The role of mastectomy in patients with stage I-II breast cancer presenting with gross multifocal or multicentric disease or diffuse microcalcifications

What's new in surgical oncology breast

It is on the backdrop of advances in tumor biology and systemic therapy for breast cancer, that progress in locoregional treatment has focused on management of the breast for invasive cancer, imaging for staging and therapeutic decision-making, and de-escalation in the management of the axilla.

Local Recurrence After Breast-Conserving Therapy in Patients With Multiple Ipsilateral Breast Cancer: Results From ACOSOG Z11102 (Alliance)

PURPOSE

Breast-conserving therapy (BCT) is the preferred treatment for unifocal breast cancer (BC). The oncologic safety of BCT for multiple ipsilateral breast cancer (MIBC) has not been demonstrated in a prospective study. ACOSOG Z11102 (Alliance) is a phase II, single-arm, prospective trial designed to evaluate oncologic outcomes in patients undergoing BCT for MIBC.

PATIENTS AND METHODS

Women age 40 years and older with two to three foci of biopsy-proven cN0-1 BC were eligible. Patients underwent lumpectomies with negative margins followed by whole breast radiation with boost to all lumpectomy beds. The primary end point was cumulative incidence of local recurrence (LR) at 5 years with an a priori rate of clinical acceptability of <8%.

RESULTS

Among 270 women enrolled between November 2012 and August 2016, there were 204 eligible patients who underwent protocol-directed BCT. The median age was 61 years (range, 40-87 years). At a median follow-up of 66.4 months (range, 1.3-90.6 months), six patients developed LR for an estimated 5-year cumulative incidence of LR of 3.1% (95% CI, 1.3 to 6.4). Patient age, number of sites of preoperative biopsy-proven BC, estrogen receptor status and human epidermal growth factor receptor 2 status, and pathologic T and N categories were not associated with LR risk. Exploratory analysis showed that the 5-year LR rate in patients without preoperative magnetic resonance imaging (MRI; n = 15) was 22.6% compared with 1.7% in patients with a preoperative MRI (n = 189; P = .002).

CONCLUSION

The Z11102 clinical trial demonstrates that breast-conserving surgery with adjuvant radiation that includes lumpectomy site boosts yields an acceptably low 5-year LR rate for MIBC. This evidence supports BCT as a reasonable surgical option for women with two to three ipsilateral foci, particularly among patients with disease evaluated with preoperative breast MRI.

Comparing the outcome between multicentric/multifocal breast cancer and unifocal breast cancer: A systematic review and meta-analysis

Objective

This systematic review and meta-analysis compares the outcome between MMBC and unifocal breast cancer (UFBC), in order to provide a theoretical basis for the design of an appropriate clinical therapeutic strategy of MMBC patients.

Methods

PubMed, Embase, The Cochrane Library, Web of science, CNKI, WanFang Data, CBM and VIP database were searched from inception to July 2021, and observational studies reporting the outcome of patients with MMBC and UFBC were included. We extracted or calculated the mortality rates of MMBC and UFBC patients; and obtained the hazard ratios; odds ratios; relative risks; and the corresponding 95% confidence intervals from the eligible studies. All the meta-analyses were conducted by using the Stata 15.0 software.

Results

31 eligible studies comprising a total of 15,703 individuals were included. The meta-analysis revealed that MMBC did not have a significant association with poor overall survival (HR=1.04, 95% CI=0.96-1.12), disease-free survival (HR= 1.07, 95% CI= 0.84-1.36), breast cancer-specific survival (HR=1.42, 95% CI= 0.89-2.27), recurrence-free survival (HR= 0.878, 95% CI= 0.652-1.182), local recurrence-free survival (HR= 0.90, 95% CI= 0.57-1.42), and contralateral breast cancer risk (RR= 0.908, 95% CI= 0.667-1.234). However, MMBC appeared to have a correlation with a slightly higher risk of death (OR=1.31, 95% CI=1.18-1.45).

Conclusion

Patients with MMBC appeared to have a higher risk of death, however, it may not be independently associated with poorer outcomes. Considering the inter-study heterogeneity and other limitations, our results need to be validated by further multicenter prospective studies with a large sample size in the future.

Worm-Based Microfluidic Biosensor for Real-Time Assessment of the Metastatic Status

Simple Summary

We proposed a high-throughput screening and low-cost worm-based (WB) microfluidic biosensor to monitor biochemical cues related to metastasis. Caenorhabditis elegans placed in the WB biosensor chambers and exposed to samples conditioned with cancer cell clusters reflect differences in the chemotactic preference of worms. We observed a higher distribution of worms associated with samples of higher metastatic potential (p < 0.005). A chemotaxis index (CI) was defined to standardize the quantitative assessment from the WB biosensor, where increased metastatic potential was associated with higher CI levels (6.5 ± 1.37). We found that the secreted metabolite glutamate was a chemorepellent, and lower glutamate levels were associated with samples derived from more metastatic cancer cell clusters. In conclusion, WB biosensors could evaluate patient status in real time, thereby facilitating early detection of metastases and routine management.

Abstract

Background: Metastasis is a complex process that affects patient treatment and survival. To routinely monitor cancer plasticity and guide treatment strategies, it is highly desired to provide information about metastatic status in real-time. Here, we proposed a worm-based (WB) microfluidic biosensor to rapidly monitor biochemical cues related to metastasis in a well-defined environment. Compared to conventional biomarker-based methods, the WB biosensor allowed high throughput screening under low cost, requiring only visual quantification of outputs; Methods: Caenorhabditis elegans were placed in the WB biosensor and exposed to samples conditioned with cancer cell clusters. The chemotactic preference of these worms was observed under discontinuous imaging to minimize the impact on physiological activity; Results: A chemotaxis index (CI) was defined to standardize the quantitative assessment from the WB biosensor, where moderate (3.24–6.5) and high (>6.5) CI levels reflected increased metastasis risk and presence of metastasis, respectively. We demonstrated that the secreted metabolite glutamate was a chemorepellent, and larger clusters associated with increased metastatic potential also enhanced CI levels; Conclusions: Overall, this study provided a proof of concept for the WB biosensors in assessing metastasis status, with the potential to evaluate patient-derived cancer clusters for routine management.

Comparison of breast cancer patients who underwent partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (M + I) regarding quality of life (QOL), cosmetic outcome and survival rates

PURPOSE

The latissimus dorsi muscle has long been used in breast cancer (BC) patients for reconstruction. This study aimed to compare early stage BC patients who had partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (MI) with respect to quality of life (QoL), cosmetic outcome (CO), and survival rates.

PATIENTS AND METHODS

The data of patients who underwent PM + MLDF (Group 1) and M + I (Group 2) between January 2010 and January 2018 were evaluated. Both groups were compared in terms of demographics, clinical and pathological characteristics, surgical morbidity, survival, quality of life, and cosmetic results. The EORTC-QLQ C30 and EORTC-QLO BR23 questionnaires and the Japanese Breast Cancer Society (JBCS) Cosmetic Evaluation Scale were used to assess the quality of life and the cosmetic outcome, respectively.

RESULTS

A total of 317 patients were included in the study, 242 (76.3%) of them in group 1 and 75 (23.6%) of them in group 2. Median follow-up time was 56 (14-116) months. There were no differences identified between the groups in terms of tumor histology, hormonal receptors and HER-2 positivity, surgical morbidity, and 5-year overall and disease-free survival. Group 2 patients were significantly younger than group 1 (p = 0.003). The multifocality/multicentricity rate was higher in group 2 (p ≤ 0.001), whereas tumor size (p = 0.009), body mass index (BMI, p = 0.006), histological grade (p ≤ 0.001), lymph node positivity (p = 0.002), axillary lymph node dissection (ALND) rate (p = 0.005), and presence of lympho-vascular invasion (LVI, p = 0.013) were significantly higher in group 1. When the quality of life was assessed by using the EORTC QLQ C30 and BR23 questionnaires, it was seen that the body image perception (p < 0.001) and nausea/vomiting score (p = 0.024) were significantly better in PM + MLDF group whereas physical function score was significantly better in M + I group (p = 0.012). When both groups were examined in terms of cosmesis with JBCS Cosmetic Evaluation Scale, good cosmetic evaluation score was significantly higher in patients in MLDF group (p = 0.01).

DISCUSSION

The results of this study indicate that in comparison to M + I procedure, the PM + MLDF procedure provides significantly superior results in terms of body image and cosmetic result with similar morbidity and oncologic outcomes. In selected patients with small breasts and a high tumor/breast ratio, PM + MLDF may be an alternative to subcutaneous mastectomy and implant.

Local Control of Breast Conservation Therapy versus Mastectomy in Multifocal or Multicentric Breast Cancer: A Systematic Review and Meta-Analysis

Objective

Breast conservation therapy (BCT) for female patients with multifocal or multicentric (MF/MC) breast cancer remains controversial. The purpose of the present meta-analysis was to explore whether BCT was feasible for female patients with MF/MC breast cancer and to compare the results of treatment with those of female patients with unifocal breast cancer who underwent BCT and female patients with MF/MC breast cancer who underwent mastectomy.

Methods

Online databases, including PubMed and Embase, were independently searched from inception to January 2018 and reviewed by two authors. The present meta-analysis compared local relapse (LR) of BCT versus mastectomy for patients with MF/MC breast cancer and LR of patients with unifocal breast cancer versus patients with MF/MC breast cancer who underwent BCT. Ten studies comprising 19,272 patients were included.

Results

The cumulative incidence of LR was 5.6% (65/1,163) for MF/MC disease treated with BCT, 4.2% (750/17,656) for unifocal disease treated with BCT, and 2.0% (9/453) for MF/MC disease treated with mastectomy. Thus, the cumulative incidence of LR for MF/MC patients treated with BCT was significantly higher than for mastectomy (p < 0.001). However, the forest plot analysis showed no significant differences in LR between BCT and mastectomy procedures (OR = 1.22, 95% CI = 0.49-3.00, p = 0.67, I² = 0%). Compared with the unifocal group treated with BCT, BCT for MF/MC breast cancer showed a significant difference in LR (OR = 2.25, 95% CI = 1.48-3.42, p = 0.0001, I² = 0%).

Conclusion

The LR of BCT for patients with MF/MC breast cancer was higher than that of BCT for patients with unifocal breast cancer. However, no significant difference was found in the incidence of LR between the BCT group and the mastectomy group in patients with MF/MC breast cancer.

Prognostic impact of multifocal and multicentric breast cancer versus unifocal breast cancer

PURPOSES

The clinical behavior of multifocal and multicentric breast cancers (MMBCs) is not well characterized. We conducted this study to ascertain whether patients with MMBCs have a worse prognosis than patients with unifocal breast cancers (UBC).

METHODS

The subjects of this retrospective study were 734 consecutive patients who underwent definitive surgery for invasive breast carcinoma at our hospital between January 2004 and December 2006. MMBC was defined as ≥ 2 separate invasive unilateral breast tumors and pathological T stage was redefined based on the sum of the maximum diameter of each tumor. We evaluated disease-free survival (DFS) using the Kaplan-Meier method and Cox proportional hazards models.

RESULTS

Of the 734 patients, 136 (18.5%) had MMBC. The pathological T stage of 36 of the patients with MMBC was upstaged by adopting the sum of each focus. MMBC did not have any survival impact, but MMBC upstaged by the modified pathological T stage was associated with worse DFS than non-upstaging MMBC (P = 0.004). Multivariate analysis revealed that upstaging MMBC was an independent factor for poor prognosis and worse DFS (HR 2.757, P = 0.043).

CONCLUSIONS

MMBC itself may not be predictive of a worse prognosis; however, the sum of the invasive diameters of MMBC might be an important prognostic factor. Further studies are needed to confirm the prognosis associated with MMBC, taking into consideration the biological characteristics of each invasive focus.

The Effect of Total Size of Lesions in Multifocal/Multicentric Breast Cancer on Survival

BACKGROUND

In this study, we aimed to assess the prognostic performance of determining the T stage according to the total size of lesions compared with the size of the largest lesion in the breast in patients with multifocal/multicentric (MF/MC) breast cancer.

PATIENTS AND METHODS

The charts of the patients with MF/MC breast cancer who were diagnosed between 2003 and 2014 were reviewed. The T stage of MF/MC tumors was determined according to the largest lesion size (T_max) as well as the sum of the longest diameters of the lesions (T_sum) in the breast.

RESULTS

Multifocal/multicentric tumors were identified in 323 of 3890 patients (8.3%) with breast cancer. Ten-year rates of overall survival (OS; 75% and 74%; P = .965) and disease-free survival (DFS; 66% and 61%; P = .817) were similar in patients with unifocal and MF/MC tumors, respectively. When the T stage was determined by summing the sizes of the lesions, the T stage of 67 (20.7%) and 63 (19.5%) patients advanced from T1 to T2 and from T2 to T3, respectively. Thus, the T stage increased in 130 patients (40.2%) according to American Joint Committee on Cancer. Discriminatory ability of T_sum was better than T_max in terms of OS and DFS, as shown with higher Royston D and Harrel C statistics and Schemper V values.

CONCLUSION

The new T classification proposed in this report stands out as a better predictive classification particularly in patients with low disease burden.

Immunohistochemical features of multifocal and multicentric lobular breast carcinoma

PURPOSE

Patient age, tumor size, axillary lymph node status, expression of estrogen, progesterone and HER2 receptors, as well as the histological grade, are widely accepted prognostic and predictive parameters in breast carcinoma. In invasive lobular carcinoma (ILC), the prognostic factors, such as nodal status and tumor size are believed to be the most valuable ones. The aim of this was set to determine the possible linkage between MFity/MCity of ILC and immunohistochemical predictive (ER, PR, HER2) and prognostic parameters (BRCA1, p53, E-cadherin, Ki-67).

MATERIAL/METHODS

Out of 2486 cases diagnosed with BC from south-eastern Serbia, the presence ILC was noted in 334 cases. Immunohistochemical characterization of predictive and prognostic parameters in ILC was done.

RESULTS

The occurrence of multifocal (MFC) and multicentric carcinoma (MCC) was observed in 18.9% of ILC. Bilateral (BL) BCs were found to be statistically significantly more frequent in younger women, compared to those with MFC, MCC or nonMFC/MCC/BL. No significant correlation was found between MFC/MCC and the presence of axillary lymph node metastases, and expression of immunohistochemical predictive and prognostic parameters. Based on literature data and the findings from the current work, MFity/MCtiy might represent negative morphologic prognostic parameters in ILC.

CONCLUSIONS

In 334 cases analyzed, no statistically significant correlations were observed between MF/MC and the expression of immunohistochemical predictive and prognostic parameters.

Disease recurrence and survival in patients with multifocal breast cancer: a follow-up study with 7-year results

BACKGROUND

Few studies have shown that multifocal breast cancer (MBC) has poorer outcomes compared with unifocal breast cancer (UBC). Currently, there is no long-term data on disease recurrence and survival in patients with MBC. The aim of this study is to evaluate whether patients with MBC have worse outcomes compared with UBC in respect to disease recurrence and survival.

METHODS

This is a retrospective study of patients diagnosed with stage I-III MBC from 2000 to 2007 in comparison with UBC with a median follow-up of 7 years. Prognostic factors were prospectively collected from the breast cancer unit database. Univariate and multivariable analyses for disease recurrence and survival were performed as well as Kaplan-Meier curves.

RESULTS

A total of 152 patients were included; 75 with MBC, 77 with UBC. The multifocal group was treated more aggressively with mastectomy (73% versus 25%, P < 0.0001) and chemotherapy (53% versus 42%). Breast cancer recurred in nine (11.7%) patients in the UBC group and nine (12%) patients in the MBC group respectively (hazard ratio (HR): 1.13, 95% confidence interval (CI): 0.45-2.86, P = 0.794). There were 10 (13%) mortalities in the unifocal group as compared with 11 (14.7%) in the multifocal group (HR: 1.02, 95% CI: 0.42-2.48, P = 0.969). There were no statistically significant differences in the all-cause mortality and disease recurrence rates between both groups.

DISCUSSION

There were no statistically significant differences in disease recurrence or mortality rates between MBC and UBC at a median follow-up of 7 years. However, patients in the MBC group received more aggressive treatment than the unifocal group.

Effect of multifocality and multicentricity on outcome in early stage breast cancer: a systematic review and meta-analysis

Women with multifocal or multicentric breast tumors (multifocality henceforth) have been reported to have greater probability of nodal metastasis and relapse and worse survival than women with unifocal tumors. However, these associations have been inconsistent and multifocality is not taken into account by staging guidelines and prognostic models. A systematic review of electronic databases identified publications exploring the association between multifocality and overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), and loco-regional relapse (LRR). The hazard ratios (HRs) for OS and DFS for multifocal compared to unifocal tumors were extracted from multivariable analyses and included in a meta-analysis. For studies not reporting multivariable analyses, odds ratios (OR) were estimated from Kaplan-Meier curves for all endpoints at 5 and 10 years. Twenty-two studies comprising 67,557 women were included. Multifocality was reported in 9.5 % of patients. Classical prognostic factors were well balanced between unifocal and multifocal populations. In multivariable analyses, multifocality was associated with significantly worse OS (HR 1.65; P = 0.02), and a non-significant association with worse DFS (HR 1.96; P = 0.07). In univariable analyses, multifocality was associated with worse OS, DFS, DSS, and LRR at 5 years (OR 1.39, P = 0.02; OR 1.52, P = 0.02; OR 1.56, P = 0.03; and OR 3.23, P = 0.02, respectively). Similar estimates were observed at 10 years, but statistical significance was only reached for DSS and LRR. Mutifocality appears to be associated with a worse prognosis, however, substantial inter-study heterogeneity limits the precise determination of increased risk. Further validation of the independent prognostic impact of multifocality is warranted.

Breast cancer multifocality and multicentricity and locoregional recurrence

The impact of multifocal (MF) or multicentric (MC) breast cancer on locoregional (LR) control rates is unknown. Methods. MF was defined as two or more separate invasive tumors in the same quadrant of the breast. MC was defined as two or more separate invasive tumors occupying more than one quadrant of the same breast. Patients were categorized by LR treatment: breast conservation therapy (BCT; n = 256), mastectomy (n = 466), or mastectomy plus postmastectomy radiation therapy (PMRT; n = 184). All patients with MC disease had mastectomy (10 patients treated with BCT for MC disease were excluded). The Kaplan-Meier product limit method was used to calculate 5-year LR control rate. Cox proportional hazards models were used to determine independent associations of multifocality or multicentricity with LR control. Results. A total of 906 patients had either MF disease (n = 673) or MC disease (n = 233). With median follow-up of 52 months, the 5-year LR control rate was 99% for MF, 96% for MC, and 98% for unifocal tumors (p = .44). Subset analysis revealed no difference in LR control regardless of the LR treatment (p = .67 for BCT, p = .37 for mastectomy, p = .29 for mastectomy plus PMRT). There were five in-breast recurrences after BCT in the MF group. MF and MC did not have an independent impact on LR control rate on multivariate analysis. Conclusion. MF and MC disease are not independent risk factors for LR recurrence. Patients with MF and MC breast cancer had rates of LR control similar to those of their unifocal counterparts. These data suggest that BCT is a safe option for patients with MF tumors and that MF or MC disease alone is not an indication for PMRT.

The case against routine preoperative breast MRI

In patients with primary breast cancer, preoperative MRI identifies additional foci of tumor in the ipsilateral or contralateral breast that are not evident with standard imaging. Breast cancer patients who are otherwise deemed suitable candidates for breast-conserving surgery might, therefore, be urged to undergo mastectomy or even bilateral mastectomy following staging with preoperative breast MRI. The effect of preoperative breast MRI on clinical end points (rates of ipsilateral breast tumor recurrence) and surgical end points (rates of reoperation) have been assessed in several large studies. These studies indicate that the routine use of preoperative breast MRI is not beneficial. The additional occult foci of tumor detected with preoperative breast MRI seem to either have no clinical significance, or can be adequately treated with radiotherapy and/or systemic therapy. This article reviews these studies and highlights the potential harms associated with the routine use of preoperative MRI in patients with primary breast cancer.

Clinical and pathologic features of multifocal and multicentric breast cancer in chinese women: a retrospective cohort study

Purpose

This study aims to analyze the clinical-pathological characteristics of multifocal and multicentric breast cancer (MMBC) in Chinese women.

Methods

Sixty-seven cases with MMBC were randomly collected and reviewed at seven hospitals in representative districts of China during 1999 to 2008.

Results

The incidence of MMBC in breast cancer in China was 1.75%. Compared to those with unifocal breast cancer, women with MMBC were more likely to have larger tumor size, lymph node metastasis (59.70% vs. 45.62%) and stage III to IV (46.26% vs. 21.10%). The peak age at onset of MMBC was 40 to 49 years old and has been gradually increasing during 1999 to 2008. Most of the MMBC women were treated with surgery and adjuvant therapy.

Conclusion

In China, the incidence of MMBC in breast cancer is significantly lower than that in Western countries. Compared to unifocal breast cancer, MMBC is biologically more aggressive. Most MMBC women underwent mastectomy, instead of breast conservation surgery.

Breast cancer multifocality, disease extent, and survival

The prognostic information implied in subgross morphologic parameters such as lesion distribution (unifocal, multifocal, or diffuse) and disease extent in breast cancer has remained largely unexplored in the literature. We aimed to test whether these parameters influence survival in breast carcinoma. The parameters were assessed in a series of 574 cases, all documented in large-format histology sections. We used Cox proportional hazards regression accompanied by Kaplan-Meyer survival curves, with P < .05 regarded as significant. The invasive component was unifocal in 62% (311/499), multifocal in 24% (122/499), and diffuse in 5% (26/499) of the cases. Combining the in situ and invasive tumor components resulted in 48% (274/574) unifocal, 25% (141/574) multifocal, and 20% (117/574) diffuse tumors. Sixty percent (347/574) of the tumors were categorized as having limited extent (occupying an area <40 mm in largest dimension) and 29% (164/574) as extensive. Highly significant (P < .0001) differences were observed in 10-year disease-specific cumulative survival among the cases with unifocal, multifocal, and diffuse invasive (89.6%, 76.0%, and 63.6%, respectively) and combined (92.3%, 82.3%, and 75.7%, respectively) lesion distribution. Patients with extensive tumors exhibited a significantly lower cumulative survival (P < .0001) compared with those with limited extent (91.6% and 75.5%) and a statistically significantly 1.89-fold (95% confidence interval, 1.07-3.37; P = .03) risk for breast cancer death after controlling for tumor attributes, type of surgery, and adjuvant therapy. The hazard ratio for breast cancer death for mutifocal and/or diffuse tumors versus unifocal ones was 1.96 (95%; 1.11-3.48; P = .02) after controlling for the same factors. Lesion distribution and disease extent represent important independent survival-related prognostic parameters in breast carcinoma.

Tumor size and survival in multicentric and multifocal breast cancer

PURPOSE

Current AJCC/UICC staging of early breast cancer defines tumor stage using the largest focus, adding the suffix "(m)" to indicate multiplicity. This method may underestimate the total tumor burden in multifocal and multicentric breast cancer (MMBC). This study examines other measures of tumor size in MMBC to determine which provides the best fit in a multivariate model for survival outcomes.

PATIENTS AND METHODS

This prospective cohort study used data from the Australian Capital Territory and New South Wales Breast Cancer Treatment Group database to identify 812 women with ipsilateral invasive breast cancer; 141 of these women had MMBC. The pathology slides of all women with MMBC were reviewed and all foci of invasive breast cancer were re-measured. The measures of interest were the diameter of the largest deposit, the aggregate diameter and the aggregate volume. These measures of tumor size were included with other clinicopathological features of MMBC in a multivariate analysis to assess their relationship with progression-free survival (PFS) and overall survival (OS).

RESULTS

Tumor size was associated with PFS and OS in MMBC using any of the three measures; however, the diameter of the largest deposit provided the best fit in the multivariate model for OS.

CONCLUSION

Tumor size is an important prognostic factor for MMBC, and the diameter of the largest deposit provides a better fit in a multivariate model for OS than aggregate diameter and aggregate volume. Therefore, tumor size in MMBC should continue to be measured using the diameter of the largest deposit.

Oncological and aesthetic considerations of conservational surgery for multifocal/multicentric breast cancer

Conventional indications for mastectomy (MX) reflect circumstances where breast conserving therapy (BCT) could compromise oncological or cosmetic outcome. MX continues to be recommended for the majority of women with multiple lesions within the same breast. In this article, we review the oncological safety and aesthetic considerations of BCT in the context of multifocal (MF) or multicentric (MC) breast cancer. Literature review facilitated by Medline and PubMed databases. Published studies have reported divergent results regarding the oncological adequacy of BCT in the management of MF or MC disease. Earlier studies demonstrated high rates of local recurrence (LR) for BCT. More recent series have found BCT to be comparable to MX in terms of LR, distant failure, disease free and overall survival. Few studies have adequately evaluated cosmetic outcomes following BCT for MF or MC breast cancer. Contemporary oncoplastic techniques have extended the clinical utility of BCT and are of particular relevance to breast conservation in the context of MF or MC lesions. Appropriate case selection, preoperative oncological and aesthetic planning, satisfactory clearance of the surgical margins and adjuvant radiotherapy are of paramount importance. In the absence of level-1 guidance concerning the management of women with MF or MC disease, each case requires discussion with regard to tumor and patient related factors in the context of the multidisciplinary team. In selected patients with MF or MC disease, BCT is oncologically safe and cosmetically acceptable. Uniformity of practice and the establishment of a standard of care will require an evidence-base from prospective studies.

Breast conservation in women with multifocal-multicentric breast cancer: is it feasible?

BACKGROUND

The incidence of preoperatively identified multifocal and multicentric breast cancer is rising with improved sensitivity of imaging modalities. Based on retrospective, historic data, breast conservation in women with multiple tumors has been discouraged because of high rates of local regional recurrence (LRR). These studies, however, do not extrapolate to contemporary practice as they do not incorporate the use of modern therapies and surgical techniques. This study is designed to evaluate the feasibility of breast conservation in women with multiple breast primaries.

MATERIALS AND METHODS

We retrospectively reviewed the charts of 22 women who underwent breast conservation surgery for 2 or more synchronous, ipsilateral cancers between 1998 and 2008. We extracted data including tumor size, nodal staging, receptor status, adjuvant therapies administered, and local-regional recurrence.

RESULTS

A total of 22 patients were identified. Average follow up is 3.5 years. One patient (4.5%) experienced an in-breast recurrence. Both initial tumors in this patient were invasive ductal carcinoma, ER/PR, negative and HER2 positive. Time to LRR was 2.5 years.

CONCLUSIONS

Our data are consistent with those of recent studies in which multifocal/multicentric local regional recurrence in multicentric/multifocal breast is equivalent to that seen in women with unifocal cancer. The single local recurrence in this study occurred in a premenopausal women with ER/PR- disease who were HER2+. Prior retrospective studies have identified ER/PR- and HER2 overexpression as independent risk factors for recurrence following breast conservation. Additional prospective trials are warranted to better assess the oncologic safety of breast conservation in this population.

Multicentric and multifocal versus unifocal breast cancer: is the tumor-node-metastasis classification justified?

For classification of breast cancer (BC), tumor-node-metastasis (TNM) staging has been considered state of the art for more than 50 years. The T category is well defined, and in multicentric and multifocal tumors, tumor size is assessed by the largest tumor focus. The aim of this study was to compare multicentric/multifocal tumor spread in breast cancer with unifocal disease and to evaluate the diagnostic relevance of multifocality. A retrospective analysis was performed on survival related events in a series of 5,691 breast cancer patients between 1963 and 2007. By matched-pair analysis, patients were entered into two comparable groups of 288 patients after categorizing them as having multifocal/multicentric or unifocal breast cancers. Matching criteria were tumor size, grading, and hormone receptor status, which were equally distributed between both groups (P = 1.000 each). Disease free survival and the occurrence of relapse or of metastatic disease were evaluated. Cox's regression analysis was used for multivariate analysis. In the unifocal group, the mean breast cancer-specific survival time was 221.6 months as opposed to 203.3 months in the multicentric/multifocal group (P < 0.001, log-rank test). The occurrence of local relapse and distant metastasis was significantly increased in the multifocal group in comparison to the unifocal equivalent group (P < 0.001 and P < 0.003, respectively). Cox regression analysis for multivariate analyses demonstrated focality and centricity to be highly significant predictors for reduced overall survival (P = 0.016), local relapse (P = 0.001) and distant metastasis (P = 0.038). Tumor size, histopathological grading, hormone receptor status, and staging of lymph nodes are well-established prognostic parameters. Additionally, the number of foci should be considered as an independent prognostic parameter, which is currently not reflected in the TNM classification. We conclude that multicentric/multifocal BC is an independent BC risk factor and should be included in the risk assessment by re-evaluating the current TNM classification of the UICC.

Synchronous multiple ipsilateral breast cancers: implications for patient management

Interest in the presence and management of synchronous multiple ipsilateral breast cancer has been reported since the early 1920s. The demonstration of multiple foci of breast cancer has been reported in 9-75% of breast cancer related specimens. The large difference in reported incidence is multifactorial and related to the definitions applied, mode of detection and pathological assessment. However, randomised clinical trials comparing total mastectomy and segmental mastectomy with or without radiation over many years have shown no difference in distant disease-free survival or overall survival in patients with synchronous multiple ipsilateral breast cancer compared with unifocal breast cancer. This review examines the current definitions, incidence, pathological assessment, staging and surgical options of synchronous multiple ipsilateral breast cancer.

Increased lymph node positivity in multifocal and multicentric breast cancer

BACKGROUND

Multifocal and multicentric (MF/MC) breast cancers have been reported to be associated with increased lymph node metastases. The limited data on this issue prompted us to investigate the pathologic and clinical differences between unifocal and MF/MC breast cancer.

STUDY DESIGN

Between 1990 and 2002, 1,322 patients with operable invasive breast cancer underwent a definitive operation at our Breast Clinic. Patients with MF/MC breast cancer (n=147, 11%) were compared with patients with unifocal breast cancer (n=1,175; 89%) in terms of pathologic and clinical characteristics.

RESULTS

Patients with MF/MC were found to have a higher frequency of lymph node metastases when the largest diameter was used as a tumor size estimate for MF/MC cancer (unifocal T1 and T2, 35% and 49%, respectively, versus MF/MC T1 and T2, 48% and 67%, respectively; p=0.05 and p=0.003, respectively). When the combined diameter assessment was used, the frequency of lymph node positivity was similarly higher in MF/MC patients versus unifocal patients (unifocal T1 and T2, 35% and 49%, respectively, versus MF/MC T1 and T2, 49% and 61%, respectively; p=0.08 and p=0.046, respectively). At a median followup of 55 months (range 12 to 153 months), 5-year disease-free survival (DFS; unifocal, 88% versus MF/MC, 82%, p=0.14) and overall survival (OS) rates (unifocal, 92% versus MF/MC, 93%, p=0.43) did not show any significant difference between two groups.

CONCLUSIONS

Our data suggest that breast tumors with multiple foci have a different biology, with an increased metastatic potential to axillary lymph nodes, regardless of tumor size, that reflects an advanced stage. The clinical relevance of the currently used TNM classification system, which uses the diameter of the largest nodule, is supported by our findings.

Conservative surgery in patients with multifocal/multicentric breast cancer

PURPOSE

Many physicians recommend mastectomy in case of multifocal (MF) or multicentric (MC) breast cancer due to a theoretical risk of poor local control with less extensive surgery. We retrospectively evaluate outcome of patients with MF/MC cancers who had breast conservation with specific attention on local control and predictive factors of recurrence.

PATIENTS AND METHODS

Four hundred and seventy six patients with either MF (n = 421) or MC (n = 55) breast cancer, underwent breast-conserving surgery between 1997 and 2002 in a single institution. Median follow up was 73 months (range 11-118).

RESULTS

Median age was 53 years (range 23-86). Invasive lobular carcinoma was found in 88 patients (18.5%) and mixed ductal-lobular cancer in 27 (5.7%) patients. Two hundred and sixty-seven patients (76.7%) had two identified tumor foci, 55 patients (15.3%) had three and 29 patients (8.0%) had four or more. Two hundred and sixty-one patients (55.3%) had nodal involvement. The 5-year cumulative incidence of local relapse was 5.1%. At the multivariate analysis, over-expression of HER2/neu and lack of both estrogen and progesterone receptors (HR: 3.2, 95% C.I. 1.01-10.0, and HR: 2.7, 95% C.I. 1.06-7.7, respectively) were associated with a higher ipsilateral breast cancer reappearance rate. Involvement of four or more lymph nodes and lack of estrogen and progesterone receptors (HR: 2.7, 95% C.I. 1.06-6.7, and HR: 4.7, 95% C.I. 2.1-10.4, respectively) were associated with poorer overall survival.

CONCLUSIONS

In selected patients with MF/MC breast cancer, wide conservative surgery is not associated with poor local disease control and can be considered whenever acceptable cosmetic results can be achieved.

Locoregional control of clinically diagnosed multifocal or multicentric breast cancer after neoadjuvant chemotherapy and locoregional therapy

PURPOSE

The purpose was to assess whether patients with clinical multifocal or multicentric (MFMC) breast cancer determined by mammogram, ultrasound, or physical examination have inferior outcome compared with patients with clinical unicentric lesions.

PATIENTS AND METHODS

We retrospectively analyzed 706 consecutive patients with stages I-III breast cancer treated at the M.D. Anderson Cancer Center (Houston, TX) from 1976 to 2003 who received neoadjuvant anthracycline-based chemotherapy followed by breast conservation therapy (BCT), mastectomy alone, or mastectomy plus postmastectomy radiation therapy.

RESULTS

The mean follow-up was 66 months. At presentation, 97 of 706 patients had clinically MFMC disease (13.7%). The 5-year rate of locoregional failure was 10% for unicentric disease compared with 7% for MFMC disease (P = .78). Subset analyses of patients by treatment groups confirmed no statistical difference in locoregional control regardless of the type of locoregional treatment. Among patients with multifocal disease treated with BCT, there were no in-breast recurrences and one supraclavicular recurrence. Five-year disease-free survival and overall survival was equivalent between patients with MFMC and unicentric breast cancers.

CONCLUSION

Patients with clinical MFMC breast cancer at the time of diagnosis treated with neoadjuvant chemotherapy followed by locoregional therapy have similar 5-year rates of locoregional control, disease-free survival, and overall survival as those with unicentric disease. Clinically detected MFMC disease did not predict for inferior outcome.

Feasibility of breast-conserving therapy for macroscopically multiple ipsilateral breast cancer

PURPOSE

Macroscopically multiple ipsilateral breast cancer (MMIBC) is generally considered a contraindication for breast-conserving therapy (BCT). The result of BCT for MMIBC is reported and the feasibility discussed.

METHODS AND MATERIALS

Between July 1993 and February 1999, 34 patients with MMIBC underwent BCT at our clinic. The local control, disease-free survival, and cosmetic results in these patients were compared with those of patients with single disease.

RESULTS

After wide excision, 21 (62%) of 34 patients with MMIBC had a close surgical margin and the rate was significantly greater than that of patients with a single lesion. However, the size of the boost irradiation field was not significantly increased. At a median follow-up of 98 months, no statistically significant difference was noted in local control, disease-free survival, or cosmetic result compared with patients with a single lesion.

CONCLUSION

Although patients with MMIBC frequently had close surgical margins after BCT, it can be a treatment option for these patients as long as the close surgical margin is accurately detected and treated with an appropriate radiation technique.

Correlation of tumor volume and surface area with lymph node status in patients with multifocal/multicentric breast carcinoma

BACKGROUND

Multicentric breast carcinomas have a higher frequency of axillary lymph node metastasis than unifocal tumors of similar stage. It remains unclear whether this merely reflects larger tumor volumes or a different biologic behavior. The authors have shown previously that when aggregate tumor diameter are used for staging, unifocal and multifocal tumors have a similar frequency of axillary lymph node metastasis. However, summing diameter overestimates actual tumor volume because volume is proportional to the third power of the diameter. Therefore, the aim of the current study was to reanalyze the relation between size and axillary lymph node status by correcting for tumor volumes and surface areas.

METHODS

Volumes and surface areas of 122 breast tumor specimens with multiple macroscopic nodules (two foci: n = 95; three foci: n = 22; three foci: n = 5) were calculated by approximating the shape of each tumor nodule to an ellipsoid (for volume) or to a prolate spheroid (for area). For comparison, the authors used an internal control series, comprised of 469 macroscopic unifocal tumors. For all patients, multiple assessments of largest tumor size and combined size of all foci were correlated with the status of axillary lymph nodes. The associations between lymph node status, tumor volume or area, and multifocality were modeled using univariate and multivariate logistic regression.

RESULTS

When either the largest or the aggregate tumor volume was used as a size estimate, tumor specimens with multiple nodules had a higher frequency of lymph node involvement compared with unifocal tumors of a similar volume or area. The odds ratio (OR) for having positive lymph nodes was 2.34 for aggregate volume measurement (P < 0.001). Surface area estimates yielded similar results (OR = 2.2, P < 0.001).

CONCLUSIONS

Breast tumors with multiple macroscopic nodules had a different biology, with a propensity to dissemination at smaller tumor volumes (i.e., there was another factor besides volume alone that accounted for the differences in behavior).

Breast conservation in patients with multiple ipsilateral synchronous cancers

BACKGROUND

Because breast cancer survival after breast conservation has proved comparable to mastectomy, contraindications to mastectomy are increasingly being challenged. We treated the majority of our patients with multiple synchronous ipsilateral cancers with breast conservation and we compared them with patients who underwent mastectomy for comparable disease during the same interval.

STUDY DESIGN

Patients with multiple ipsilateral synchronous breast cancers between 1989 and 2002 were identified from prospective databases maintained by us. A comparison was made between 36 patients treated with lumpectomy and 19 patients treated with mastectomy.

RESULTS

There were no significant (all p values >0.2) differences between mastectomy and breast conservation patients in age, racial distribution, size of cancers, pathology, tumor differentiation, nodal involvement, or hormone receptor positivity. The majority of patients treated with breast conservation underwent at least one reexcision to obtain clear pathologic margins, and they were more likely to receive postoperative radiotherapy than patients treated with mastectomy. There were no significant differences in the local (97% versus 100%, p = 0.54) or distant (97% versus 95%, p = 0.20) 5-year disease- free survival between the group treated with breast conservation and the group treated with mastectomy. One patient in each group developed distant metastases. One patient in the breast conservation group developed local recurrence at both primary sites simultaneously 39 months after lumpectomies. She is free of disease 78 months after mastectomy. The remaining 52 patients are alive and free of disease.

CONCLUSIONS

Breast conservation is an effective treatment for patients with synchronous ipsilateral breast cancers.

Evidence-based indications for postmastectomy irradiation

The ASCO guidelines panel found that PMRT reduces the risks of both local-regional recurrence and distant recurrence, and improves survival rates for patients with invasive breast cancer with involved axillary lymph nodes receiving systemic therapy. The benefits of PMRT, however, vary with regards to particular patient subsets (such as those defined by the number of involved axillary nodes). The panel agreed that PMRT is indicated routinely for patients with four or more positive axillary nodes, tumors larger than 5 cm in size, or locally advanced cancers. There was insufficient evidence for the panel to make recommendations or suggestions for the use of PMRT for patients with T1-2 tumors with one to three positive axillary nodes or for all patients receiving neoadjuvant systemic therapy. Physicians and patients are encouraged to participate in randomized trials exploring such issues, such as the ongoing intergroup study for patients with one to three positive axillary nodes.

Conservative surgery and radiation therapy for macroscopically multiple ipsilateral invasive breast cancers

BACKGROUND

The presence of macroscopically multiple ipsilateral invasive breast cancer (MMIIBC) has been considered a contraindication for breast conservation. Early series reported high rates of local recurrence. A treatment regimen was developed to accommodate patient requests for breast conservation in MMIIBC.

METHODS

We reviewed medical records of the 15 MMIIBC patients who underwent partial mastectomy followed by radiation between 1989 and 1997. All patients had 2 or more separate macroscopic tumors greater than 2 mm in diameter. After tumor excision, all specimens were evaluated; the protocol required surgical margins of at least 2 mm.

RESULTS

As of June 2000 (median follow-up 76 months), 14 patients (93%) were alive without evidence of disease. One patient died of systemic disease without local recurrence.

CONCLUSIONS

In selected cases, the combination of breast conservative surgery and radiation therapy with systemic therapy results in acceptable local-regional control. Patients who present with MMIIBC with clear surgical margins should be considered for breast conservation.

Multicentric mammary carcinoma: evidence of monoclonal proliferation

BACKGROUND

Both the widespread use of screening mammography and emphasis on breast conservation have raised many questions regarding the clinical and therapeutic management of multicentric mammary carcinoma (MMC). MMC has been postulated to be either a clonal proliferation of a single mammary carcinoma or multiple independent synchronous primary tumors in the same breast. The goal of the current study was to evaluate the histologic features and immunohistochemical profile of MMC. We also compared the clinical outcomes of the patients in the current study with stage-matched and treatment-matched groups of patients with unicentric mammary carcinoma.

METHODS

The authors studied 32 patients with T1-T2, N0-1, M0 multicentric invasive mammary carcinomas diagnosed between 1983-1988 and treated at The University of Texas M. D. Anderson Cancer Center. The histologic features of each tumor (including tumor type, nuclear grade, presence of in situ carcinoma, pattern of in situ carcinoma, and lymphovascular invasion) were evaluated. The authors performed immunohistochemical analysis of estrogen receptor (ER), progesterone receptor (PR), HER-2/neu, and Ki-67 in 25 cases, including 14 from which > 1 tumor was available to perform comparative immunohistochemical analysis. The clinical parameters of each case were compared with those of the unicentric breast carcinoma controls.

RESULTS

The median age of the patients with MMC was 45 years (range, 28-69 years). Twelve patients had a family history of breast carcinoma (37.5%). The maximum tumor dimension ranged from 0.2-3.2 cm in the index lesion (median, 2.0 cm) and 0.1-2.5 cm in the second lesion (median, 0.9 cm). Twelve patients were clinically classified as having Stage I disease and 20 patients were considered to have Stage II disease at the time of presentation. Follow-up data were available for all the patients and follow-up ranged from 4.5-16 years (median, 6 years). The disease-free survival was 84% at 5 years and 73% at 10 years in the MMC patients and 78% and 70%, respectively, in patients with unicentric breast carcinoma (P = 0.4368). Histologically, 24 of the multicentric tumors were found to be infiltrating ductal tumors and 8 were found to be infiltrating lobular carcinomas. The nipple was involved in 10 cases. The histology of the multicentric invasive tumor was nearly identical in 31 cases (97%). Approximately 72% of the cases had in situ carcinoma in both tumors and 44% had lymphovascular invasion. Comparative immunohistochemical analysis of separate tumors was equivalent with regard to ER, PR, and HER-2/neu. The quantitative immunohistochemical staining for the proliferative marker Ki-67 differed between tumors in two cases.

CONCLUSIONS

The near-identical morphologic and immunohistochemical patterns in the MMC cases in the current study support the hypothesis that early-stage synchronous tumors are a clonal proliferation of a single mammary carcinoma. Furthermore, the results of the current study support evaluating prognostic markers in only one tumor per MMC patient. There was no appreciable difference in the disease-free survival of patients with unicentric and multicentric breast carcinoma.

Pathologic analysis of tumor size and lymph node status in multifocal/multicentric breast carcinoma

BACKGROUND

For unifocal invasive breast carcinoma, increasing tumor diameter predictably correlates with a greater frequency of lymph node involvement, thereby facilitating treatment decisions. In invasive breast tumors presenting with multiple nodules, however, it is unclear whether tumor size correlates with lymph node dissemination in a similar manner.

METHODS

The authors analyzed a series of 101 invasive breast carcinomas presenting with multiple macroscopically apparent lesions (2 foci: n = 77; 3: n = 20; 4: n = 4). Two different assessments of the tumor size (diameter of largest focus and combined diameter of all the foci) were then correlated with the status of axillary lymph nodes. For comparison with unifocal tumors, the authors used both external and internal control series (the latter consisting of 469 patients from their institution). The associations between lymph node status, tumor size, and multifocality were modeled using univariate and multivariate logistic regression, for each modality of tumor size assessment.

RESULTS

The logistic curves for multifocal and unifocal tumors were significantly different when the largest diameter was used as a tumor size estimate. Multifocal cases had higher frequencies of lymph node involvement than unifocal lesions of similar size category. In a multivariate logistic regression, the odds ratio of positive lymph node status in multifocal versus unifocal cases was 2.8 using largest diameter as a tumor size estimate (P < 0.0001). When the combined diameter assessment was used, however, the regression curve of multifocal cases was similar to that of unifocal cases, and the frequency of lymph node positivity was not significantly different in multifocal versus unifocal cases of the same size (odds ratio, 1.4; P = 0.13).

CONCLUSIONS

The authors' results show that, if aggregate diameters are used, unifocal and multifocal breast carcinomas are similar with respect to frequency of regional lymph node metastasis. Currently used algorithms, which use the diameter of the largest nodule, result in understaging of multifocal breast carcinomas due to underestimation of actual tumor size.

The Clinical Utility of Tc-99m Sestamibi Scintimammography in Detecting Multicentric Breast Cancer

The ability to recognize multicentric breast cancer preoperatively would assist in identifying appropriate candidates for breast conservation surgery. Tc-99m scintimammography (SMM) is an adjunct to conventional mammography in identifying selected patients with breast cancer. The purpose of this study is to report the utility of SMM in identifying patients with multicentric breast cancer. Breast cancer patients treated by mastectomy who underwent a preoperative SMM between 1992 and 1999 were identified using the institution's Tumor Registry. The pathology report of each patient was reviewed for multicentric disease defined as an additional focus of cancer within a different quadrant of the breast or greater than 2.5 cm from the dominant tumor mass. Each patient's preoperative SMM was reviewed and compared with the pathologic findings to obtain correlative data. Fifty-eight women treated by mastectomy had preoperative SMM (age range 35–78 years; median 52 years). Pathology revealed infiltrating ductal carcinoma in 49 patients (84.5%), infiltrating lobular carcinoma in five patients (8.6%), ductal carcinoma in situ in three patients (5.1%), and colloid carcinoma in one patient (1.7%). Multicentric disease was present in the specimens of eight patients for a prevalence of 10.3 per cent. SMM was positive for uptake in 36 of 58 patients (sensitivity 62.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of SMM in the detection of multicentric disease were 62.5, 96, 71, and 94 per cent, respectively. Although the overall sensitivity of SMM in the detection of breast cancer is superior to that of conventional mammography and physical examination in identifying multicentric breast cancer it is not an accurate modality for detecting multicentric disease in this study group. However, it may have limited applications in specific cases.

The influence of pathologic tumor characteristics on locoregional recurrence rates following mastectomy

PURPOSE

The objective of this study was to evaluate the influence of pathologic factors other than tumor size and number of involved axillary nodes on the risk of locoregional recurrence (LRR) following mastectomy.

PATIENTS AND METHODS

We reviewed the medical records of 1031 patients treated with mastectomy and doxorubicin-based chemotherapy without radiation on 5 prospective clinical trials. Median follow-up was 116 months (range, 6-262 months).

RESULTS

Patients with gross multicentric disease were at increased risk of LRR (37% at 10 years). However, patients with multifocal disease and those with microscopic multicentric disease did not experience higher rates of LRR than those with single lesions (17% at 10 years). Patients with lymph-vascular space invasion (LVSI) or involvement of the skin or nipple also experienced high rates of LRR (25%, 32%, and 50%, respectively). The presence of close (<5 mm) or positive margins was associated with an increased risk of LRR (45%). The increased risk of LRR observed for patients with pectoral fascial invasion (33%) was not reduced when negative deep margins were obtained. On multivariate analysis, the presence of 4 or more involved axillary nodes, tumor size of greater than 5 cm, close or positive surgical margins, and gross multicentric disease were found to be independent predictors of LRR (all, p < 0.01). In a separate analysis including only patients with 1-3 involved axillary nodes, microscopic invasion of the skin or nipple, pectoral fascial invasion, and the presence of close or positive margins were significant predictors of LRR.

CONCLUSION

In addition to the extent of primary and nodal disease, other factors that predict for high rates of LRR include the presence of LVSI, involvement of the skin, nipple or pectoral fascia, close or positive margins, or gross multicentric disease. These factors predict for high LRR rates regardless of the number of involved axillary nodes.

Impact of multicentricity on clinical outcome in patients with T1-2, N0-1, M0 breast cancer

BACKGROUND

The objective was to determine the impact of multicentric breast cancer on recurrence and survival and to evaluate the current tumor, node, metastasis staging system recommendations for multicentricity in the breast.

METHODS

This study included 284 nonpregnant patients with T1-2, N0-1, M0 breast cancer, without previous cancer, who were treated by modified radical mastectomy followed by doxorubicin-based adjuvant chemotherapy. Clinical and pathological data were collected retrospectively and survival was calculated from the date of initial diagnosis using the Kaplan-Meier method.

RESULTS

The median follow-up time was 8 years (range, 0.3-24.0), and the median age was 47 years (range, 23-76). The median clinical size of the index tumor was 2.5 cm. In 17% of patients, the clinical nodal status was N1. In 84% of patients, pathology of the index lesion was invasive ductal +/- in situ. Multicentric breast cancer was detected in 60 patients (21%): 30 patients with two lesions, 13 patients with three lesions, and 17 patients with four or more lesions. Locoregional recurrence, contralateral breast cancer, distant metastasis, and survival (disease-specific and disease-free) were similar in both groups of multicentric versus unicentric breast tumors. There was a significant difference between groups in estrogen receptor and axillary lymph node positivity, but these did not contribute significantly to outcome on multivariate analysis.

CONCLUSIONS

Multicentricity does not increase the risk of poor outcomes in patients with early-stage breast cancer. This supports the current recommendations of the tumor, node, metastasis staging system that tumor size should be based on the diameter of the largest lesion in patients with multicentric breast cancer.

High local recurrence risk after breast-conserving therapy in node-negative premenopausal breast cancer patients is greatly reduced by one course of perioperative chemotherapy: A European Organization for Research and Treatment of Cancer Breast Cancer Cooperative Group Study

PURPOSE

Patients with invasive breast cancer may develop a local recurrence (LR) after breast-conserving therapy (BCT). Younger age has been found to be an independent risk factor for LR. Within a group of premenopausal node-negative breast cancer patients, we studied risk factors for LR and the effect of perioperative chemotherapy (PeCT) on LR.

PATIENTS AND METHODS

The European Organization for Research and Treatment of Cancer (EORTC) conducted a randomized trial (EORTC 10854) to compare surgery followed by one course of PeCT (fluorouracil, doxorubicin, and cyclophosphamide) with surgery alone. From patients treated on this trial, we selected premenopausal patients with node-negative breast cancer who were treated with BCT to examine whether histologic characteristics and the expression of various proteins (estrogen receptor, progesterone receptor, p53, Ki-67, bcl-2, CD31, c-erbB-2/neu) are risk factors for subsequent LR. Also, the effect of one course of PeCT on the LR risk (LRR) was studied.

RESULTS

Using multivariate analysis, age younger than 43 years (relative risk [RR], 2.75; 95% confidence interval [CI], 1.46 to 5.18; P =.002), multifocal growth (RR, 3.34; 95% CI, 1.27 to 8.77; P =.014), and elevated levels of p53 (RR, 2. 14; 95% CI, 1.13 to 4.05; P =.02) were associated with higher LRR. Also, PeCT was found to reduce LRR by more than 50% (RR, 0.47; 95% CI, 0.25 to 0.86; P =.02). Patients younger than 43 years who received PeCT achieved similar LR rates as those of patients younger than 43 years who were treated with BCT alone.

CONCLUSION

In premenopausal node-negative patients, age younger than 43 years is the most important risk factor for LR after BCT; this risk is greatly reduced by one course of PeCT. The main reason for administering systemic adjuvant treatment is to improve overall survival. The important reduction of LR after BCT is an additional reason for considering systemic treatment in young node-negative patients with breast cancer.

Local Management of Primary Breast Cancer

BACKGROUND: Various options are available for the local control of cancer in the breast -- mastectomy, conservation therapy, and mastectomy with reconstruction. METHODS: To evaluate the benefits and drawbacks of the available management options, the authors combine their extensive experience with a review of the literature on outcomes from these approaches. RESULTS: Conservation therapy provides survival outcomes similar to those from mastectomy. Differences in local recurrence rates can be minimized by close adherence to guidelines for patient selection, operative approach, and radiation technique. CONCLUSIONS: The role of the physician in selecting a local therapy for breast cancer has changed from one of informing the patient of the treatment to assessing the presence of medical contraindications to any of the treatments, educating the patients on each treatment approach, providing access to multidisciplinary consultation, and allowing the patient to choose an appropriate treatment approach.

The use of mammography in breast preservation in locally advanced breast cancer

PURPOSE

As the feasibility of breast preservation in locally advanced breast cancer is currently under evaluation, little information is available correlating mammographic changes to chemotherapy with local outcome. To evaluate the role of mammography in selecting candidates with locally advanced breast cancer for conservative local therapy, we analyzed mammographic changes in the breast to induction chemotherapy and correlated the radiologic appearance with pathologic outcome.

METHODS AND MATERIALS

From 1985 through 1993, 91 patients with Stage III breast cancer were enrolled on a multimodality clinical trial using chemohormonal therapy followed by local treatment and maintenance therapy. Induction therapy consisted of cyclophosphamide, doxorubicin, methotrexate,and 5-fluorouracil with hormonal synchronization using tamoxifen and conjugated estrogens. After nine cycles, surgical biopsies of the breast were performed. Through 1988, clinical examination alone directed the site for postinduction biopsy; for patients treated after 1988, mammography, in addition to physical examination, determined the biopsy location. Local treatment was determined by biopsy result. Patients with a pathologic complete response received radiation only to the breast adn regional nodes, while those with pathologically proven residual disease underwent mastectomy and postoperative radiotherapy. Nine additional cycles of maintenance chemotherapy were administered.

RESULTS

Fifty-five of 91 patients (58%) obtained a clinical complete response (CR) to induction chemotherapy. Twenty-eight of the 53 women with a clinical CR had both pre- and postinduction mammograms. Of these 28 women, 9 obtained a pathologic CR and 19 obtained a pathologic partial response (PR). Fifty-five percent of the pathologic complete responders had resolution of mammographic abnormalities on the postinduction mammograms. Sixty-eight percent (13) of the pathologic partial responders had abnormal mammographic findings. The positive predictive value for residual cancer using physical examination was 92%, while the negative predictive value was only 36%. Among patients with a clinical complete response, the positive and negative predictive values for residual cancer using postinduction mammography were 79% and 56%, respectively. Limitations of mammography included uncertain significance of residual microcalcifications and residual masses on postinduction chemotherapy mammograms.

CONCLUSIONS

Although mammography improved the accuracy of noninvasive evaluations in patients with a clinical complete response, pathologic assessment was still required to determine appropriate local therapy. More sensitive imaging modalities or modifications of film-screen mammography may improve noninvasive detection of residual disease following induction chemotherapy.

How to predict the risk of local relapse in the preserved breast

In patients treated by macroscopically complete excision and breast irradiation, a small number of parameters appear to be useful in assessing the inherent risk of intramammary tumor recurrence. These factors include microscopic excision margin status, gross multifocality, very young age, EIC, and perhaps lymph vessel invasion. However, if microscopic resection margins are negative, and especially if systemic therapy is administered, local control is adequate, and none of these risk factors represents a contraindication to breast preservation. Conversely, in the absence of factors indicating an inherently greater risk of local failure, the status of resection margins is likely to be much less important. In such patients existing data suggest that satisfactory local control can be achieved by modern radiotherapy even in the face of microscopically positive margins, especially if such involvement is only focal. Final judgement on this issue awaits availability of additional long-term data from large series in which meticulous evaluation of margin status was prospectively carried out on inked excision specimens.