathology in the contralateral breast. We were unable to correlate any clinical or pathological characteristics in women who presented with contralateral breast cancer. This study raises serious questions regarding the clinical utility of CPM in detecting synchronous clinically and radiographically occult contralateral primaries.

Lobular breast cancer: same survival and local control compared with ductal cancer, but should both be treated the same way? analysis of an institutional database over a 10-year period

BACKGROUND

Invasive lobular carcinoma (ILC) is believed to be more often multicentric and bilateral compared with invasive ductal cancer (IDC), leading clinicians to pursue a more aggressive local and contralateral approach.

METHODS

Retrospective review of a consecutive cohort of breast cancer patients operated at one institution from January 2000 to January 2010 was performed. Median follow-up was 4 years.

RESULTS

There were 171 ILC (14.5%) and 1,011 IDC patients in the study period. Median age (63 vs. 65 years) and tumor diameter (1.7 cm) were similar in the two groups. Diagnoses of ILC were more frequent in the second half of the study period (55/465 vs. 116/662, p<0.01). Multicentricity was reported in 108/1,011 (10.6%) IDC and in 31/171 (18.1%) ILC patients (p<0.01). A positive margin of resection at initial surgery was documented in 71/1,011 (7%) IDC and in 21/171 (12.3%) ILC patients (p<0.001). Although the rate of mastectomy decreased over time in both groups, this was more pronounced for ILC patients (p<0.001). Locoregional control, contralateral cancer, overall survival, disease-free survival, and survival according to diameter, nodal status, and type of surgical intervention did not differ between IDC and ILC. On multivariate analysis, stage of disease and hormone receptor status were associated with disease-free survival, but histology was not.

CONCLUSIONS

Although ILC is more often multicentric, bilateral, and associated with a positive margin of resection, local control and survival are similar to IDC. ILC can be treated similarly to IDC with good results.

Diagnostic work-up of contralateral breast cancers has not improved over calendar period

Women who have been treated for breast cancer are typically followed up with regular mammography and palpation, with the aim of detecting recurrences and contralateral breast cancer (CBC). This study aims to investigate if the diagnostic work-up of breast cancer patients has improved over the last 25 years and resulted in earlier diagnoses of CBC. Two population-based cohorts were used; all CBCs in Sweden 1976-2004 (n: 2932), and all CBCs in Stockholm, Sweden, 1976-2005 (n: 626), both cohorts with a maximum of 3 years between the two cancers. Synchronous CBC was defined as two cancers <3 months apart, the remainder was defined as metachronous CBC. We calculated the odds ratio of being diagnosed synchronously, relative to metachronously, using logistic regression, adjusting for whether the second cancer was detected through clinical work-up or not. The odds of synchronous CBC were significantly increased: 1.27 (95% CI, 1.13-1.42) per 5-year period, compared to metachronous, and was not affected by detection mode, but seemed to be explained by adjuvant therapy. The proportion of CBCs detected by clinical work-up did not increase over the study period, and the mean size of the second tumor remained constant. We found an increase in the proportion of synchronous CBCs compared to metachronous, over calendar period, a change that was not associated with clinical work-up, but with adjuvant therapy. This study gives no indications that any improvement in diagnostic work-up of CBC have occurred over the last 25 years.

Current surgery for breast cancer

Surgeons retain the central role in the multidisciplinary care of the breast cancer patient. While technical details of the operations for these patients remain important, effective evidence-based decision making may be even more so. Advances in the methods of breast cancer diagnosis, localization techniques and surgical therapies, as well as the expanded role of the surgeon in breast cancer prevention, radiation therapy and the treatment of distant disease, requires surgeons to stay up to date with the available evidence. Herein, we present a review of the current surgical therapy of invasive breast cancer.

Tumor marker phenotype concordance in second primary breast cancer, California, 1999-2004

Breast cancer is the most common cancer among women. It is estimated that 7% of women who have breast cancer will develop a subsequent second independent breast tumor within 10 years of the first. The status of estrogen (ER), progesterone (PR) and human growth hormone (HER2) receptors, individually and as phenotypic combinations, impacts the clinical course of breast cancer and may impact the course of subsequent primary tumors and patient survival. Our aims were to determine tumor marker phenotype concordance between first and second primary breast cancers (FPBC and SPBC), describe demographic and clinical characteristics, and examine first tumor treatments associated with phenotype concordance. A total of 76,209 cases of female invasive breast cancer were identified in the California Cancer Registry from 1999 to 2004. Of those, 1,407 women who had not undergone a prophylactic mastectomy, had information on the status of three tumor markers, and were diagnosed with an SPBC during the study period were selected. SPBCs were significantly smaller, diagnosed at a higher stage and were node positive. Patients whose FPBC was ER(+)/-/PR(+)/-/HER2- and triple negative (TN) (ER-/PR-/HER2-), often had concordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2+ and HER2-positive (ER-/PR-/HER2+) FPBCs, often had discordant phenotypes for their SPBC. ER(+)/-/PR(+)/-/HER2- SPBCs often lacked HER2 expression and were ER and/or PR positive. Tumor laterality and synchronicity significantly predicted concordance as did having a FPBC whose phenotypes were ER(+)/-/PR(+)/-/HER2+, HER2-positive and TN, while first primary tumor treatment with chemotherapy predicted discordance. The relationship between multiple primary breast cancer phenotype concordance and patient prognosis has yet to be determined. Our results indicate that SPBC surveillance strategies include consideration of FPBC phenotype. Although our results are provocative, they may have been influenced by current criteria used to determine tumor independence.

Increasing Use of Contralateral Prophylactic Mastectomy for Breast Cancer Patients: A Trend Toward More Aggressive Surgical Treatment

Purpose

Many patients with unilateral breast cancer choose contralateral prophylactic mastectomy to prevent cancer in the opposite breast. The purpose of our study was to determine the use and trends of contralateral prophylactic mastectomy in the United States.

Patients and Methods

We used the Surveillance, Epidemiology and End Results database to review the treatment of patients with unilateral breast cancer diagnosed from 1998 through 2003. We determined the rate of contralateral prophylactic mastectomy as a proportion of all surgically treated patients and as a proportion of all mastectomies.

Results

We identified 152,755 patients with stage I, II, or III breast cancer; 4,969 patients chose contralateral prophylactic mastectomy. The rate was 3.3% for all surgically treated patients; 7.7%, for patients undergoing mastectomy. The overall rate significantly increased from 1.8% in 1998 to 4.5% in 2003. Likewise, the contralateral prophylactic mastectomy rate for patients undergoing mastectomy significantly increased from 4.2% in 1998 to 11.0% in 2003. These increased rates applied to all cancer stages and continued to the end of our study period. Young patient age, non-Hispanic white race, lobular histology, and previous cancer diagnosis were associated with significantly higher rates. Large tumor size was associated with a higher overall rate, but with a lower rate for patients undergoing mastectomy.

Conclusion

The use of contralateral prophylactic mastectomy in the United States more than doubled within the recent 6-year period of our study. Prospective studies are needed to understand the decision-making processes that have led to more aggressive breast cancer surgery.

Incidental lobular carcinoma scar recurrence at delayed breast reconstruction 6 years after mastectomy

A 48-year-old woman was found to have histological recurrence of lobular breast carcinoma in a mastectomy scar excised routinely during delayed breast reconstruction 6 years after a mastectomy. Prior to the subsequent wide excision of the scar, she requested prophylactic contralateral mastectomy and immediate reconstruction. The scar excision revealed positive resection margins prompting further surgery while the contralateral mastectomy showed previously undetected widely infiltrative lobular carcinoma. It is extremely rare to detect lobular carcinoma in incidental histological specimens and even rarer to encounter it in asymptomatic contralateral breasts following prophylactic mastectomy. This unusual presentation and the implications for mastectomy scar management during delayed reconstruction are discussed.

Combined breast ductal lavage and ductal endoscopy for the evaluation of the high-risk breast: a feasibility study

BACKGROUND AND OBJECTIVES

Evaluation of the ductal epithelium of the breast at increased risk for breast cancer is needed to define the carcinogenic pathway, for risk assessment, and to improve selection of women for chemoprevention therapy. We studied the feasibility of combining breast ductal endoscopy with ductal lavage in the high-risk contralateral breast of women with ipsilateral breast cancer for the evaluation of high-risk ducts and acquisition of ductal epithelial cells for analysis.

METHODS

Breast ducts were studied by ductal lavage and ductal endoscopy, and epithelial cell content studied cytologically and quantitatively.

RESULTS

Twenty-five subjects and 44 ducts, including 22 (50.0%) which did not produce nipple aspirate fluid (NAF), were studied. Cellular atypia was present in five subjects. Ductal endoscopy was performed on 1 or more ducts in 24 subjects. Structural changes were noted in 63.6% of the ducts, most commonly fibrous stranding or bridging. Ductal sampling with endoscopic brush and coil sampling devices provided additional cellular samples of relatively pure ductal epithelial content (> or = 91% purity) in 8/11 subjects.

CONCLUSIONS

Breast ductal endoscopy combined with ductal lavage represents a feasible approach for characterizing the ducts and ductal epithelium of the high-risk breast, especially in a research setting.

Prophylactic mastectomy for the prevention of breast cancer

BACKGROUND

Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in prophylactic mastectomy as a method of preventing breast cancer, particularly in those with familial susceptibility.

OBJECTIVES

The primary objective was to determine whether prophylactic mastectomy reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast. The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH STRATEGY

Electronic searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cancerlit, and the Science Citation Index.

SELECTION CRITERIA

Inclusion criteria were studies in English of any design type including randomized or nonrandomized controlled trials, cohort studies, case-control studies, and case series with at least ten participants. Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer, including subcutaneous mastectomy, total or simple mastectomy, modified radical mastectomy, and radical mastectomy.

DATA COLLECTION AND ANALYSIS

Information on patients, interventions, methods, and results were extracted by at least two independent reviewers. Methodological quality was assessed based on how well each study minimized potential selection bias, performance bias, detection bias, and attrition bias. Data for each study were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM).

MAIN RESULTS

Twenty-three studies, including more than 4,000 patients, met inclusion criteria. No randomized or nonrandomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of BPM. No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed contralateral prophylactic mastectomy. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%.

REVIEWERS' CONCLUSIONS

While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery. Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for contralateral prophylactic mastectomy. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.

What about the other breast? A review of a series of bilateral breast carcinomas

The BreastScreen Queensland Brisbane Southside BreastScreen Service reports on a study of 10 cases of bilateral breast carcinomas from a total cancer population of 217 cases. All cases were patients of screening examinations that were recalled for a suspicious lesion in one breast. Two cases were mammographically suspicious of bilateral tumours. In eight cases, tumours were ultrasonically visible in both breasts and in two further cases, the suspicion of bilateral malignancy was raised by the presence of bilateral microcalcification. It is not the purpose of this paper to provide a statistical analysis of the occurrence of bilateral breast cancer. This is a radiological paper from a breast screening service reporting on findings that conventional wisdom may find unusual. The incidence of bilateral breast malignancy in the study was found to be somewhat higher than expected. These cases have been diagnosed by the utilization of a particularly high standard of ultrasound and mammography, performed and interpreted by diagnosticians possessing an elevated level of suspicion of the possible presence of a second primary lesion. It is therefore proposed that an increased rate of diagnosis of bilateral tumours is possible with an evolution of assessment protocols, combined with quality ultrasound and mammography.

Cancer du sein bilatéral. Incidence et facteurs de risque

OBJECTIVE

To clarify, thanks to a retrospective study of 24 bilateral breast cancer cases, the frequency, the risk factors and the prognosis of bilateral breast cancers.

PATIENTS AND METHOD

Between 1984 and 1999, out of 506 patients treated for unilateral non-metastatic breast cancer at Gynecologic and Obstetric ward, at Maternity Souissi of Rabat, 24 cases of bilateral breast cancers were diagnosed. Our results were compared to those of the literature.

RESULTS

The frequency of bilateral breast cancers was 4.7% (24/506). In 87.5% of cases, these were metachronous cancers with a mean interval of 45 months (12-144 months). Patients under 40 at first cancer ran a fivefold superior risk than women more than 40 (P < 0.05). In cases of T3 or T4 tumors, the risk was 10-fold superior to that in smaller ones (P < 0.05).

DISCUSSION AND CONCLUSION

Significantly more first metachronous tumors were invasive adenocarcinoma cancers. Histologic type of first and second tumor was the same in all cases. The prognosis depends at once on the first and second cancer staging and the treatment must be done according to the same rules as in the first cancer.

Bilateral synchronous breast cancer: a population-based study of characteristics, method of detection, and survival

BACKGROUND

The frequency of bilateral synchronous breast cancer (BSBC) is reportedly about 1%-3%, but there is limited information from population-based cancer registries regarding the clinical and prognostic features of these cancers.

METHODS

The population-based Connecticut Tumor Registry (CTR), which is part of the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program of registries, was used to identify BSBC (ie, a second cancer diagnosed within 3 months of the first). Information was obtained on the method of detection of BSBC, and clinical characteristics and survival (through 2000) were compared with unilateral cases.

RESULTS

Of 15,542 patients reported to the CTR, 300 (1.9%) had BSBC. BSBC was detected most often by mammography of both breasts (35%) or contralateral mammography after a palpable first cancer (18%). Compared to unilateral cases, BSBC patients did not differ in age or stage at diagnosis, but lobular histology was statistically significantly more frequent and use of total mastectomy (vs lesser surgery) was more common. Although length of follow-up was limited, risk of death was statistically, significantly higher among BSBC than unilateral patients. Among BSBC patients, risk of death was higher among those with cancers detected by breast exam/symptoms versus mammography. CONCLUSIONS; While uncommon, BSBCs differ from unilateral cancer in histology and survival, and their study emphasizes the opportunity for detection of contralateral cancers at an early stage.

Clinicopathological study of unilateral multiple breast cancer

BACKGROUND

The tendency for breast cancer to form multiple lesions is important to consider when planning breast-conserving surgery. However, many unknowns remain regarding the pathology and prognosis of multiple breast cancer, and therefore it is clinically significant to investigate its clinicopathological properties.

METHODS

Over the past 25 years, in the period between April 1972 and March 1997, we investigated the clinicopathological findings including the 5-year and 10-year survival rates of 66 patients treated for unilateral multiple breast cancer.

RESULTS

Of the total of 1,334 female patients with unilateral breast cancer who underwent curative surgery at our hospital, we identified 66 (5.0%) patients with unilateral multiple cancer. The incidence of such cancer has been higher in recent years. Of the 66 patients, 50 (75.8%) were premenopausal, and the remaining patients were postmenopausal, but multiple cancer among postmenopausal women is a recent phenomenon. The ER positivity rate of the main lesion in patients with multiple breast cancer was 69.2% and that of PgR was 50.0%. The 5-and 10-year overall survival rate in all 66 patients with multiple breast cancer was 90.8% and 79.7%, respectively.

CONCLUSION

In the past, multiple breast cancer was frequently identified in premenopausal women. However, the current findings indicate that its incidence among postmenopausal women has increased in recent years. In addition, prognoses were comparable for patients with multiple or solitary breast cancer, a relevant finding in the planning of breast-conserving surgery.

A new contralateral split-breast flap for breast reconstruction and its salvage after complication: an alternative for select patients

Different approaches to breast reconstruction have been described and nowadays nearly optimized. One major aim in further developments is to reduce donor site morbidity as low as possible. Theoretically, the lowest donor site morbidity could be achieved by using tissue that would be normally discarded during an operation necessary for a different reason. The authors present a new method of breast reconstruction in a mastectomy patient who needed a reduction mammaplasty on the remaining side in addition to the reconstruction. A single-stage split-breast flap from the reduced contralateral side pedicled on its internal mammary perforators was used, thus lowering donor site morbidity by using otherwise discarded tissue. The technical details, patient selection, advantages, possible pitfalls, management of complications, and the risk factors for contralateral malignancy are discussed.

Prophylactic surgery to reduce breast cancer risk: a brief literature review

Prophylactic mastectomy reduces the likelihood of developing breast cancer among women at heightened risk for breast cancer, but at significant personal cost. Women at increased breast cancer risk on the basis of hormonal history, family history and/or genetic mutation carrier status may consider bilateral prophylactic mastectomy with or without reconstruction to reduce their cancer risk and/or decrease their chances of cancer mortality. Women having received mastectomy as treatment for breast cancer may request contralateral mastectomy to decrease the chances of developing a second breast primary. The potential oncologic value of these procedures must be weighed carefully on a case-by-case basis against the operation's physical and psychological morbidity. The purpose of this literature review is to provide a practice-oriented summary of recent clinical studies attempting to address the relative risks and benefits of preventive surgery for breast cancer. Data are included regarding the psychological factors surrounding patient selection and quality of life outcomes, which become the cornerstone of patient satisfaction and acceptance. Taken together, these data support the Society of Surgical Oncology position statement regarding the proper application of prophylactic surgery for breast cancer.

Bilateral synchronous breast cancer: mode of detection and comparison of histologic features between the 2 breasts

BACKGROUND

Bilateral synchronous breast cancer is uncommon (accounting for 1.0%-2.6% of all patients with breast cancer), and most physicians do not accumulate a large personal experience of patients with this disease. We reviewed our experience with patients with bilateral synchronous breast cancer, focusing on the mode of detection and histologic features in the 2 breasts.

METHODS

The charts of patients who were treated at this institution for bilateral synchronous breast cancer during the 15-year period of 1984 through 1999 were reviewed. Information regarding age, mode of detection, histopathologic features, treatment, and overall survival were analyzed.

RESULTS

During the study period, 51 patients (all women) were treated at our institution for bilateral synchronous breast cancer. This comprised 2.1% of all patients (n = 2382 patients) treated for breast cancer during the same period of time. The first cancer was detected by palpation in 81% and by mammography in 14%. The corresponding figures for the contralateral cancer were 24% and 54%, respectively. The histologic type of cancer was identical in the 2 breasts in 29 patients (57%) and was different between the 2 breasts in 22 patients (43%). The overall 10-year survival rate was 63%.

CONCLUSIONS

Bilateral synchronous breast cancer is often detected by mammography and is frequently of the same histologic type as the index cancer. A better awareness of the risk for this disease may help detect bilateral breast cancer earlier.

Incidence and Detection of Contralateral Breast Cancer

In this study we estimated the efficacy of contralateral breast biopsy as a subsidiary method of early detection of bilateral breast cancer. We performed blind biopsies in the upper outer quadrant of the opposite breast in 195 patients undergoing surgical treatment for primary breast cancer. The histologic examination of the biopsy specimens showed 12 malignant lesions, which accounts for an incidence of 6.1%. In detail, we had two infiltrating ductal cancers, two infiltrating lobular cancers, three ductal in situ cancers, and five lobular in situ cancers. The overall incidence of invasive disease was 2.05%. We concluded that contralateral breast biopsy should be reconsidered as a method for enhancing early detection of contralateral breast cancer in high-risk groups, especially when it meets the emotional needs of patients. Permission given, it is included in the main surgical treatment of patients, avoiding the cost and complications of anesthesia, and it is cosmetically acceptable, without being an emotional burden for the woman.

Issues of regret in women with contralateral prophylactic mastectomies

BACKGROUND

Patients with a history of carcinoma of one breast have an estimated risk of 0.5% to 0.75% per year of developing a contralateral breast cancer. This risk prompts many women to consider contralateral prophylactic mastectomy (CPM) as a preventive measure. Virtually nothing is known about patient acceptance following CPM. We have developed a National Prophylactic Mastectomy Registry comprised of a volunteer population of 817 women from 43 states who have undergone prophylactic (unilateral or bilateral) mastectomy.

METHODS

Of the 346 women with CPM who responded to national notices, 296 women returned detailed questionnaires. The information obtained included patient demographics, family history, reproductive history, ipsilateral breast cancer staging and treatment, as well as issues involving the CPM.

RESULTS

At median follow-up of 4.9 years, the respondents were primarily married (79%), white (97%) women who had some level of college education or above (81%). These women cited the following reasons for choosing CPM: (1) physician advice regarding the high risk of developing contralateral breast cancer (30%); (2) fear of developing more breast cancer (14%); (3) desire for cosmetic symmetry (10%); (4) family history (7%); (5) fibrocystic breast disease (4%); (6) a combination of all of these reasons (32%); (7) other (2%); and (8) unknown (1%). Eighteen of the 296 women (6%) expressed regrets regarding their decision to undergo CPM. Unlike women with bilateral prophylactic mastectomies, regrets tended to be less common in the women with whom the discussion of CPM had been initiated by their physician (5%) than in the women who had initiated the discussion themselves (8%) (P = ns). Family history and stage of index lesion had no impact on regret status. The reasons for regret included: (1) poor cosmetic result, either of the CPM or of the reconstruction (39%); (2) diminished sense of sexuality (22%); (3) lack of education regarding alternative surveillance methods or CPM efficacy (22%); and (4) other reasons (17%).

CONCLUSIONS

To minimize the risk of regrets in women contemplating CPM, it is imperative that these women be counseled regarding an estimation of contralateral breast cancer risk, the alternatives to CPM, and the efficacy of CPM. In addition, these women should have realistic expectations of the cosmetic outcomes of surgery and understand the potential impact on their body image.