Does sentinel lymphadenectomy improve staging and alter therapy in elderly women with breast cancer?

Long-term outcome and axillary recurrence in elderly women (≥70 years) with breast cancer: 10-years follow-up from a matched cohort study

BACKGROUND AND OBJECTIVES

The oncological benefit of axillary surgery (AS), with sentinel lymph node biopsy (SLNB) or axillary dissection (ALND), in elderly women affected by breast cancer (BC) is controversial. We evaluated AS trends over a 10-year follow-up period as well as locoregional and survival outcomes in this subset of patients.

METHODS

Patients aged 70 years or older, treated between 1994 and 2008, were selected and divided in two groups, depending on whether or not AS was performed. A (1:1) matched analysis for all relevant clinicopathological features was performed. Outcomes were analyzed using the Kaplan-Meier method and univariate Cox-proportional hazard ratio analysis.

RESULTS

A total of 1.748 patients were identified and stratified by age (70-74, 75-79, 80-84). A matched analysis was performed for 252 patients: 122 who underwent AS and 122 who did not. At 10-year follow-up, ipsilateral breast tumor recurrence, distant metastasis and contralateral BC were similar, p = 0.83, p = 0.42 and p = 0.28, respectively. In the no-AS group, a significant increased risk of axillary lymph-node recurrence was identified at 5- and confirmed at 10-years (p = 0.038), without impact on overall survival at 5- and 10-years (p = 0.52). In the non-AS group, higher rate of axillary recurrence at 10-years was observed in patients with poorly differentiated (24.1%, 95% CI 7.2-46.2), highly proliferative (Ki67 ≥ 20%: 17.1%, 95% CI 0.6-33.3) and luminal B tumors (16.8%, 95% CI 5.9-35.5).

CONCLUSIONS

Axillary staging in elderly women does not impact long-term survival. Tailoring surgery according to tumor biology and age may improve locoregional outcome.

Nodal staging affects adjuvant treatment choices in elderly patients with clinically node-negative, estrogen receptor-positive breast cancer

Background

In response to Choosing Wisely recommendations that sentinel lymph node biopsy (slnb) should not be routinely performed in elderly patients with node-negative (cN0), estrogen receptor-positive (er+) breast cancer, we sought to evaluate how nodal staging affects adjuvant treatment in this population.

Methods

From a prospective database, we identified patients 70 or more years of age with cN0 breast cancer treated with surgery for er+ her2-negative invasive disease during 2012-2016. We determined rates of, and factors associated with, nodal positivity (pN+), and compared the use of adjuvant radiation (rt) and systemic therapy by nodal status.

Results

Of 364 patients who met the inclusion criteria, 331 (91%) underwent slnb, with 75 (23%) being pN+. Axillary node dissection was performed in 11 patients (3%). On multivariate analysis, tumour size was the only factor associated with pN+ (p = 0.007). Nodal positivity rates were 0%, 13%, 23%, 33%, and 27% for lesions preoperatively sized at 0-0.5 cm, 0.5-1 cm, 1.1-2.0 cm, 2.1-5.0 cm, and more than 5.0 cm. Compared with patients assessed as node-negative, those who were pN+ were more likely to receive axillary rt (lumpectomy: 53% vs. 1%, p < 0.001; mastectomy: 43% vs. 2%, p < 0.001), and adjuvant systemic therapy (endocrine: 82% vs. 69%; chemotherapy plus endocrine: 7% vs. 2%, p = 0.002).

Conclusions

Of elderly patients with cN0 er+ breast cancer, 23% were pN+ on slnb. Size was the primary predictor of nodal status, and yet significant rates of nodal positivity were observed even in tumours preoperatively sized at 1 cm or less. The use of rt and systemic adjuvant therapies differed by nodal status, although the long-term oncologic implications require further investigation. Multidisciplinary input on a case-by-case basis should be considered before omission of slnb.

Association of LN Evaluation with Survival in Women Aged 70 Years or Older With Clinically Node-Negative Hormone Receptor Positive Breast Cancer

BACKGROUND

Some suggest that lymph node (LN) evaluation not be performed routinely in women aged ≥70 years with clinically (c) LN-negative (-), hormone receptor (HR)-positive (+) breast cancer. We sought to determine the association of omission of LN evaluation on survival.

METHODS

Patients who met the above criteria and were diagnosed from 2004 to 2012 were identified in the NCDB and SEER databases. Overall survival (OS) and breast cancer-specific survival (BCSS) were determined.

RESULTS

Using the NCDB, we identified 157,584 cLN- HR+ patients aged ≥70 years in whom survival and LN evaluation data were available. A total of 126,638 patients (80.2%) had regional LN surgery. With a median follow-up of 41.6 months, there was a significant difference in OS between those who had LN evaluation and those who did not (median OS: 100.5 vs. 70.9 months, respectively, p < 0.001). After adjusting for patient age, race, insurance, income, comorbidities, tumor characteristics and treatment, patients who had undergone LN evaluation still had a lower hazard rate for death than those who had not (hazard ratio = 0.633; 95% confidence interval [CI] 0.613-0.654, p < 0.001). We then did a parallel analysis using SEER data that showed LN evaluation was associated with a lower hazard rate for both BCSS (hazard ratio = 0.452; 95% CI 0.427-0.479, p < 0.001) and non-BCSS (hazard ratio = 0.465; 95% CI 0.447-0.482, p < 0.001).

CONCLUSIONS

Roughly 20% of patients older than aged 70 years with cLN-, HR+ breast cancer did not have LN evaluation. Those who did had better OS controlling for sociodemographic, pathologic, and treatment variables; however, this may be due to patient selection.

Treatment options for older woman with early breast cancer

Breast cancer is the most common cancer in women and its incidence increases with age. Older women are not often offered optimal treatment compared with younger women for any particular stage. This is due to various reasons, including the lack of evidence for older women from well-conducted clinical trials. In this paper, the currently available evidences from clinical trials are reviewed and the various treatment options for older women with early breast cancer are discussed.

Breast cancer in elderly women (≥ 80 years): variation in standard of care?

OBJECTIVE

The study aim was to investigate the methods of breast cancer diagnosis and treatment for women at advanced ages.

METHODS

We identified 134 patients ≥ 80 years old treated for breast cancer. Data included patient and tumor characteristics, treatment, and outcomes.

RESULTS

Of 134 women ≥ 80 years old, 146 breast cancers were diagnosed. Sixty-five (45%) were detected by mammography. Surgical therapy included partial mastectomy in 50% and mastectomy in 50%. Although 12 (9%) women had no axillary staging, 22 (16%) underwent axillary lymph node dissection for node-negative disease. Of 73 patients undergoing partial mastectomy, 34 (47%) received adjuvant radiation. Of 113 cancers with known estrogen receptor (ER) status, 83% were ER positive; 95% received endocrine therapy. Fourteen (10%) received adjuvant chemotherapy. Eleven (8%) were Her-2 neu-amplified; one patient received adjuvant trastuzumab. At follow-up, 87 (65%) patients were alive without evidence of disease, while 6 (4%) died of breast cancer.

CONCLUSIONS

Breast cancer in women ≥ 80 years is more likely to be early-stage with favorable tumor biology. While most women eligible for anti-estrogen therapy received it, adjuvant radiation, chemotherapy, and/or trastuzumab were utilized infrequently. Despite these variations, older women with breast cancer are unlikely to suffer breast cancer-related mortality.

Can sentinel node biopsy be avoided in some elderly breast cancer patients?

OBJECTIVE

The purpose of this study was to determine factors associated with lymph node metastasis among hormonally-responsive breast cancer patients > or = 70 years old, and to develop and validate a clinical prediction rule to predict the risk of lymph node metastasis in this population.

SUMMARY BACKGROUND DATA

Nodal evaluation in elderly women with breast cancer remains controversial. The ability to predict which elderly patients may be node-negative may spare them the morbidity of lymph node evaluation.

METHODS

Hormone-receptor positive breast cancer patients > or = 70 years old who participated in a prospective multicenter trial were divided into a training set (n = 554) and a test set (n = 146). Univariate and multivariate analyses were conducted to determine factors predictive of final nodal status. A clinical prediction rule was developed on the training set, and validated in the independent test set.

RESULTS

Median patient age was 76; median tumor size was 1.4 cm. 15.9% and 16.2% were LN+ in the training and test sets, respectively. On univariate analysis, patient age, tumor size, palpability, grade, and lymphovascular invasion predicted lymph node status. On multivariate analysis, patient age, tumor size, and lymphovascular invasion remained significant. A prediction rule was created; patients were categorized into quartiles by predicted risk. 5.4% and 0% of patients in the lowest quartile were node positive in the training and test sets, respectively.

CONCLUSION

Some elderly breast cancer patients at low likelihood of lymph node metastasis may be spared lymph node evaluation.

Treatment of breast cancer in older women

BACKGROUND

Breast carcinoma management in the elderly often differs from the management in younger women and there is considerable controversy about what constitutes appropriate cancer care for older women. This controversy is reflected in the persistence of age-dependent variations in care over time, with older women being less likely to receive definitive care for breast cancer. There has been a significant increase in the last years in the number of studies conducted in older patients with breast cancer. Although available age-specific clinical trials data demonstrate that treatment efficacy is not modified by age, this evidence is limited by the lack of inclusion of substantial numbers of older women, particularly those of advanced age and those with comorbidities.

METHOD

The literature-based evidence of the last 10 years was extensively reviewed on the main issues concerning the treatment of breast cancer in older women.

RESULTS

Surgical treatment in older patients has evolved from avoidance to mastectomy to breast-conserving surgery, similarly to younger patients. Given its negative effect on the quality of life, in the last few years the role of adjuvant radiotherapy has been questioned in elderly patients with breast cancer. Adjuvant chemotherapy benefit in older patients applies mainly to Estrogen-receptor-negative patients, while in Estrogen-receptor-positive patients a major role is played by endocrine treatment. New "elderly-friendly" drugs, that can help clinicians to reduce toxicity, are now available for breast cancer.

Assessment of Surgical Treatment in Elderly Patients with Breast Cancer

Aims and Background

The incidence of breast cancer increases with advancing age and in clinical practice approximately 50% of new cases occur in women over the age of 65 years. Although breast cancer in elderly patients presents more favorable biological characteristics than similar-stage cancer in younger women, disease control still remains uncertain and is becoming a major health problem.

Patients and Methods

Between 1984 and 2006, 133 patients aged over 65 with operable breast cancer underwent surgical treatment. Patients with ductal or lobular carcinoma in situ, bilateral breast cancer or a previous malignancy were excluded. The mean age was 72.8 years (range, 66–89). Breast-conserving surgery was performed in patients with early breast cancer (T1, T2 <2.5 cm), while most patients with advanced tumors (T2 >2.5 cm, T3, T4) were treated by modified radical mastectomy.

Results

The pathological stage was I in 44, IIA in 54, IIB in 18, IIIA in 10 and IIIB in 7 patients. Postoperative complications occurred in 13 patients (9%); there were no postoperative deaths. Eighty-nine patients underwent adjuvant therapy (chemotherapy, hormonal therapy). After a median follow-up of 96 months (range, 5–266), disease progression was observed in 21 patients (15.8%). The overall mortality from breast cancer was 11%, whereas the cancer-unrelated mortality was 9%.

Conclusion

There is no evidence that breast cancer has a more favorable prognosis in the elderly and surgical procedures should be carried out as has been established in younger women. At present, elderly patients are much less likely to be entered into randomized clinical trials and are often undertreated. However, in the absence of serious comorbid disease, they are able to withstand standard multimodal treatment options as well as do younger patients.

The role of surgery in the management of older women with breast cancer

Standard treatment for early breast cancer usually involves multi-modality treatment with a combination of surgery and one or more adjuvant therapies. These may include chemotherapy, radiotherapy, endocrine therapy and Trastuzumab. The treatment schedule for an individual patient may be complex, prolonged and associated with significant morbidity. The benefits of such regimens are clear to see in the improving mortality statistics for this breast cancer. However, such protocols may not appropriate for all women. Older women (over 70 years) have increasing rates of co-morbidities, reduced life expectancy and generally have more favourable breast cancer disease biology. Competing causes of death mean that they are less likely to die of their breast cancer, stage for stage, than a younger woman. In addition, their tolerance to some of the therapies is reduced which increases treatment related morbidity and reduces the risk to benefit ratio. It may therefore be appropriate to modify treatment protocols in selected older women. This should be done in consultation with the multi-disciplinary team with input from specialists in Medicine for the Elderly. The views and wishes of the patient should be respected during these discussions. This article reviews these issues.

Breast conservation: Current results and future perspectives at the European Institute of Oncology

In the recent 10 years breast cancer treatments' scenario is radically changed. Extraordinary new surgical approaches give more and more conservative solutions both for the breast and especially for the axilla avoiding dissection in more than 80% of early cases. Instrumental early diagnosis and clinical prediction are now able to identify very initial cases often in premalignant stage. Technology arrived in the operating theatre for the intraoperative radiotherapy treatments giving to the patients the better quality of life with the help also of the plastic surgeons. There are still near horizons to reach: modern neo-adjuvant and adjuvant treatments are going quickly from the laboratory to patient's bed.

Selective Application of Axillary Node Dissection in Elderly Women with Early Breast Cancer

BACKGROUND

Routine use of axillary lymph node dissection (ALND) has been questioned in elderly women. This study examines whether selective application of ALND in early stage breast cancer affects breast cancer-related survival.

METHODS

From the Surveillance, Epidemiology, and End Results (SEER) database, records of women >or=70 years of age with stage I or II breast cancer diagnosed between 1990 and 1995 were reviewed. Hazard ratios (HR) of cause-specific survival (CSS) between women receiving ALND and those who did not were compared. To minimize the potential for bias in the selection of women to receive ALND, HR of CSS was compared within propensity analysis deciles.

RESULTS

20,151 women entered the analysis. Median follow up was 6 years (interquartile range 4.33-7.67 years). Seventy-five percent underwent ALND. Women with higher risk disease and younger age were more likely to undergo ALND. Five year unadjusted CSS in women who did and did not receive ALND was 92.1% and 90.6%, respectively, with a HR of 0.85, P = 0.002. Using the propensity analysis method, the adjusted HR for CSS associated with ALND was 0.89, P = 0.066.

DISCUSSION

After adjusting for differences in the probability of receiving ALND, no clinically or statistically significant difference in survival was observed among women who received ALND when compared with those who did not, although we could not account for differences in co-morbidity or use of systemic therapy between groups.

CONCLUSION

Surgeons select elderly women with early stage breast cancer for ALND with a negligible impact on CSS.

Older age independently predicts a lower risk of sentinel lymph node metastasis in breast cancer

BACKGROUND

The influence of patient age on the risk of sentinel lymph node (SLN) metastasis in breast cancer has not been defined.

METHODS

A breast cancer SLN database was analyzed. Factors associated with SLN metastasis were assessed by multiple logistic regression modeling. Age, T stage, estrogen receptor status, HER-2/neu status, grade, angiolymphatic invasion, lobular histology, tubular/mucinous histology, and the number of SLNs resected were assessed.

RESULTS

Data were available for 810 patients with invasive breast cancer. SLN metastasis was observed in 22% of the patients. The factors most strongly associated with SLN metastasis were angiolymphatic invasion, T stage, and age. Age ranged from 29 to 95 years. The median age was 66 years. Overall, SLN metastasis was more common in younger patients (< or =66 years) than in older patients (>66 years; P < .001). Among patients without angiolymphatic invasion, SLN metastasis was nearly twice as common in the younger patients as in the older patients. The effect of angiolymphatic invasion as a risk for SLN metastasis was much greater in the older age group.

CONCLUSIONS

In addition to known risk factors, age independently predicts the risk of SLN metastasis in breast cancer. Angiolymphatic invasion seems to be a more powerful predictor of SLN metastasis in older patients.

The value of sentinel lymph node biopsy in elderly breast cancer patients

BACKGROUND

Although sentinel lymph node biopsy has been accepted as a useful procedure for certain breast cancer patients, the value of this procedure in the elderly remains unknown. We undertook this study to evaluate changes in adjuvant treatment attributable to sentinel lymph node biopsy.

METHODS

A total of 104 patients > or =65 years underwent sentinel lymph node biopsy plus lumpectomy or mastectomy for the treatment of clinically node-negative invasive breast cancer. Demographic, pathologic, and treatment data were evaluated using an SAS software package (SAS, Cary, North Carolina).

RESULTS

Twenty-nine of 104 patients (28%) had metastatic disease in > or =1 sentinel lymph node. Nonsurgical treatment was modified in 38% of patients because of sentinel lymph node biopsy results. Changes included adjuvant chemotherapy and/or hormonal therapy, adjuvant axillary radiotherapy, and decisions against adjuvant therapy.

CONCLUSIONS

These data suggest that sentinel lymph node biopsy in elderly breast cancer patients is beneficial.

Sentinel lymph node as a new marker for therapeutic planning in breast cancer patients

BACKGROUND AND OBJECTIVES

Literature review suggests that the sentinel lymph node (sN) represents a reliable predictor of axillary lymph node status in breast cancer patients; however, some important issues, such as the optimisation of the technique for the intraoperative identification of the sN, the role of intraoperative frozen section examination of the sN, and the clinical implications of sN metastasis as regards the surgical management of the axilla, still require further confirmation. The authors aimed (1) to assess the feasibility of sN identification with a combined approach (vital blue dye lymphatic mapping and radioguided surgery, RGS) and the specific contribution of either techniques to the detection of the sN, (2) to determine the accuracy and usefulness of intraoperative frozen section examination of the sN in order to perform a one-stage surgical procedure, and (3) to define how the sN might modulate the therapeutic planning in different stages of disease.

MATERIALS AND METHODS

From October 1997 to June 2001, 334 patients with early-stage (T(1-2) N(0) M(0)) invasive mammary carcinoma underwent sN biopsy; the average age of patients was 61.5 years (range, 39-75 years). In a subset of 153 patients, both vital blue dye (Patent Blue-V) lymphatic mapping and RGS were used to identify the sN, and the relative contribution of each of the two techniques was assessed.

RESULTS

In the whole group, the sN was identified in 326 of 334 patients (97.6%), and 105 of 326 patients (37.3%) had positive axillary lymph nodes (pN+). In 9 of 105 pN+ patients, the definitive histologic examination of the sN did not show metastases but these were detected in non-sN, thus giving an 8.6% false-negative rate, a negative predictive value of 94.5% (156/165), and an accuracy of 96.5% (252/261). As regards the specific contribution of the two different techniques used in the identification of the sN, the detection rate was 73.8% (113/153) with Patent Blue-V alone, 94.1% (144/153) with RGS alone, and 98.7% (151/153) with Patent Blue-V combined with RGS (P < 0.001). Noteworthy, whenever the sN was identified, the prediction of axillary lymph node status was remarkably similar (93-95% sensitivity; 100% specificity; 95-97% negative predictive value, and 97-98% accuracy) whichever of the three procedures was adopted (Patent Blue-V alone, RGS alone, or combined Patent Blue-V and RGS). Intraoperative frozen section examination was performed in 261 patients, who had at least one sN identified, out of 267 patients who underwent complete axillary dissection; 170 patients had histologically negative sN (i.o. sN-) and 91 patients histologically positive sN (i.o. sN+). All 91 i.o. sN+ were confirmed by definitive histology, whereas in 14 of 170 i.o. sN- patients (8.2%) metastases were detected at definitive histology. As regards the correlation between the size of sN metastasis, the primary tumour size, and the status of non-sN in the axilla, micrometastases were detected at final histology in 23 patients and macrometastases in 82 patients. When only micrometastases were detected, the sN was the exclusive site of nodal metastasis in 20 of 23 patients (86.9%) while in 3 patients with tumour size larger than 10 mm micrometastases were detected also in non-sN. Macrometastases were never detected in pT(1a) breast cancer patients; the sN was the exclusive site of these metastases in 30 patients (36.6%), while in 52 patients (63.4%) there were metastases both in sN and non-sN.

CONCLUSIONS

Sentinel lymphadenectomy can better be accomplished when both procedures (lymphatic mapping with vital blue dye and RGS) are used, because of the significantly higher sN detection rate, although the prediction of axillary lymph node status remains remarkably similar whichever method is used. The intraoperative frozen section examination proved to be rather accurate in predicting the actual pathologic status of the sN, with a negative predictive value of 91.8%; in 35% of patients it allowed sN biopsy and axillary dissection to be performed in a one-stage surgical procedure. Finally, specific clinical and histopathologic features of the primary tumour and sN might be used to tailor the loco-regional and systemic treatment in different clinical settings, such as in ductal carcinoma in-situ (DCIS), early-stage invasive breast cancer, and patients with large breast cancer undergoing neo-adjuvant CT for breast-saving surgery as well as elderly patients with operable breast cancer.

The need for targeted research into breast cancer in the elderly

BACKGROUND

Breast cancer is a major source of morbidity and mortality in elderly women. Despite this, many trials on which clinical practice is based have under-represented the elderly. Consequently there is little evidence to guide best practice in this age group.

METHODS

A search of the major literature databases was performed using the search terms 'breast cancer' and 'elderly'. Articles relevant to the treatment of breast cancer in the elderly were selected.

RESULTS

The elderly receive less aggressive treatment for breast cancer compared with younger patients. Primary endocrine therapy is sometimes substituted for operation, and axillary surgery, adjuvant chemotherapy and adjuvant radiotherapy are commonly omitted. Evidence for and against such treatment strategies is inadequate, making it difficult to determine what constitutes best practice.

CONCLUSION

There is a need for research to be targeted at the older age group of patients with breast cancer to enable the development of specific treatment guidelines.

How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer?

BACKGROUND

There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients.

DATA SOURCES

Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve.

CONCLUSIONS

The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current recommendations.

Sequelae of axillary lymph node dissection in older women with stage 1 and 2 breast carcinoma

BACKGROUND

There are few data on the long-term sequelae of axillary dissection among older breast carcinoma patients. We describe the impact of axillary dissection in a cohort of older women.

METHODS

A longitudinal cohort of 571 patients with Stage 1 and 2 breast carcinoma, 67 years and older, diagnosed between 1995 and 1997 from 29 hospitals in five regions, and followed for 2 years. Data were collected from patients and medical charts. The primary outcome was posttreatment quality of life. Generalized estimation equation longitudinal modeling was used to evaluate the outcome, controlling for baseline function, comorbidity, age, clinical status, and other factors.

RESULTS

Sixty percent of women reported arm problems at some time in the 2 years after surgery. The cumulative risk of having arm problems 2 years posttreatment was three times higher (95% confidence interval 1.94-4.67) for women who underwent axillary surgery compared with women without axillary surgery, controlling for covariates. The effects of having axillary dissection and arthritis were multiplicative 2 years postsurgery. Arm problems were, in turn, the primary determinate of lower physical and mental functioning (P = 0.0001 and 0.04, respectively), controlling for other factors. Undergoing axillary dissection did not lessen fears about recurrence.

CONCLUSIONS

Arm problems after axillary dissection have a consistent negative impact on quality of life, suggesting that the risks may outweigh the potential benefits in this population.

Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients

BACKGROUND

Involvement of the internal mammary chain lymph nodes (IMNs) is associated with worsened prognosis in breast cancer. Use of lymphoscintigraphy to visualize sentinel nodes reveals that IMNs often receive lymph from the area containing the tumor.

METHODS

We biopsied IMNs in 182 patients because there was radiouptake to the IMNs or because the tumor was located in the medial portion of the breast. After tumor removal, pectoralis major fibers were divided to expose intercostal muscle. A portion of intercostal muscle adjacent to the sternum was removed. Lymph nodes and surrounding fatty tissue in the intercostal space were freed, removed, and analyzed histologically. The pleural cavity was breached in four cases (2.2%), with spontaneous resolution.

RESULTS

IMNs were found in 160 (88%) of 182 patients; 146 (94.4%) were negative and 14 (8.8%) were positive. The latter received internal mammary chain radiotherapy. The axilla was negative in 4 of 14 cases and positive in 10.

CONCLUSIONS

IMNs can be quickly and easily removed via the breast incision with insignificant risk and no increase in postoperative hospitalization. The patients with a positive IMN migrated from N0 (4 cases) or N1 (10 cases) to N3, prompting modification of both local (radiotherapy to internal mammary chain) and systemic treatment; without IMN sampling, they would have been understaged.

Breast conservation therapy as a treatment option for the elderly. The M. D. Anderson experience

BACKGROUND

Although almost half of all incidents of breast carcinoma occur in women age > or = 65 years, not enough is known about appropriate care for patients in this age group. The objective of the current study was to evaluate the role of breast conservation therapy in the management of breast carcinoma in women age > or = 65 years.

METHODS

From 1970 to 1994, 1325 patients with carcinoma of the breast were treated with breast conservation therapy (segmental mastectomy and radiation therapy with or without axillary lymph node dissection) at The University of Texas M. D. Anderson Cancer Center. From this patient group, the authors identified 184 elderly women (> or = 65 years) with Stage 0-III disease at the time of diagnosis.

RESULTS

The median patient age was 70 years (range, 65-88 years). The distribution of disease by stage among the women was Stage 0 disease in 12 patients (7%), Stage I disease in 107 patients (58%), Stage II disease in 63 patients (34%), and Stage III disease in 2 patients (1%). Comorbid conditions that may have influenced treatment planning were reported in 91 patients (50%). An axillary lymph node dissection was performed in 135 patients (73%), with positive axillary lymph nodes found in 30 patients (22%). Adjuvant chemotherapy was given to 10 patients (5%), and tamoxifen therapy was given to 63 patients (34%). Complications from treatment were reported in 24 patients (13%). With a median follow-up of 7.3 years (range, 0.25-23.5 years), 9 patients developed locoregional disease recurrence (5%), 10 patients developed contralateral breast carcinoma (5%), and 21 patients developed distant metastasis (11%). At last follow-up, 113 patients (61%) were alive, 15 patients (8%) were dead of disease, and 56 patients (30%) were dead of other causes. The 5-year and 10-year disease specific survival rates were 96% and 91%, respectively.

CONCLUSIONS

Breast conservation therapy with segmental mastectomy and postoperative radiation therapy with or without axillary lymph node dissection provides excellent local control and disease free survival in elderly women with breast carcinoma. This treatment should be considered as the standard of care for elderly patients without severe comorbid disease.