Recursive partitioning identifies patients at high and low risk for ipsilateral tumor recurrence after breast-conserving surgery and radiation

Evaluation of Concurrent Chemoradiotherapy for Survival Outcomes in Patients With Synchronous Oligometastatic Esophageal Squamous Cell Carcinoma

IMPORTANCE

The optimal treatment for and potential benefit populations of synchronous oligometastatic esophageal squamous cell carcinoma (SOESCC) remain unclear.

OBJECTIVES

To evaluate outcomes of concurrent chemoradiotherapy (CCRT) and to construct decision tree models for predicting the risk of progression and mortality in patients with SOESCC.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic study included 532 patients with SOESCC who were treated at 2 cancer centers in China from January 2012 to December 2018 and consisted of a development cohort (n = 381) and a validation cohort (n = 151). Data were analyzed from March 2019 to December 2021.

EXPOSURES

All patients received chemotherapy alone or CCRT.

MAIN OUTCOMES AND MEASURES

The primary end points of the study were progression-free survival (PFS) and overall survival (OS), and the secondary end points were locoregional control and treatment-related toxic effects. Propensity score matching was performed to control potential confounding factors. Cox regression was used to screen important explanatory variables. Decision trees for optimally partitioning patients were established using recursive partitioning analysis and were then subjected to internal and independent external validation.

RESULTS

Among the 532 patients (median [range] age, 63 [32-82] years; 367 men [69.0%]), 292 patients received chemotherapy alone and 240 patients underwent CCRT. With a median (IQR) follow-up time of 37.0 (21.6-55.8) months, CCRT was associated with improved objective response rate (139 of 240 [57.9%] vs 123 of 292 [42.1%]; P < .001), median (IQR) PFS (9.7 [8.5-10.9] months vs 7.6 [6.6-8.6] months; P < .001), and median (IQR) OS (18.5 [16.1-20.9] months vs 15.2 [13.6-16.8] months; P < .001) compared with chemotherapy alone. Propensity score matching analysis verified the results. Cox multivariate analysis indicated that treatment modality (CCRT vs chemotherapy alone) was an independent prognostic factor related to PFS (hazard ratio, 0.69; 95% CI, 0.57-0.83; P < .001) and OS (hazard ratio, 0.75; 95% CI, 0.61-0.93; P = .008). The final decision trees divided patients with SOESCC into low-, intermediate-, and high-risk groups in both the internal and external validations, and the corresponding cumulative risk function curves had significant differences (all P < .001). Time-dependent maximum areas under receiver operating curves of decision trees for progression risk at 3 years and mortality risk at 5 years were 0.820 (95% CI, 0.693-0.948) and 0.894 (95% CI, 0.822-0.966), respectively. Calibration curves also demonstrated that the decision trees had favorable performance of risk stratification.

CONCLUSIONS AND RELEVANCE

In this study, CCRT vs chemotherapy alone as a first-line treatment for patients with SOESCC had superior survival. Patients with low risk had promising long-term survival based on the current treatment modality. The predictive information of the decision tree could provide accurate decision-making for the management of patients with SOESCC.

Breast Cancer in Young Women Presents With More Aggressive Pathologic Characteristics: Retrospective Analysis From an Argentine National Database

PURPOSE

Multiple studies have reported that breast cancer in young patients is associated with aggressive characteristics, and it is suggested that prognosis is worse independently of pathologic variables.

PATIENTS AND METHODS

We performed a retrospective analysis of the Breast Cancer Registry of the Argentinian Society of Mastology, including public and private centers. Patients ≤ 40 years of age at diagnosis were classified as "young," and patients ≤ 35 years of age at diagnosis were classified as "very young." Univariate and multivariate analyses were performed to detect differences between groups.

RESULTS

Patients ≤ 40 years of age comprised 10.40% (739/7,105) of the participants, with an average age of 35.61 ± 4.04 years. Multivariate analysis showed that human epidermal growth factor receptor 2 (HER2)-positive tumor phenotype (odds ratio [OR], 1.82), nodal involvement (OR, 1.69), histologic grade (grade 3 OR, 1.41), and tumor size (T2 OR, 1.37; T3-T4, 1.47) were independently associated with younger age at diagnosis. Patients ≤ 35 years of age (n = 286), compared with patients 36 to 40 years of age, had a higher proportion of HER2 tumors (24.58% v 16.94%; P = .021), absence of progesterone receptor expression (29.85% v 22.95%; P = .043), and stage 3 cancer (29.34% v 18.52%; P < .001). Fewer breast-conserving surgeries (75.37% v 62.89%; P < .001) and more adjuvant chemotherapy (59.04% v 36.66%; P < 0.001) were reported in patients ≤ 40 years of age.

CONCLUSION

In the population studied, breast cancer in young women was associated with aggressive pathologic features and locally advanced disease at the time of diagnosis. Moreover, tumor characteristics in very young patients with breast cancer nested in the population ≤ 40 years of age showed differences in important prognostic factors. More high-quality evidence is needed to improve treatment strategies in these patients.

Diagnosis and Treatment of Breast Cancer in Young Women

OPINION STATEMENT

Despite the increase of breast cancer incidence with age, approximately 7 to 10% ofwomen diagnosed with breast cancer are younger than the age 40. This subgroup ofpatients has different risk factors, tumour biology, clinical outcomes, and specific psy- chosocial issues, such as fertility preservation, family planning, and job reintegration. However, age alone should not be the main consideration when choosing the aggressive- ness of the treatment, as other factors must be considered, including the biologic aggressiveness of the tumour, potential long-term toxicities, and the preferences of the patient. Fertility preservation techniques should be discussed with the patient before starting any cancer treatment. Despite the significant percentage of breast cancer patients younger than age 40, fewclinical studies have specifically investigated disease characteristics and outcomes of this population, and most therapies routinely administered to these younger women were tested in older patients. Moreover, young women who have breast cancer are at a greater risk of sexual and psychological distress, and clinicians should address these issues in order to properly support patients during the long diagnostic and therapeutic journey. Consequently, it is essential to follow diagnostic and treatment guidelines specificallyaddressed to young women. Additional specific procedures should be followed to treat pregnant patients with breast cancer.

Hypofractionated radiotherapy with concomitant boost for breast cancer: a dose escalation study

METHODS:

Patients with breast cancer with pathological stage pT 1-2 and at least one risk factor for local recurrence such as N1 disease, lymphovascular invasion, extensive intraductal component, close margins, non-hormone sensitive disease, grading G3 were enrolled. Patients were treated with hypofractionated RT to whole breast with a dose of 40.05 Gy in 15 fractions. The dose was escalated to the tumour bed through a daily concomitant boost technique at three dose levels: 48 Gy (3.2 Gy/die), 50.25 Gy(3.35 Gy/die) and 52.5 Gy (3.5 Gy/die). Dose escalation to a higher step was carried out if all patients of the lower dose had completed the treatment without dose limiting toxicity (DLT). Skin toxicity, cosmetic evaluation and quality of life was evaluated at baseline, at treatment end and at 3 and 12 months after RT end.

RESULTS:

Three patients for each dose level were enrolled. No DLT occurred. The maximum toxicity collected during RT was G2 skin toxicity in 3 (33.3%) patients, one for each dose level. No G2 toxicity at 3 and 12 months was collected. At median follow up of 21.8 months (range: 13.5 - 40.9 months), no G2 late toxicity was recorded.

CONCLUSION:

The 3 week course of post-operative RT with dose escalation to the tumour bed to 52.5 Gy has been achieved without dose limiting toxicities and can be tested in Phase II trials.

ADVANCES IN KNOWLEDGE:

In our study, we tested the highest dose level to the tumour bed ever reported in studies using accelerated hypofractionation with concomitant boost in high risk patients.

Pre-treatment neutrophil-to-lymphocyte ratio predicts survival in patients with laryngeal cancer

An increased neutrophil-to-lymphocyte ratio (NLR) is associated with poorer prognostic outcomes in numerous types of cancer. However, a small number of studies have demonstrated the prognostic role of NLR in patients with laryngeal cancer. The present study evaluated the association between NLR and survival outcomes in patients with laryngeal squamous cancer. All patients were scheduled for follow-up visits. The levels of cytokines from tumor tissues were analyzed by ELISA. A classification and regression tree (CART) was used to determine the optimal cutoff values of NLR. The clinical features and NLR were determined using Kaplan-Meier analysis and Cox regression to analyze the survival outcomes and associated risks. Of the total 654 patients, 70 patients (70/654; 10.7%) failed to receive follow-up. Blood and biochemical parameters, including NLR, platelet-to-lymphocyte ratio and albumin-to-globulin ratio were associated with clinical characteristics of the patients, with the exception of histologic grade. Only one node with NLR at 3.18 divided patients into different categories, according to CART analysis. Survival analysis demonstrated that NLR at cutoff values subdivided patients into different survival outcomes (P<0.001). Subsequent to adjustments for age and other clinical features, NLR was identified to be an independent prognostic factor for overall survival and progression-free survival (P<0.05). Increased levels of cytokines, including IL-6 and IL-8, in tumor tissues were associated with NLR values. In summary, pre-treatment NLR was associated with the prognostic outcomes for patients with laryngeal cancer, and may assist to establish prognostic factors for these patients.

Histopathological Study on Conservatively Operated Breast Carcinomas

In this histopathological study we looked at 303 cases of breast carcinomas, managed though conservative breast surgery and later analysed with the help of a classical histopathological technique, paraffin embedding. The carcinomas were assessed in terms of tumor size, lymph node status, histological type, correlation between invasive tumors and an situ carcinoma component, resection margins, grading and patients age. Following assessment, we looked at associations between above morphological and clinical parameters and ipsilateral local recurrences. We concluded that more than half of our cases were carcinomas, measuring between 2 cm and 5 cm, with no associated lymph node involvement, in keeping with pTNM criteria for stage II. By far, in our study, the most frequent histopathological type was type NOS (63.37%) followed by invasive lobular carcinoma (10.56%) and mixed ducto-lobular invasive carcinoma (6.27%). Other types of invasive carcinoma were rarer, each representing less than 4% of cases. In regards to in situ carcinomas we noted the most common histological types to be both cribriform intraductal carcinoma and comedocarcinoma, each identified in 1.65% of cases. Amongst invasive breast carcinomas, infiltrating ductal carcinoma not otherwise specified (NOS) was found to be most commonly associated with in situ ductal carcinoma lesions. This was seen in 34.9% of cases, and was the only type associated with an extensive in situ component. Analysing the grading of mammary carcinomas in our study showed that the vast majority of cases (63.04%) were grade 3 tumors. In regards to surgical resection margins, ¾ of cases were noted to have negative margins. Tumor recurrences were noted in 12 cases. These cases were most commonly noted to reoccur following initial poorly differentiated, infiltrating ductal carcinomas, not otherwise specified (NOS), with positive resection margins, measuring less than 2 cm. Patiens tended to be under the age of 40 and had positive lymph nodes. The emergence of local recurrences after conservative surgery for early breast cancer is singnificantly linked to poorly differentiated primary tumors (p <0.05) but not correlated with histological type, presence of extensive intraductal carcinoma component, size of primary breast tumor or lymph node status ( p> 0.05). In terms of increasing the risk of ipsilateral recurrence the most important aspect highlighted in our sudy was the status of the resection margins. Patients with positive resection margins had a significantly high risk to develop recurrences after the conservative surgery, compared to those with negative margins (p <0.001).

Surgical Resection Margins after Breast-Conserving Surgery: Senonetwork Recommendations

This paper reports findings of the “Focus on Controversial Areas” Working Party of the Italian Senonetwork, which was set up to improve the care of breast cancer patients. After reviewing articles in English on the MEDLINE system on breast conserving surgery for invasive carcinoma, the Working Party presents their recommendations for identifying risk factors for positive margins, suggests how to manage them so as to achieve the highest possible percentage of negative margins, and proposes standards for investigating resection margins and therapeutic approaches according to margin status. When margins are positive, approaches include re-excision, mastectomy, or, as second-line treatment, radiotherapy with a high boost dose. When margins are negative, boost administration and its dose depend on the risk of local recurrence, which is linked to biopathological tumor features and surgical margin width. Although margin status does not affect the choice of systemic therapy, it may delay the start of chemotherapy when further surgery is required.

Breast cancer in young women: special considerations in multidisciplinary care

Breast cancer is one of the most prevalent cancers in females, and 5%-7% of breast cancer cases occur in women under 40 years of age. Breast cancer in the young has gained increased attention with an attempt to improve diagnosis and prognosis. Young patients tend to have different epidemiology, presenting with later stages and more aggressive phenotypes. Diagnostic imaging is also more difficult in this age group. Multidisciplinary care generally encompasses surgeons, medical oncologists, radiation oncologists, radiologists, and social workers. Other special considerations include reconstruction options, fertility, genetics, and psychosocial issues. These concerns enlarge the already diverse multidisciplinary team to incorporate new expertise, such as reproductive specialists and genetic counselors. This review encompasses an overview of the current multimodal treatment regimens and the unique challenges in treating this special population. Integration of diagnosis, treatment, and quality of life issues should be addressed and understood by each member in the interdisciplinary team in order to optimize outcomes.

Breast cancer in adolescent and young adult women

Breast cancer is one of the most frequently diagnosed malignancy among adolescent and young adult (AYA) women, accounting for approximately 14% of all AYA cancer diagnoses and 7% of all breast cancer. Breast cancer in AYA women is believed to represent a more biologically aggressive disease, but aside from commonly known hereditary predispositions, little is still known about the underlying molecular genetic causes. This review examines the current trends of breast cancer in AYA women as they relate to clinical, social, genetic, and molecular pathologic characteristics. We highlight existing trends, treatment and imaging approaches, and health burdens as they relate to breast cancer in AYA women and provide a discussion on ways to help improve the overall management of this breast cancer cohort.

The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis

PURPOSE

There is no consensus on what constitutes adequate negative margins in breast-conserving therapy (BCT). We systematically review the evidence on surgical margins in BCT for invasive breast cancer to support the development of clinical guidelines.

METHODS

Study-level meta-analysis of studies reporting local recurrence (LR) data relative to final microscopic margin status and the threshold distance for negative margins. LR proportion was modeled using random-effects logistic meta-regression.

RESULTS

Based on 33 studies (LR in 1,506 of 28,162), the odds of LR were associated with margin status [model 1: odds ratio (OR) 1.96 for positive/close vs negative; model 2: OR 1.74 for close vs. negative, 2.44 for positive vs. negative; (P < 0.001 both models)] but not with margin distance [model 1: >0 mm vs. 1 mm (referent) vs. 2 mm vs. 5 mm (P = 0.12); and model 2: 1 mm (referent) vs. 2 mm vs. 5 mm (P = 0.90)], adjusting for study median follow-up time. There was little to no statistical evidence that the odds of LR decreased as the distance for declaring negative margins increased, adjusting for follow-up time [model 1: 1 mm (OR 1.0, referent), 2 mm (OR 0.95), 5 mm (OR 0.65), P = 0.21 for trend; and model 2: 1 mm (OR 1.0, referent), 2 mm (OR 0.91), 5 mm (OR 0.77), P = 0.58 for trend]. Adjustment for covariates, such as use of endocrine therapy or median-year of recruitment, did not change the findings.

CONCLUSIONS

Meta-analysis confirms that negative margins reduce the odds of LR; however, increasing the distance for defining negative margins is not significantly associated with reduced odds of LR, allowing for follow-up time. Adoption of wider relative to narrower margin widths to declare negative margins is unlikely to have a substantial additional benefit for long-term local control in BCT.

Patient, hospital, and neighborhood factors associated with treatment of early-stage breast cancer among Asian American women in California

BACKGROUND

Clinical guidelines recommend breast-conserving surgery (BCS) with radiation as a viable alternative to mastectomy for treatment of early-stage breast cancer. Yet, Asian Americans are more likely than other groups to have mastectomy or omit radiation after BCS.

METHODS

We applied polytomous logistic regression and recursive partitioning to analyze factors associated with mastectomy, or BCS without radiation, among 20,987 California Asian Americans diagnosed with stage 0 to II breast cancer from 1990 to 2007.

RESULTS

The percentage receiving mastectomy ranged from 40% among U.S.-born Chinese to 58% among foreign-born Vietnamese. Factors associated with mastectomy included tumor characteristics such as larger tumor size, patient characteristics such as older age and foreign birthplace among some Asian Americans ethnicities, and additional factors including hospital [smaller hospital size, not National Cancer Institute cancer center, low socioeconomic status (SES) patient composition, and high hospital Asian Americans patient composition] and neighborhood characteristics (ethnic enclaves of low SES). These hospital and neighborhood characteristics were also associated with BCS without radiation. Through recursive partitioning, the highest mastectomy subgroups were defined by tumor characteristics such as size and anatomic location, in combination with diagnosis year and nativity.

CONCLUSIONS

Tumor characteristics and, secondarily, patient, hospital, and neighborhood factors are predictors of mastectomy and omission of radiation following BCS among Asian Americans.

IMPACT

By focusing on interactions among patient, hospital, and neighborhood factors in the differential receipt of breast cancer treatment, our study identifies subgroups of interest for further study and translation into public health and patient-focused initiatives to ensure that all women are fully informed about treatment options.

Identifying representative trees from ensembles

Tree-based methods have become popular for analyzing complex data structures where the primary goal is risk stratification of patients. Ensemble techniques improve the accuracy in prediction and address the instability in a single tree by growing an ensemble of trees and aggregating. However, in the process, individual trees get lost. In this paper, we propose a methodology for identifying the most representative trees in an ensemble on the basis of several tree distance metrics. Although our focus is on binary outcomes, the methods are applicable to censored data as well. For any two trees, the distance metrics are chosen to (1) measure similarity of the covariates used to split the trees; (2) reflect similar clustering of patients in the terminal nodes of the trees; and (3) measure similarity in predictions from the two trees. Whereas the latter focuses on prediction, the first two metrics focus on the architectural similarity between two trees. The most representative trees in the ensemble are chosen on the basis of the average distance between a tree and all other trees in the ensemble. Out-of-bag estimate of error rate is obtained using neighborhoods of representative trees. Simulations and data examples show gains in predictive accuracy when averaging over such neighborhoods. We illustrate our methods using a dataset of kidney cancer treatment receipt (binary outcome) and a second dataset of breast cancer survival (censored outcome).

Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy

PURPOSE

There is no consensus on what constitutes adequate negative margins in breast-conserving therapy (BCT). We review the evidence on surgical margins in BCT for early-stage invasive breast cancer.

METHODS

Meta-analysis of studies reporting local recurrence (LR) relative to quantified final microscopic margin status and the threshold distance for negative margins. The proportion of LR was modelled using random effects logistic meta-regression.

RESULTS

Based on 21 studies (LR in 1,026 of 14,571 subjects) the odds of LR were associated with margin status [model 1: odds ratio (OR) = 2.02 for positive/close versus negative; model 2: OR = 1.80 for close versus negative, 2.42 for positive versus negative (P<0.001 both models)] but not with margin distance [1mm versus 2mm versus 5mm (P > 0.10 both models)], adjusting for median follow-up time. However, there was weak evidence in both models that the odds of LR decreased as the threshold distance for declaring negative margins increased. This bordered significance in model 2 [OR for 1mm, 2mm, 5mm: 1.0, 0.75, 0.51 (P = 0.097 for trend)], and was not significant in model 1 [OR for 1mm, 2mm, 5mm: 1.0, 0.85, 0.58 (P = 0.11 for trend)] but was evident when one study (of women ≤ 40 years) was excluded from this model [OR for 1mm, 2mm, 5mm: 1.0, 0.72, 0.52 (P = 0.058 for trend)]: this trend was rendered insignificant by adjustment for the proportion of subjects receiving a radiation boost or the proportion of subjects receiving endocrine therapy.

CONCLUSIONS

Margin status has a prognostic effect in all women treated for invasive breast cancer; increasing the threshold distance for declaring negative margins is weakly associated with reduced odds of LR, however adjustment for covariates (adjuvant therapy) removes the significance of this effect. Adoption of wider margins, relative to narrower widths, for declaring negative margins is unlikely to a have substantial additional benefit for long-term local control in BCT.

Breast cancer in young women

Although uncommon, breast cancer in young women is worthy of special attention due to the unique and complex issues that are raised. This article reviews specific challenges associated with the care of younger breast cancer patients, which include fertility preservation, management of inherited breast cancer syndromes, maintenance of bone health, secondary prevention, and attention to psychosocial issues.

Outcome after Mastectomy for Ipsilateral Breast Tumor Recurrence after Breast Conserving Surgery

Ipsilateral breast tumor recurrence (IBTR) is a risk after breast conserving surgery, and is traditionally treated with mastectomy. Given the limited literature on outcome after mastectomy for IBTR, we evaluated our long-term data for this group. A retrospective review was conducted using a database of 2101 breast cancer patients at a single institution. Fifty-nine patients underwent breast conserving surgery and experienced an IBTR. Exclusion criteria included repeat lumpectomy or metastatic disease before mastectomy. Patients presented with invasive ductal (58%), invasive lobular (7%), other invasive (11%), or ductal carcinoma in situ (24%). Initial tumors were Tis (24%), T1 (42%), T2 (20%), T3 (2%), or not recorded (12%). IBTR lesions were Tis (20%), T1 (46%), T2 (25%), or T3 (9%). Median follow-up after mastectomy was 4.6 years. Thirteen patients (22%) had post-mastectomy recurrence (PMR), which decreased overall survival ( P = 0.002). PMR was more common with larger IBTR tumors ( P = 0.03), specifically IBTR ≥ T2 ( P = 0.003). Eighty-five per cent of PMR occurred within 2 years of mastectomy. Mastectomy for IBTR remains effective treatment for most patients, but the risk of PMR remains. Patients with IBTR tumors >2 cm have an increased risk of PMR. Strict follow-up should be routine, especially during the first 24 months.

Predictors of venous thromboembolism in patients with advanced common solid cancers

There is uncertainty about risk heterogeneity for venous thromboembolism (VTE) in older patients with advanced cancer and whether patients can be stratified according to VTE risk. We performed a retrospective cohort study of the linked Medicare-Surveillance, Epidemiology, and End Results cancer registry in older patients with advanced cancer of lung, breast, colon, prostate, or pancreas diagnosed between 1995-1999. We used survival analysis with demographics, comorbidities, and tumor characteristics/treatment as independent variables. Outcome was VTE diagnosed at least one month after cancer diagnosis. VTE rate was highest in the first year (3.4%). Compared to prostate cancer (1.4 VTEs/100 person-years), there was marked variability in VTE risk (hazard ratio (HR) for male-colon cancer 3.73 (95% CI 2.1-6.62), female-colon cancer HR 6.6 (3.83-11.38), up to female-pancreas cancer HR 21.57 (12.21-38.09). Stage IV cancer and chemotherapy resulted in higher risk (HRs 1.75 (1.44-2.12) and 1.31 (1.0-1.57), resp.). Stratifying the cohort by cancer type and stage using recursive partitioning analysis yielded five groups of VTE rates (nonlocalized prostate cancer 1.4 VTEs/100 person-years, to nonlocalized pancreatic cancer 17.4 VTEs/100 patient-years). In a high-risk population with advanced cancer, substantial variability in VTE risk exists, with notable differences according to cancer type and stage.

Locoregional recurrence of triple-negative breast cancer after breast-conserving surgery and radiation

BACKGROUND

The results of radiation on the local control of triple receptor-negative breast cancer (negative estrogen [ER], progesterone [PR], and HER-2/neu receptors) was studied.

METHODS

Conservative surgery and radiation were used in 753 patients with T1-T2 breast cancer. Three groups were defined by receptor status: Group 1: ER or PR (+); Group 2: ER and PR (-) but HER-2 (+); and Group 3: triple-negative (TN). Factors analyzed were age, menopausal status, race, stage, tumor size, lymph node status, presentation, grade, extensive in situ disease, margins, and systemic therapy. The primary endpoint was 5-year locoregional recurrence (LRR) isolated or total with distant metastases.

RESULTS

ER- and PR-negative patients were statistically significantly more likely to be black, have T2 disease, have tumors detectable on both mammography and physical examination, have grade 3 tumors, and receive chemotherapy. There were no significant differences noted with regard to ER- and PR- patients by HER-2 status. There was a significant difference noted in rates of first distant metastases (3%, 12%, and 7% for Groups 1, 2, and 3, respectively; P = .009). However, the isolated 5-year LRR was not significantly different (2.3%, 4.6%, and 3.2%, respectively; P = .36) between the 3 groups.

CONCLUSIONS

Patients with TN breast cancer do not appear to be at a significantly increased risk for isolated LRR at 5 years and therefore remain appropriate candidates for breast conservation.

Allelic imbalances and homozygous deletion on 8p23.2 for stepwise progression of hepatocarcinogenesis

Early hepatocellular carcinoma (eHCC) originates from the hepatocytes of chronic liver disease and develops into classical hepatocellular carcinoma (HCC). To identify sequential genetic changes in multistep hepatocarcinogenesis, we analyzed molecular karyotypes using oligonucleotide genotyping 50K arrays. First, 1q21.3-44 gain and loss of heterozygosity (LOH) on 1p36.21-36.32 and 17p13.1-13.3 were frequently observed in eHCC, but not in chronic liver diseases, suggesting that such chromosomal aberrations are early, possibly causative events in liver cancer. Next, we detected 25 chromosomal loci associated with liver cancer progression in five HCCs with nodule-in-nodule appearance, in which the inner nodule develops within eHCC lesion. Using these chromosomal regions as independent variables, decision tree analysis was applied on 14 early and 25 overt HCCs, and extracted combination of chromosomal gains on 5q11.1-35.3 and 8q11.1-24.3 and LOH on 4q11-34.3 and 8p11.21-23.3 as distinctive attributes, which can classify early and overt HCCs recursively. In these four altered regions identified as late events of hepatocarcinogenesis, two tumors in 32 overt HCCs analyzed in the present study and one in a set of independent samples of 36 overt HCCs in our previous study harbored a homozygous deletion near the CSMD1 locus on 8p23.2. CSMD1 messenger RNA expression was decreased in HCC without 8p23.2 deletion, possibly due to hypermethylation of the CpG islands in its promoter region.

CONCLUSION

1q gain and 1p and 17p LOH are early molecular events, whereas gains in 5q and 8q and LOH on 4q and 8p only occur in advanced HCC, and inactivation of the putative suppressor gene, CSMD1, may be the key event in progression of liver cancer.

Breast-Conservative Surgery With Close or Positive Margins: Can the Breast Be Preserved With High-Dose-Rate Brachytherapy Boost?

PURPOSE

To evaluate the likelihood of preserving the breast in women who show close or positive margins after conservative surgery for early breast carcinoma.

METHODS AND MATERIALS

Since 1996, 125 women with less than 5 mm or positive margins and positive separate cavity margin sampling were entered in a prospective trial with high-dose radiotherapy. A standard dose of 50 Gy to the whole breast was followed by a high-dose-rate brachytherapy application delivering 3 fractions of 4.4 Gy in 24 hours. The median follow-up was 84 months.

RESULTS

There were only seven local recurrences, with an actuarial local control rate of 95.8% at 5 years and 91.1% at 9 years. Actuarial overall and cause-specific survival rates were 92.6% and 95% at 5 years and 86.7% and 90.4% at 9 years, respectively. Late fibrosis was the most common complication, in 30% of patients, with good or excellent cosmetic results in 77%. The final result was that 95.2% of breasts were preserved.

CONCLUSIONS

Close or positive-margin breast cancer can be well managed with a high-dose boost in a wide tumor bed by means of high-dose-rate brachytherapy. This technique can avoid mastectomy or poor cosmetic resection, with minimal risk of local or general failure.

MR mammography is useful in the preoperative locoregional staging of breast carcinomas with extensive intraductal component

PURPOSE

To determine the role of magnetic resonance (MR) mammography in detection and assessment of extent of tumors with extensive intraductal component (EIC+).

MATERIAL AND METHODS

In a prospective study, 233 consecutive women with a suspicious lesion underwent preoperative MR mammography and 209 invasive ductal carcinomas were detected. We studied the prediction of intraductal spread on mammography (MX), ultrasound (US) and MR. We compared the size of the total lesion on MX, US and MR and correlated it with histopathology. Enhancement patterns on MR were described.

RESULTS

Of 209 invasive ductal carcinomas, 50 were EIC+ (24%). MX predicted intraductal spread in EIC+ carcinomas in 48.5%, US in 34.2% and MR in 68%. Compared to MX and US, MR was best in assessment of total tumor size. On MR, ductal spread in EIC+ tumors presented as ductal or linear enhancement, long spicules, a regional enhancing area or nodules adjacent to a mass.

CONCLUSION

MR had the highest sensitivity to predict intraductal spread and was superior in assessing total tumor size.

Recurrence Rates and Analysis of Close or Positive Margins in Patients Treated Without Re-Excision Before Radiation for Breast Cancer

PURPOSE

This study examines the risk of local recurrence in a group of patients accepted for radiation therapy after breast-conserving surgery despite having a close or positive resection margin.

METHODS AND MATERIALS

Two hundred patients with early-stage breast cancer were treated by radiation with a nonnegative margin < or =2 mm from January 1974 to September 2001. The median age was 61 years. Margins were positive in 29% and close (< or =2 mm) in 71%. The median dose was 64 to 66 Gy. The median follow up was 5.9 years.

RESULTS

The number of resection margins close or positive was 1 in 73% of patients, 2 in 14%, 3 in 1%, and unknown in 12%. The margin location was 23% anterior, 24% posterior, 12% medial, 12% lateral, 17% superior, and 12% inferior. Reasons for not reexcising were advanced age/comorbidities in 7%, anterior location under skin in 25%, posterior location to muscle in 15%, focal involvement in 13%, no extensive intraductal component in 5%, surgeon refusal in 15%, and patient refusal in 20%. There was a strong association between an anterior or posterior margin location and the rationale of no additional breast tissue at the margin to reexcise before radiation. The risk of local recurrence at 5 and 10 years was 3% and 5%, respectively.

CONCLUSIONS

Further research of close and positive margins is needed to validate features identified in this series, particularly nonbreast tissue anatomic margins, that are associated with low risks of local recurrence after radiation.

Is mastectomy superior to breast-conserving treatment for young women?

PURPOSE

To examine whether modified radical mastectomy (MRM) improves outcomes compared with breast-conserving treatment (BCT) in young women.

METHODS AND MATERIALS

Women aged 20-49 years, diagnosed with early breast cancer between 1989 and 1998, were identified. Management with BCT or MRM was compared for local (L), locoregional (LR), and distant relapse-free survival (DRFS) and breast cancer-specific survival (BCSS) by age group (20-39 years, 40-49 years). The analysis was repeated for patients considered "ideal" candidates for BCT: tumor size < or =2 cm, pathologically negative axillary nodes, negative margins, and no reported ductal carcinoma in situ.

RESULTS

A total of 1,597 women received BCT, and 801 had MRM. After a median follow-up of 9.0 years, the outcomes (L, LR, BCSS) were worse for the younger age group; however, the outcomes were not statistically different by type of local treatment. For women aged 20-39 years considered "ideal" for BCT, those treated with BCT had slightly lower LRFS compared with those treated with MRM (p = 0.3), but DRFS and BCSS were similar.

CONCLUSIONS

A difference in LRFS at 10 years potentially favored MRM among women aged 20-39 years considered "ideal" BCT candidates but was not statistically significant and did not translate into a noticeable difference in DRFS or BCSS. Our data suggest that young age alone is not a contraindication to BCT.

Changes in surgical management resulting from case review at a breast cancer multidisciplinary tumor board

BACKGROUND

The treatment of breast cancer requires a multidisciplinary approach, and patients are often referred to a multidisciplinary cancer clinic. The purpose of the current study was to evaluate the impact of this approach on the surgical management of breast cancer.

METHODS

The medical records of 149 consecutive patients referred to a multidisciplinary breast cancer clinic over a 1-year period with a diagnosis of breast cancer were reviewed retrospectively for alterations in radiologic, pathologic, surgical, and medical interpretations and the effect that these alterations had on recommendations for surgical management.

RESULTS

A review of the imaging studies resulted in changes in interpretations in 67 of the 149 patients studied (45%). This resulted in a change in surgical management in 11% of patients. Review of the pathology resulted in changes in the interpretation for 43 of the 149 patients (29%). Thirteen patients (9%) had surgical management changes made solely as a result of pathologic reinterpretation. In 51 patients (34%), a change in surgical management was recommended after discussion with the surgeons, medical oncologists, and radiation oncologists that was not based on reinterpretation of the radiologic or pathologic findings. Overall, a second evaluation of patients referred to a multidisciplinary tumor board led to changes in the recommendations for surgical management in 77 of 149 of those patients studied (52%).

CONCLUSIONS

The changes in management stemmed from differences in mammographic interpretation, pathologic interpretation, and evaluation by medical and radiation oncologists and surgical breast specialists. Multidisciplinary review can provide patients with useful additional information when making difficult treatment decisions.

A Clinical Oncology Perspective on the Use of Breast MR

MR imaging of the breast detects additional carcinoma in as many as 30% of women thought to have localized disease by clinical examination and mammography. This has led some to advocate its routine use in the preoperative evaluation of breast cancer patients. However, local failure rates in patients selected for breast conservation by conventional methods are less than 5% at 10 years, suggesting that he majority of this disease is controlled with radiotherapy. The potential role of MR in the preoperative evaluation and postoperative follow-up of patients with early-stage breast cancer is discussed.

Placing the boost in breast-conservation radiotherapy: A review of the role, indications and techniques for breast-boost radiotherapy

Randomised trials have established that the addition of a boost dose of radiotherapy to the lumpectomy site after whole-breast adjuvant radiotherapy further improves local control achieved by whole-breast radiotherapy alone. The absolute size of this benefit varies according to the baseline risk of local recurrence. Age is the strongest predictor of benefit. Below the age of 40 years, the absolute benefit of a boost seems to be substantial, and there are no clearly identified groups unlikely to benefit. Above the age of 50 years, the benefit is small, and several additional risk factors for local failure would need to be present to merit boost treatment. These may include tumour size, high grade, high mitotic rate, lymphovascular invasion, extensive and high grade associated with intraduct carcinoma, receptor-positive tumours when avoidance of anti-oestrogen therapy is desired or receptor-negative tumours. Other independent reasonable indications for the use of a boost would be positive margins where further surgery is not indicated. If a boost is indicated, a variety of techniques may be used and toxicity and cosmetic results remain highly acceptable. Overall, there seems to be no substantial differences in boost technique results; however, interstitial techniques may have advantages for deeper targets compared with electrons. Irrespective of technique, accurate localisation will maximise the benefit of a boost. Surgical clips are strongly recommended to facilitate localisation.

Ipsilateral breast tumor recurrence (IBTR) after breast-conserving treatment for early breast cancer: risk factors and impact on distant metastases

BACKGROUND

The clinical features of ipsilateral breast tumor recurrence (IBTR) after breast conserving therapy (BCT) for early stage breast cancer were analyzed from long-term follow-up of BCT in Japan. The purpose of this study was to clarify risk factors of IBTR and the impact of IBTR on development of distant metastases in this ethnic group.

METHODS

Patients (N = 1901)with unilateral breast cancer < or = 3 cm in diameter who underwent BCT at 18 Japanese major breast cancer treatment institutes from 1986 to 1993 were registered in this study. Survival rates, the incidences of IBTR and distant metastases, and annual rates of IBTR and distant metastases after primary operation were calculated by the Kaplan-Meier method. A Cox proportional hazards model was used to estimate the risks of IBTR and distant metastases. A Cox model was also used to estimate the risks of distant metastases after IBTR in the group of IBTR.

RESULTS

At a median follow-up time of 107 months, the 10-year overall and disease-free survival rates were 83.9% and 77.8%, respectively. The 10-year cumulative rates of IBTR were 8.5% in the patients with postoperative irradiation and 17.2% in the patients without irradiation. The 10-year cumulative distant metastasis rate was 10.9%. On multivariate analysis, young age, positive surgical margin, and omission of radiation therapy were significant predictors of IBTR. In addition, IBTR significantly correlated with subsequent distant metastases (hazard ratio, 3.93; 95% confidence interval, 2.676-5.771; P < 0.0001). Among patients who developed IBTR, initial lymph node metastases and short interval to IBTR were significant risk factors for subsequent distant metastasis.

CONCLUSIONS

Young age, positive surgical margin, and omission of radiation therapy seemed to be important factors in relation to local control. The authors' results also indicated that IBTR is significantly associated with subsequent distant metastasis. Patients with positive nodal status at primary operation or with short interval from primary operation to IBTR are at especially high risk of distant metastasis. It remains unclear, however, whether IBTR is an indicator or a cause of subsequent distant metastases.

Factors increasing local recurrence in breast-conserving surgery

From 20-year follow-up results of two pioneering randomized controlled trials demonstrating equal survival after mastectomy and breast-conservation therapy, recent high-quality, evidence-based clinical practice recommendations have been made. Breast-conservation therapy undoubtedly represents substantial progress for a better quality of life for women with early-stage breast cancer. However, lumpectomy is associated with a substantial proportion, approximately 10-20%, of local recurrence in long-term follow-up studies even after accounting for postoperative radiotherapy. Risk factors for local failure include margin status, young age and an extensive intraductal component. Young age and family history strongly suggest the need for genetic testing before initiation of treatment. Women with BRCA1 or BRCA2 mutations should be informed about the increased risk of contralateral breast cancer and ipsilateral failure after breast-conservation therapy. Bilateral mastectomy should also be offered as a treatment option. There is controversy over whether current effective adjuvant treatment, including chemotherapy and endocrine therapy, beyond appropriate local treatment as surgery and radiotherapy, can improve local control. Instead of debate over whether an ipsilateral tumor after breast-conservation therapy is local recurrence or a new primary cancer by analyzing conflicting data lacking strong evidence, efforts should be focused on reducing this risk irrespective of origin. Selecting women for breast-conservation therapy and achieving margin control can reduce ipsilateral failures.

Improving the quality of patient care using reliability measures: a classification tree approach

This paper considers the application and interpretation of new reliability measures for a classification tree-based medical risk assessment tool. Following the construction of a classification tree reliability measures may then be used to provide an estimate of the precision of the classification and the probability in each terminal node of the classification tree. Identification of unreliable nodes (those that have low precision) in this application may indicate patient groups requiring closer monitoring or scenarios in which further information about the patient is required, thereby providing medical practitioners with an avenue for more informed decision making.

Randomized Trials of Breast-Conserving Therapy Versus Mastectomy for Primary Breast Cancer

We have undertaken a pooled analysis of the 6 major randomized trials comparing mastectomy (MT) and breast-conserving therapy (BCT) in the treatment of primary breast cancer. Specifically, these trials compared the 2 most widely used options in local treatment: mastectomy and axillary dissection (MT) versus breast-conserving surgery, axillary dissection, and breast radiotherapy (BCT). The early results of these 6 trials formed the basis for a 1990 National Institutes of Health Consensus statement. However, most of these trials have recently published long-term follow-up results, and this pooled analysis incorporates the updated results of these 6 trials. For each of these trials, the observed number of treatment events was compared with that expected under the null hypothesis, given the number of patients per arm and the total number of events. Approximate odds ratios were computed using the observed and expected number of events, and the variance of the observed number of events. These were then pooled across trials to give overall odds ratios for the risk of locoregional recurrence, total recurrence, and death. Four of the 6 trials show that MT significantly reduces the risk of locoregional recurrence when compared with BCT, and the pooled odds ratio also shows a significant benefit for MT (odds ratio [OR], 1.561; 95% confidence interval [CI], 1.289-1.890; P < 0.001). However, only 1 trial shows a statistically significant benefit for MT in reducing mortality, and the pooled odds ratio shows no significant difference between MT and BCT (OR, 1.070; 95% CI, 0.935-1.224; P = 0.33). This pooled analysis confirms that MT and BCT have comparable effects on mortality, even after long-term follow up. However, BCT is associated with a significantly greater risk of locoregional recurrence.

Predictors of local recurrence after breast-conservation therapy

Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.

Solving the dilemma of the immunohistochemical and other methods used for scoring estrogen receptor and progesterone receptor in patients with invasive breast carcinoma

BACKGROUND

The authors attempted to resolve the dilemma posed by the lack of unanimity concerning the optimal immunohistochemical (IHC) method for determining and scoring estrogen receptor (ER) and progesterone receptor (PR).

METHODS

Sections for IHC were prepared from paraffin embedded tumor samples from 402 patients with lymph node positive breast carcinoma who had biochemical receptor values (obtained with the dextran-coated charcoal [DCC] method) and who were enrolled in a prospective, randomized trial (National Surgical Adjuvant Breast and Bowel Project protocol B-09). IHC receptors were scored independently by two observers according to percent, intensity, and any-or-none algorithms. Results from these evaluations and from two computer-assisted evaluations, DCC, and common pathologic characteristics were analyzed for optimum splits for positive reactions in univariate and multivariate analyses using a tree-structured model. Concordance, sensitivity, and specificity were determined between the DCC method and all other methods.

RESULTS

Interobserver agreement and concordance between the DCC method and the other methods and among the methods were high. Univariate analyses revealed that a positive ER score obtained with all methods was related significantly to overall survival (OS) at 5 years and at 10 years. Results related to PR scores and disease-free survival and recurrence-free survival were less consistent. In multivariate analysis, it also was found that all methods for scoring ER predicted a better prognosis for OS in patients with an unfavorable lymph node status at 5 years and 10 years. Patients in a favorable lymph node status group were discriminated further by nuclear grade.

CONCLUSIONS

All IHC methods for scoring ER appeared valid as prognostic indicators of OS in patients with positive lymph nodes. The any-or-none IHC method, by virtue of its simplicity, represents an appropriate choice for practical use.

Improving local control with breast-conserving therapy

BACKGROUND

The risk of ipsilateral breast tumor recurrence (IBTR) after breast-conserving therapy (BCT) is associated with treatment and tumor-related variables, such as surgical margin status and the use of systemic therapy, and these variables have changed over time. Correspondingly, the authors of the current study hypothesized that the contemporary multidisciplinary management of breast carcinoma would lead to an improvement in IBTR rates after BCT.

METHODS

Between 1970 and 1996, 1355 patients with pathologic Stage I-II invasive breast carcinoma underwent BCT (breast-conserving surgery and adjuvant radiation therapy) at The University of Texas M. D. Anderson Cancer Center. Contemporary methods of analyzing surgical margins were in routine use by 1994. To analyze the effect of this variable and others, patient and tumor characteristics and IBTR rates in patients treated during 1994-1996 were compared with those in patients treated from 1970 to 1993.

RESULTS

Characteristics were similar in patients treated during 1994-1996 (n = 381) and those treated before 1994 (n = 974) except for patients aged >50 years (63.3% vs. 51.7%, P < 0.001), and patients who had a family history of breast carcinoma (37.9% vs. 30.8%, P = 0.017). Patients treated after 1994 were less likely to have positive or unknown margins (2.9 % vs. 24.1 %, P = 0.0001), more likely to receive chemotherapy (40.5% vs. 26%, P < 0.001), and more likely to receive hormonal therapy (33.3% vs. 19.4%, P < 0.001), but less likely to receive radiation boosts to the primary tumor bed (59.8% vs. 89%, P < 0.001). The 5-year cumulative IBTR rate was significantly lower among patients treated in 1994-1996 than among patients treated before 1994 (1.3% vs. 5.7%, P = 0.001) largely because of the drop in IBTR rates among patients aged < or = 50 years (1.4 % vs. 9.1 %, P = 0.0001). On multivariate analysis, age > 50 (hazards ratio [HR] = 0.401; P = 0.0001), presence of negative surgical margins (HR = 0.574; P = 0.017), and use of adjuvant hormonal therapy (HR = 0.402; P = 0.05) were independent predictors of improved 5-year IBTR-free survival. On subgroup analysis, use of chemotherapy was associated with increased IBTR-free survival among women aged < or = 50 years (HR = 0.383; P = 0.001). Although 5-year cumulative IBTR rates were lower among women aged > 50 years than among younger women before 1994 (2.6 % vs. 9.1%, P < 0.0001), no such difference was found in the group treated in 1994-1996 (1.2 % for age > 50 yrs vs. 1.4 % for < or = 50 yrs, P = 0.999).

CONCLUSIONS

The IBTR rate after BCT appears to be declining, especially among patients < 50 years of age. However, long-term follow-up is necessary to confirm this finding. This finding may reflect changes in surgical approaches and pathologic evaluation as well as an increased use of systemic therapy. The current low incidence of IBTR with multidisciplinary management of breast carcinoma may result in more patients choosing BCT over mastectomy.

Selection criteria for accelerated partial-breast irradiation: impact on applicability

This study examines the potential applicability of accelerated partial-breast irradiation (APBI) based on clinical and pathologic selection criteria in patients with stage I/II breast cancer. The records of 535 patients treated with breast-conserving surgery and radiation were reviewed. The patient database was analyzed for the following factors: age, extensive intraductal carcinoma (EIC), lymphovascular invasion (LVI), margin status, histologic type, pathologic nodal status, and pathologic tumor size. Two hundred seventeen records were located. The minimal selection criteria for APBI were assumed to include patient age of >/= 45 years, nonlobular histology, negative margins (> 2 mm), absence of EIC, and node-negative status. The potential variations in selection criteria for age, tumor size, and LVI were investigated with regard to the proportion of patients who would be eligible for APBI. In addition, predictors for true versus diffuse recurrence were examined among 40 patients who had a local recurrence. Using variable patient age cutoffs and T2 tumors as well as LVI, 9%-47% of patients could have been considered for APBI in this study. Using an age cutoff of >/= 65 years, 9%-15% of patients could have been eligible for APBI. However, using an age cutoff of >/=45 years, 28%-47% might be eligible, with the consideration of LVI becoming important. Among 40 local recurrences, 12 occurred at the primary site; 15 occurred elsewhere, diffusely, or with dermal involvement; and the locations of 13 could not be determined. Extensive intraductal carcinoma was the only significant predictor for recurrence at the primary site (P = 0.01). The potential impact of APBI on breast radiation therapy practice needs to be further delineated, and appropriate selection criteria should be refined.

Tamoxifen with or without breast irradiation in women 50 years of age or older with early breast cancer

BACKGROUND

We determined the effect of breast irradiation plus tamoxifen on disease-free survival and local relapse in women 50 years of age or older who had T1 or T2 node-negative breast cancer.

METHODS

Between December 1992 and June 2000, 769 women with early breast cancer (tumor diameter, 5 cm or less) were randomly assigned to receive breast irradiation plus tamoxifen (386 women) or tamoxifen alone (383 women). The median follow-up was 5.6 years.

RESULTS

The rate of local relapse at five years was 7.7 percent in the tamoxifen group and 0.6 percent in the group given tamoxifen plus irradiation (hazard ratio, 8.3; 95 percent confidence interval, 3.3 to 21.2; P<0.001), with corresponding five-year disease-free survival rates of 84 percent and 91 percent (P=0.004). A planned subgroup analysis of 611 women with T1, receptor-positive tumors indicated a benefit from radiotherapy (five-year rates of local relapse, 0.4 percent with tamoxifen plus radiotherapy and 5.9 percent with tamoxifen alone; P<0.001). Overall, there was a significant difference in the rate of axillary relapse at five years (2.5 percent in the tamoxifen group and 0.5 percent in the group given tamoxifen plus irradiation, P=0.049), but no significant difference in the rates of distant relapse or overall survival.

CONCLUSIONS

As compared with tamoxifen alone, radiotherapy plus tamoxifen significantly reduces the risk of breast and axillary recurrence after lumpectomy in women with small, node-negative, hormone-receptor-positive breast cancers.

The effect of delaying radiation therapy for systemic chemotherapy on local-regional control in breast cancer

BACKGROUND

It remains controversial as to whether the administration of chemotherapy prior to radiation following the surgical treatment for localized breast cancer compromises local control.

METHODS

The outcome of 290 patients who received chemotherapy prior to breast or chest wall irradiation following curative breast cancer surgery was retrospectively analyzed to determine if delaying radiation from the time of surgery adversely affects local-regional control. The patients were divided into three groups according to the time interval from definitive surgery to the start of radiation: group 1, < 5 months; group 2, 5 to < 7 months, and group 3, 7+ months. Local-regional and distant failure events were analyzed according to the time delay from surgery to radiation.

RESULTS

The median follow-up was 6.0 years (range, 7 months to 15 years). Loco-regional failure was observed in 22 patients, 18 of which occurred within the original radiation fields. There was no significant adverse effect on local control or distant failure from delaying radiation for systemic chemotherapy. Univariate and multivariate analyses revealed that positive margins after surgery were associated with increased local recurrence.

CONCLUSION

Delaying radiation therapy for greater than 7 months, in order to administer chemotherapy following curative breast cancer surgery, does not compromise local control. However, positive margins were significantly associated with higher rates of local failure and even an increase in radiation boost dose was not able to fully counteract the increased risk of local failure.

Breast conservation in breast cancer: surgical and adjuvant considerations

PURPOSE OF REVIEW

Breast-conserving surgery is accepted as an alternative to mastectomy for the treatment of early breast cancer. This paper reviews the recent contributions to the literature, with special emphasis on breast-conserving surgery in the management of invasive breast cancer.

RECENT FINDINGS

Long-term follow-up of randomized trials confirms that in women with early stage breast cancer, breast-conserving surgery achieves similar survival compared with mastectomy. Increase in early breast cancer detection, and efforts in patient and physician education are likely to enhance breast-conserving surgery use. Patients with locally advanced tumors may also become eligible for breast-conserving surgery after tumor downsizing with preoperative chemotherapy, with acceptable rates of ipsilateral breast tumor recurrence. Efforts should be made to minimize the risk of ipsilateral breast tumor recurrences after breast-conserving surgery as they have been associated with worse distant-disease-free and breast cancer-specific survival rates. One of the most effective strategies to minimize ipsilateral breast tumor recurrence risk is to ensure negative surgical margins. This necessitates careful surgical planning, tumor localization, precise surgical technique and careful pathological processing. Radiation therapy is also a critical therapeutic tool to minimize the risk. Although the standard of care has been whole-breast irradiation, preliminary results with accelerated partial breast irradiation are promising. Adjuvant systemic therapy can further reduce the risk of ipsilateral breast tumor recurrence, but it cannot replace adequate surgery and radiation therapy for achieving local control after breast-conserving surgery.

SUMMARY

Breast-conserving surgery is confirmed to be appropriate therapy for patients with early stage breast cancer. Increasing numbers of patients are likely to be eligible for surgery in the future. Strategies to minimize the risk of ipsilateral breast tumor recurrence while enhancing the convenience of breast-conserving surgery need to be pursued.

Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial

BACKGROUND

Between 1979-1987, the National Cancer Institute conducted a randomized, prospective study of mastectomy (MT) versus breast conservation therapy (BCT) in the treatment of patients with early-stage breast carcinoma. After a median potential follow-up of 18.4 years, the authors present the updated results.

METHODS

After informed consent was obtained from each patient, 237 evaluable women with clinical AJCC Stage I and Stage II breast carcinoma were enrolled on an institutionally reviewed protocol and randomly assigned to undergo modified radical MT (116 patients) or BCT (121 patients), which was comprised of lumpectomy, axillary lymph node dissection, and radiation therapy. Negative surgical margins in the lumpectomy arm were not required. The 237 randomized patients were followed for a median potential follow-up of 18.4 years. The primary endpoints were overall survival and disease-free survival.

RESULTS

At a median follow-up of 18.4 years, there was no detectable difference with regard to overall survival between patients treated with MT and those treated with BCT (58% vs. 54%; P = 0.67 overall). Twenty-seven women in the BCT arm (22%) experienced an in-breast event. After censoring in-breast events in the BCT arm that were salvaged successfully by MT, disease-free survival also was found to be statistically similar (67% in the MT arm vs. 63% in the BCT arm; P = 0.64 overall). There was no statistically significant difference with regard to contralateral breast carcinoma between the two treatment arms (P = 0.70).

CONCLUSIONS

After nearly 20 years of follow-up, there was no detectable difference in overall survival or disease-free survival in patients with early-stage breast carcinoma who were treated with MT compared with those treated with BCT. For BCT patients, long-term in-breast failures continued to occur throughout the duration of follow-up. There was no statistically significant difference in the incidence of contralateral breast carcinoma between the two treatment groups.