Prognostic significance of number and level of axillary node metastases in breast cancer

Biomarkers in Breast Cancer: An Old Story with a New End

Breast cancer is the second most frequent cancer in the world. It is a heterogeneous disease and the leading cause of cancer mortality in women. Advances in molecular technologies allowed for the identification of new and more specifics biomarkers for breast cancer diagnosis, prognosis, and risk prediction, enabling personalized treatments, improving therapy, and preventing overtreatment, undertreatment, and incorrect treatment. Several breast cancer biomarkers have been identified and, along with traditional biomarkers, they can assist physicians throughout treatment plan and increase therapy success. Despite the need of more data to improve specificity and determine the real clinical utility of some biomarkers, others are already established and can be used as a guide to make treatment decisions. In this review, we summarize the available traditional, novel, and potential biomarkers while also including gene expression profiles, breast cancer single-cell and polyploid giant cancer cells. We hope to help physicians understand tumor specific characteristics and support decision-making in patient-personalized clinical management, consequently improving treatment outcome.

Real-time diagnosis of sentinel lymph nodes involved to breast cancer based on pH sensing through lipid synthesis of those cells

Lipid synthesis is the recently found metabolism of cancer cells after their metastasis to lymph nodes (LNs). Carbonic acid is the main byproduct of the lipid metabolism in such cells which resulted in acidification of LN ambient. Hence, calibrated pH sensing could be a diagnostic method to find involved LNs. Here, we designed a simple pH sensing method by a syringe containing sterile PBS and embedded by litmus paper to intraoperatively check the pH of LN fluid. Injected phosphate buffer saline (PBS) would homogenize the LN fluid and litmus needle would detect the pH of the LN. We presented an experimental pathological calibration for the pH values in correlation with cancerous states of the LNs. This system named metabolism based metastatic lymph diagnoser (MMLD) could be a real-time noninvasive tool for precise and fast diagnosis of involved LNs.

The impact of nodal micrometastasis on mortality among women with early-stage breast cancer

PURPOSE

The clinical significance of nodal micrometastasis is debated. Our primary objective was to determine whether, among women with early-stage breast cancer, regional lymph node micrometastasis is an independent risk factor for mortality. The secondary objective was to identify subgroups of women who have the highest risk of death from early-stage breast cancer with micrometastases.

METHODS

206,625 women diagnosed with early-stage breast cancer (IA, IB, and IIA) from 2004 to 2012 were identified in the Surveillance, epidemiology, and end results database. Nodal status was classified as node-negative, isolated-tumor cells, micrometastases, and macrometastases. Women were classified into eight ethnic groups. Logistic regression was performed to estimate the odds ratio of being diagnosed with micrometastases. The Cox proportional hazard model was used to estimate the hazard ratio (HR) of breast cancer-specific death associated with micrometastases for each ethnic group.

RESULTS

The 8-year breast cancer-specific survival was 96.6 % for women with node-negative breast cancers and was 94.6 % for women with micrometastases (adjusted HR 1.49; 95 % CI 1.31-1.69; P < .001). Among women with micrometastases, the 8-year breast cancer-specific survival was 95.1 % for white women and was 90.6 % for black women (HR 1.80; 95 % CI 1.29-2.52; P = .0006).

CONCLUSION(S)

Nodal micrometastasis is an independent risk factor for breast cancer mortality among women with early-stage breast cancer. Black women are more likely to die from breast cancer with micrometastases than white women.

Exploring factors related to metastasis free survival in breast cancer patients using Bayesian cure models

BACKGROUND

Breast cancer is a fatal disease and the most frequently diagnosed cancer in women with an increasing pattern worldwide. The burden is mostly attributed to metastatic cancers that occur in one-third of patients and the treatments are palliative. It is of great interest to determine factors affecting time from cancer diagnosis to secondary metastasis.

MATERIALS AND METHODS

Cure rate models assume a Poisson distribution for the number of unobservable metastatic-component cells that are completely deleted from the non-metastasis patient body but some may remain and result in metastasis. Time to metastasis is defined as a function of the number of these cells and the time for each cell to develop a detectable sign of metastasis. Covariates are introduced to the model via the rate of metastatic-component cells. We used non-mixture cure rate models with Weibull and log-logistic distributions in a Bayesian setting to assess the relationship between metastasis free survival and covariates.

RESULTS

The median of metastasis free survival was 76.9 months. Various models showed that from covariates in the study, lymph node involvement ratio and being progesterone receptor positive were significant, with an adverse and a beneficial effect on metastasis free survival, respectively. The estimated fraction of patients cured from metastasis was almost 48%. The Weibull model had a slightly better performance than log-logistic.

CONCLUSIONS

Cure rate models are popular in survival studies and outperform other models under certain conditions. We explored the prognostic factors of metastatic breast cancer from a different viewpoint. In this study, metastasis sites were analyzed all together. Conducting similar studies in a larger sample of cancer patients as well as evaluating the prognostic value of covariates in metastasis to each site separately are recommended.

Prognostic factors for breast cancer and their use in the clinical setting

Breast cancer is the second leading cause of cancer deaths in US women today. This year, approximately 216,000 US women will be diagnosed with invasive breast cancer and another 60,000 with in situ disease. Numerous factors can quantify individual risks for breast cancer, guide therapy and predict outcome. This review focuses on the clinical, pathologic, molecular and genetic prognostic tools available for use in patients with breast cancer, and their impact on clinical decisions and treatment selection.

Trace elements as tumor biomarkers and prognostic factors in breast cancer: a study through energy dispersive x-ray fluorescence

Background

The application and better understanding of traditional and new breast tumor biomarkers and prognostic factors are increasing due to the fact that they are able to identify individuals at high risk of breast cancer, who may benefit from preventive interventions. Also, biomarkers can make possible for physicians to design an individualized treatment for each patient. Previous studies showed that trace elements (TEs) determined by X-Ray Fluorescence (XRF) techniques are found in significantly higher concentrations in neoplastic breast tissues (malignant and benign) when compared with normal tissues. The aim of this work was to evaluate the potential of TEs, determined by the use of the Energy Dispersive X-Ray Fluorescence (EDXRF) technique, as biomarkers and prognostic factors in breast cancer.

Methods

By using EDXRF, we determined Ca, Fe, Cu, and Zn trace elements concentrations in 106 samples of normal and breast cancer tissues. Cut-off values for each TE were determined through Receiver Operating Characteristic (ROC) analysis from the TEs distributions. These values were used to set the positive or negative expression. This expression was subsequently correlated with clinical prognostic factors through Fisher’s exact test and chi-square test. Kaplan Meier survival curves were also evaluated to assess the effect of the expression of TEs in the overall patient survival.

Results

Concentrations of TEs are higher in neoplastic tissues (malignant and benign) when compared with normal tissues. Results from ROC analysis showed that TEs can be considered a tumor biomarker because, after establishing a cut-off value, it was possible to classify different tissues as normal or neoplastic, as well as different types of cancer.

The expression of TEs was found statistically correlated with age and menstrual status. The survival curves estimated by the Kaplan-Meier method showed that patients with positive expression for Cu presented a poor overall survival (p < 0.001).

Conclusions

This study suggests that TEs expression has a great potential of application as a tumor biomarker, once it was revealed to be an effective tool to distinguish different types of breast tissues and to identify the difference between malignant and benign tumors. The expressions of all TEs were found statistically correlated with well-known prognostic factors for breast cancer. The element copper also showed statistical correlation with overall survival.

Lymph Node Ratio

St. Gallen 2005 expert consensus guideline modified its criteria for the risk category of breast cancer (BC) patients by integrating a combination of lymph nodes with metastasis (positive lymph nodes [PLNs]) and HER-2/neu status of tumor. Recently, some studies have shown that lymph node ratio (LNR), defined as the ratio of axillary lymph nodes with tumor metastasis to the total lymph nodes dissected, was a better independent prognostic indicator than PLN and should be considered as an alternative to the status of regional lymph nodes in the staging of breast cancer (pN). In the current study, the authors retrospectively reviewed 1095 primary BC patients with PLN and assessed the prognostic effect of LNR measured by relapse-free survival and overall survival to explore the feasibility of LNR and HER-2/neu status in stratifying the risk category of BC. Our results indicate that although by univariate analysis and when assessed as single covariate in multivariate analysis, both PLN and LNR were independent prognostic factors, PLN lost its significance when combined with LNR as covariates. A cutoff value of LNR = 0.30 was identified to show high accuracy in separating patients based on their survivals. The risk categories defined by LNR combined with HER-2/neu status were compatible to those defined by the PLN in combination with HER-2/neu status. LNR was a strong prognostic predictor of node-positive BC patients, superior to PLN. It should be considered as a new factor to couple with HER-2/neu status in defining risk category of BC patients.

Vascular endothelial growth factor and its relationship to the prognosis and treatment of breast, ovarian, and cervical cancer

Tumor neovascularization is a complex process that plays a crucial role in the development of many different types of cancer. Vascular endothelial growth factor (VEGF) is a potent mitogen that is involved with mitogenesis, angiogenesis, endothelial survival, and the induction of hematopoiesis. By increasing vascular permeability in endothelial cells, it helps tumors recruit wound-healing proteins fibrin and fibrinogen from the plasma, suggesting that tumor formation is a process of abnormal wound healing dependent on the ability to generate a blood supply. The human female reproductive tract is highly dependent on VEGF for normal functions such as endometrial proliferation and development of the corpus luteum. The unique influence of female sex steroid hormones on the expression and activity of VEGF deems angiogenesis an important facet of the development of breast and ovarian cancer. Additionally, the up-regulation of VEGF by the E6 oncoprotein of the human papillomavirus suggests that VEGF plays an important role in the development of cervical cancer. Clinical trials have investigated the humanized monoclonal antibody bevacizumab as potential treatment for all three forms of cancer; the data show that in breast cancer, the use of bevacizumab may lengthen the disease-free survival for women with advanced breast cancer, but does not appear to change their overall survival. It may have a role as salvage chemotherapy for ovarian and cervical cancer, though further research is needed to establish it as a definitive form of treatment.

Expression of bcl-2 in breast cancer: correlation with clinicopathological characteristics and survival

Breast cancer is the most common malignancy in women. It is an immensely heterogeneous disease, characterised by a broad variety of clinical development. The research in recent years has focused on finding new markers of prognosis. This study investigates the role of expression of the bcl-2 protein in breast cancer. We analysed bcl-2 expression in 57 women with primary breast carcinoma who were treated with neoadjuvant (primary) chemotherapy, followed by a surgical procedure. The bcl-2 expression was correlated with other clinicopathological characteristics of the tumour- histological grade, stage, expression of hormonal receptors, proliferation rate, and with the survival of the patients. No significant association of bcl-2 expression with either overall survival or disease free survival was found.

Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience

BACKGROUND

Axillary lymph node dissection is an established procedure in breast cancer staging. However, it is associated with unpleasant side effects. A promising alternative to assess axillary lymph node status in early breast cancer patients is Sentinel Lymph Node Biopsy (SLNB). Isosulfan blue has traditionally been the dye used to identify the Sentinel Lymph Node (SLN). This article is a validation study of SLNB using methylene blue dye and radioactive sulphur colloid in early breast cancer Indian patients. MATERIALS #ENTITYSTARTX00026;

METHODS

With written informed consent, 100 patients with cytology or biospy proven carcinoma breast, clinical stage T1/ T2 N0 M0, underwent SLNB using combination of methylene blue dye & radioactive technetium 99m sulphur colloid as a part of validation study from June 2003 to February 2006. After validation study, from March 2006 to February 2007, 35 patients have undergone SLNB followed by complete axillary clearance in only those patients with SLNB being positive for metastases.

RESULTS

In all 100 patients of the validation study SLN was identified. Total number of cases with positive axillary nodes was 27, out of which SLN was only positive node for metastases in 69% of cases. The overall sensitivity, specificity, positive predictive valve and negative predictive valve of SLNB 96.2%, 100%, 100% and 98.6% respectively with false negative rate of 3.7%. In subsequent 35 patients who underwent SLNB followed by complete axillary clearance, SLNs was identified in all the cases.

CONCLUSIONS

SLNB is effective in early breast cancer patients of Indian population. SLNB using combination of methylene blue dye and radio-active Tc99m sulphur colloid can stage the axilla with high accuracy & low risk of false negativity in early breast cancer patients.

Current controversies in the management of early breast cancer

Medical professionals in general, and medical oncologists in particular, have highly stressful practices because they are under constant pressure to have the highest-quality, up-to-date evidence available in order to make the right decision for each individual patient. From a practical point of view, being updated on oncological and other medical specialties may seem an insurmountable task because the number of scientific publications has increased dramatically. The use of systematic reviews of randomised controlled trials or the application of results obtained from high-quality randomised controlled trials are some of the most common ways to address this need. Unfortunately, they do not cover all complex clinical situations that the majority of medical oncologists face in their outpatient consultations. In this review, we report the conclusions achieved in a multiexpert meeting where five important controversies in the treatment of breast cancer were analysed. Five highly experienced medical oncologists were required to defend an affirmative answer and another five were required to defend a negative answer for each of the clinical questions. After that, a one-day meeting was organised to debate each clinical question and to reach a consensus. We report here the content of this multi-expert meeting along with the conclusions drawn.

The prevention, detection, and management of breast cancer

The reduction in the incidence of contralateral breast cancer in women treated with adjuvant tamoxifen provided a model for prevention using endocrine agents. Oestrogen-receptor-positive cancer can be prevented with tamoxifen, but side effects limit its clinical utility, and the risk-benefit ratio is not sufficiently high to routinely recommend tamoxifen as a preventive agent. Agents being evaluated in prevention trials include raloxifene and the aromatase inhibitors; these are expected to be at least as effective as tamoxifen and to have fewer side effects. Core needle biopsy (providing histological information) and high-resolution breast ultrasound enhance preoperative assessment of breast cancer. Mammography remains the only screening test shown to reduce breast cancer deaths in randomised trials. Magnetic resonance imaging may have a role in screening women with inherited mutations of the breast cancer genes. Sentinel lymph node biopsy accurately assesses lymph node status and is associated with less morbidity than axillary dissection. Where the biopsy is negative (no histologic evidence of metastases), no further axillary treatment is necessary. Breast reconstruction after mastectomy can produce good cosmetic results, especially where autologous tissue is used. Myocutaneous flaps using latissimus dorsi or transverse rectus abdominus muscles are increasingly popular. Adjuvant trastuzumab therapy in patients whose tumours overexpress HER2 (growth factor receptor) can reduce recurrence rates and improve survival. Neoadjuvant endocrine therapy (as an initial treatment before surgery) is an underutilised treatment in postmenopausal women with oestrogen-receptor-positive large operable or locally advanced cancers. It makes more patients suitable for surgery and offers others the choice of breast conservation.

Breast cancer severity score is an innovative system for prognosis

BACKGROUND

Survival in breast cancer maybe more accurately predicted by a scoring system based on the biologic characteristics of the tumor such as diameter, number of involved nodes, and hormone receptor status than by conventional staging.

METHODS

Medical records of 419 patients with a diagnosis of breast cancer from a university hospital between 1997 and 2002 were reviewed. Tumor characteristics were given a value reflecting the impact on survival. Tumor diameter was assigned 1 point per cm, specifically: 1 point for 0.1 to 1 cm, 2 points for 1.1 to 2 cm, 3 points for 2.1 to 5 cm, and 4 points for 5.1 cm and over. Nodal status was assigned 1 point if the patient had 1 to 3 positive nodes, 5 points if 4 to 10 positive nodes were found, and 10 points if more than 10 nodes were identified. Hormone receptor status was given 1 point if either estrogen or progesterone receptors were not present or 2 points if both were absent. The breast cancer severity score (BCSS) was used to analyze overall and disease-free survival by Kaplan-Meier analysis. Significance of differences in survival was determined by log-rank analysis.

RESULTS

An increased severity score was inversely proportional to overall and disease-free survivals. A BCSS of greater than 7 was most predictive of outcome with 5-year survival of 68%; and a BCSS of less than 7 had a 5-year survival of 98% (P = 0.0028). A BCSS of greater than 7 also discriminated disease-free survival within stage II (P = 0.02) and stage III (P = 0.01).

CONCLUSIONS

The BCSS provides a better resolution of outcome than traditional staging, and works both for overall survival and within specific stages. Using the BCSS, management and follow-up can be specifically tailored for low- and high-risk patients.

Ethics in sentinel node biopsy in breast cancer: an open question

The sentinel node concept agrees with the modern principles of surgical oncology in breast cancer, which are related to lymphatic dissection, accurate axillary study, and less traumatic surgery. After publication of many series, it has proven its capacity to correctly stage axilla and select patients who need axillary dissection. The Brazilian Society of Senology established the current norms for its practice. However, the transportation of new surgical techniques from research to practice always occurs with some ethical dilemmas related to its introduction in clinical practice. The aim of this study was to analyze the ethical challenges of the sentinel node technique and problems with its implementation.

[Correlation of size of the primary tumor and axillary node status with the p53 tumor suppressor gene in carcinoma of the breast]

Correlation of standard pathomorphological prognostic parameters, primary tumor size and axillary nodal status with new prognostic factor in breast carcinoma: tumor suppressor gene p53 was analyzed. The studied sample included 65 women who underwent surgery for breast carcinoma at the Surgical Clinic of Clinical Center Banja Luka, from January 1st 1997 till January 1st 1999. Statistical data analysis was performed and correlation of prognostic factors was determined. The majority of authors in this field agree that the primary tumor size and axillary nodal status are the two most important prognostic factors. These factors are the best predictors of prognosis and survival of women who had the tumor and were operated on. Tumor markers were immunohistochemically determined in the last ten years and, according to the majority of authors, are still considered the additional or relative prognostic factors in breast carcinoma. Their prognostic value and significance increase almost daily. Most frequently determined tumor markers are bcl-2, pS2, Ki-67 and p53. There was a positive, directly proportional relationship between primary tumor size and tumor suppressor gene p53, but there was no positive correlation between the axillary nodal status and tumor suppressor gene p53. Significance of determination of new tumor markers as the prognostic factors was emphasized. These markers represent a powerful tool in the early detection and prevention of breast carcinoma.

Linfonodo sentinela: um novo conceito no tratamento cirúrgico do câncer de mama

O linfonodo sentinela é o primeiro linfonodo que recebe a drenagem linfática proveniente do câncer de mama. A sua detecção tem a finalidade de predizer o estado da axila e evitar o esvaziamento axilar nos pacientes sem comprometimento metastático. Os autores realizaram uma ampla revisão da literatura, envolvendo os aspectos cirúrgicos, de Medicina Nuclear e de Anatomia Patológica do linfonodo sentinela. Muitos estudos demonstraram a eficácia do linfonodo sentinela em predizer o comprometimento axilar. Entretanto, existem várias técnicas empregadas para a identificação desse linfonodo, sem haver ainda um consenso em relação ao método mais adequado e reproduzível. A associação do corante vital com o probe, até o presente, é a que tem apresentado os melhores resultados. Também não existe uma padronização do exame patológico intra-operatório do linfonodo sentinela e os índices de falso-negativos encontrados são bastante variáveis. A biópsia do linfonodo sentinela pode oferecer uma alternativa segura à dissecção axilar e com menos efeitos colaterais nos pacientes com axila clinicamente negativa. Entretanto alguns pontos conflitantes devem ser resolvidos antes que o método passe a ser utilizado na prática com o câncer de mama. O objetivo desse trabalho foi discutir os principais aspectos envolvidos no desenvolvimento e na aplicação dessa técnica.

Prognostic and predictive factors in primary breast cancer and their role in patient management: The Nottingham Breast Team

Breast cancer is the most common carcinoma amongst women in the Western world, yet there are now encouraging signs that improvements in mortality may be a realistic target. Increasing breast awareness amongst women due to better health education can lead to earlier clinical detection. In addition, population screening with mammography can achieve a significant improvement in survival. With significant changes in the range and type of therapeutic options available for patients with breast cancer, there is now a trend towards patients exercising their right in management and therapeutic decisions. All these developments highlight the increasing importance of prognostic and predictive factors in the management of patients with breast cancer. In this review we will discuss current prognostic and predictive factors with particular emphasis on those of relevance in routine histopathology, especially with respect to their clinical applications.

Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, a multidisciplinary group of clinicians, pathologists, and statisticians considered prognostic and predictive factors in breast cancer and stratified them into categories reflecting the strength of published evidence.

MATERIALS AND METHODS

Factors were ranked according to previously established College of American Pathologists categorical rankings: category I, factors proven to be of prognostic import and useful in clinical patient management; category II, factors that had been extensively studied biologically and clinically, but whose import remains to be validated in statistically robust studies; and category III, all other factors not sufficiently studied to demonstrate their prognostic value. Factors in categories I and II were considered with respect to variations in methods of analysis, interpretation of findings, reporting of data, and statistical evaluation. For each factor, detailed recommendations for improvement were made. Recommendations were based on the following aims: (1) increasing uniformity and completeness of pathologic evaluation of tumor specimens, (2) enhancing the quality of data collected about existing prognostic factors, and (3) improving patient care.

RESULTS AND CONCLUSIONS

Factors ranked in category I included TNM staging information, histologic grade, histologic type, mitotic figure counts, and hormone receptor status. Category II factors included c-erbB-2 (Her2-neu), proliferation markers, lymphatic and vascular channel invasion, and p53. Factors in category III included DNA ploidy analysis, microvessel density, epidermal growth factor receptor, transforming growth factor-alpha, bcl-2, pS2, and cathepsin D. This report constitutes a detailed outline of the findings and recommendations of the consensus conference group, organized according to structural guidelines as defined.

Sentinel lymph node biopsy and axillary dissection in breast cancer: results in a large series

BACKGROUND

Axillary lymph node dissection is an established component of the surgical treatment of breast cancer, and is an important procedure in cancer staging; however, it is associated with unpleasant side effects. We have investigated a radioactive tracer-guided procedure that facilitates identification, removal, and pathologic examination of the sentinel lymph node (i.e., the lymph node first receiving lymphatic fluid from the area of the breast containing the tumor) to predict the status of the axilla and to assess the safety of foregoing axillary dissection if the sentinel lymph node shows no involvement.

METHODS

We injected 5-10 MBq of 99mTc-labeled colloidal particles of human albumin peritumorally in 376 consecutive patients with breast cancer who were enrolled at the European Institute of Oncology during the period from March 1996 through March 1998. The sentinel lymph node in each case was visualized by lymphoscintigraphy, and its general location was marked on the overlying skin. During breast surgery, the sentinel lymph node was identified for removal by monitoring the acoustic signal from a hand-held gamma ray-detecting probe. Total axillary dissection was then carried out. The pathologic status of the sentinel lymph node was compared with that of the whole axilla.

RESULTS

The sentinel lymph node was identified in 371 (98.7%) of the 376 patients and accurately predicted the state of the axilla in 359 (95.5%) of the patients, with 12 false-negative findings (6.7%; 95% confidence interval = 3.5%-11.4%) among a total of 180 patients with positive axillary lymph nodes.

CONCLUSIONS

Sentinel lymph node biopsy using a gamma ray-detecting probe allows staging of the axilla with high accuracy in patients with primary breast cancer. A randomized trial is necessary to determine whether axillary dissection may be avoided in those patients with an uninvolved sentinel lymph node.

Comparison of the surgical procedures for breast conserving treatment of early breast cancer in seven EORTC centres

The aim of this study was to develop a standardised surgical report for breast-conserving procedures, supporting the systematic documentation of the different aspects of the surgery. The surgical procedure for tumourectomy and axillary clearance was translated into a series of steps that could be quantitatively documented. This description was submitted twice to a group of surgeons from different departments to ensure that all steps that are considered to have relevance for outcome were included and that no superfluous data were collected. After two corrective phases, a first test format was developed. Between February 1993 and May 1994, seven surgical departments, participating in EORTC trials, completed this questionnaire for a number of their patients. The data collected related to general information on the department, the tumour excision itself, the axillary dissection and, in a later phase, on pathology. 269 questionnaires (264 tumour excisions, 259 axillary dissections and 189 pathology reports) were collected and analysed. Even though the participating departments were involved in a single trial on breast-conserving surgery and had previously developed regular contacts about the practical aspects of treatment, many differences were detected. In general, variations were found in the waiting time between treatment prescription and execution, experience of the surgeon, duration of the procedure, and the use of prophylactic antibiotics. Also, in the practical execution of the procedure, major variations in the type of incision, width of tumour excision, closure of the breast tissue and skin, the use of frozen sections and the extent of the axillary dissection were found. The most relevant differences and their possible consequences are discussed. It has been proven possible and feasible to document quantitatively a surgical procedure. The fact that within a group of surgeons participating in the same clinical trials, many differences in the surgical techniques are observed, stresses the need to reach a consensus on a stricter set of guidelines for breast-conserving procedures and their documentation, especially when conducting clinical trials.

More detailed documentation of operative procedures in breast conserving treatment: what good will it do us?

When researching the literature, many differences within surgical techniques for breast conservation, tumour excision and axillary dissection are described in the smallest detail. Most authors have their own preferences but little clinical research has been done to evaluate the impact of those differences on outcome: local control, cosmesis, complications or costs. Even when prospective, randomized clinical trial protocols provide many instructions to perform the surgery, the case report forms almost never document the surgery actually performed. This is in contrast to radiotherapy and chemotherapy regimens, which have had higher standards of quality of care implemented. The development of more detailed and standardized procedural information should lead to more accurate and specific information, which can be easily transferred in a learning process, and enable more reliable clinical research. Documentation and guidelines for surgery are essential tools in implementing a process of quality audit for a type of surgery where accuracy is essential.

Interpretation of the risk associated with the unexpected finding of lobular carcinoma in situ

BACKGROUND

The risk of developing invasive breast cancer after finding lobular carcinoma in situ (LCIS) is controversially reported in the literature. The surgeon who finds LCIS unexpectedly may be tempted to remove the breast, or even remove both breasts.

METHODS

From 1976 to 1991, 157 consecutive women with palpable or mammographically detected breast lesions underwent surgery to resolve doubt as to the presence of invasive cancer. We report on the women in whom LCIS was found after diagnostic breast surgery and analyze the incidence of breast cancer after a mean 5 years of follow-up in comparison with that in the normal reference population.

RESULTS

Eight patients developed infiltrating breast carcinoma (four ipsilateral, four contralateral as first events), equal to a homolateral rate of 0.00625. The expected rate in the normal reference population is 0.00152; ratio 4.11 (95% confidence interval 1.1-10.5). For a contralateral event the rate ratio is 3.0 (95% confidence interval 0.8-7.6).

CONCLUSION

LCIS is one of many markers for later infiltrating cancer, so patients should be carefully followed. Ablative surgery is not justified.