Axillary Lymph Node Metastases from Occult Carcinoma of the Breast

From the case records of the Istituto Nazionale Tumori of Milan from 1956 to 1976, 49 cases of metastases in axillary lymph nodes from an occult carcinoma of the breast were selected. Forty-four patients underwent removal of the suspicious breast. In 11 patients no tumor was found at the pathologic examination. The survival of these patients was no different from the survival of those in whom the tumor was found. The 5-year survival of the total series was 87%, confirming that this type of presentation of breast cancer has a prognosis that is better than that generally reported for stage II carcinoma of the breast.

Combination Chemiotherapy with 5-(3,3 dimethyl-1-triazeno) imidazole-4-carboxamide (DTIC; NSC-45388), 1,3-bis (2-chloroethyl)-1-nitrosourea (BCNU; NSC-409962) and Vincristine (VCR; NSC - 67574) in Metastatic Malignant Melanoma

The toxic and therapeutic effects obtained with a triple drug combination (BCNU, DTIC and VCR) administered in a cyclic fashion to 41 unselected evaluable patients with metastatic malignant melanoma are reported. Side effects were moderate and reversible. The overall regression rate was 44% without difference between males and females. Partial remission (> 50%) plus complete remission was 19.5% with an average duration of 5.1 months (1–20+). With the exclusion of bone lesions, all types of metastases showed regression especially those located in the soft tissues (lymph nodes and skin). The actuarial analysis of survival shows that responders live twice as long as non responders (median survival 12 months versus 6 months). However, the superior therapeutic efficacy of BCNU + DTIC + VCR over DTIC alone in metastatic melanoma remains to be demonstrated. A controlled study with different triple combinations is now in progress.

Chemoprevention Trial of Contralateral Breast Cancer with Fenretinide. Rationale, Design, Methodology, Organization, Data Management, Statistics and Accrual

The Fenretinide (4-HPR) Breast Cancer Study is a randomized multicenter clinical trial originally designed and conducted by the investigators of the Istituto Nazionale Tumori of Milan. The study is sponsored by the National Cancer Institute of Bethesda and by the Italian National Research Council. The trial was designed to evaluate the effectiveness of the synthetic retinoid 4-HPR, at a dose of 200 mg per os every day for 5 years, in reducing the incidence of contralateral breast cancer in a population of patients previously operated on for breast cancer. Between 1987 and 1993, the Istituto Nazionale Tumori of Milan and 9 other collaborating Centers enrolled 2,972 women between the ages of 30 and 70 years who had been previously operated on for T1-T2 N- M0 breast cancer. This paper describes the rationale, design, methodology, organization, data management, statistics and accrual of the participating population.

Results of Preoperative Radiotherapy in T-3 Mammary Carcinoma

Between 1958 and 1966, 184 patients with T-3 mammary carcinoma were subjected to preoperative radiotherapy and 113 (61.4 %) subsequently underwent mastectomy. Sterilisation of the mammary tumor was achieved in about a quarter of the cases but the efficacy of radiotherapy on the lymphnode metastases was mach lower. Long-term survival was no better in these patients than in T-3 breast cancer cases subjected to mastectomy without radiotherapy before 1958. The frequency of recurrences and of new local manifestations was not significantly different either. It is concluded that preoperative radiotherapy with conventional X-rays does not improve the prognosis of T-3 breast cancer cases.

Chemoprevention of Breast Cancer with Fenretinide (4-HPR): Study of Long-Term Visual and Ophthalmologic Tolerability

Background

Fenretinide (4-HPR) is a synthetic retinoid being clinically tested in the chemoprevention of different tumors and precancerous lesions. Though safer than many other retinoids in experimental models, in humans 4-HPR may induce adverse effects that mainly affect the eye and visual function. Such effects are thought to be caused by the reduction of plasma retinol levels, which occurs after administration of the retinoid.

Methods

A series of 826 women treated with 4-HPR was studied to quantify the incidence and temporal pattern of occurrence of visual (dark adaptation) and ophthalmologic complaints (ocular dryness, lacrimation, conjunctivitis or photophobia) and to investigate the possible association between their occurrence and plasma retinol levels.

Results

The cumulative incidence of visual complaints reached nearly 20% at 5 years. The occurrence of these symptoms was more frequent at the start of treatment. The probability of developing visual complaints was significantly higher in patients with lower plasma retinol concentrations following 4-HPR treatment. The cumulative incidence of ophthalmologic complaints was 8% at 5 years. The occurrence of these complaints was evenly distributed during treatment. Ophthalmologic complaints were not associated with a greater degree of reduction of plasma retinol concentrations, but rather with the patient's age, since symptomatic patients were generally older than asymptomatic patients.

Conclusions

Visual and ophthalmologic complaints are common during 4-HPR treatment: their estimated 5-year cumulative incidence is close to 20% and 8%, respectively. However, the pattern of occurrence over time and the underlying mechanisms of these two types of complaints seem different.

Accrual Issues for Chemoprevention Trials: The Example of the 4-HPR Study for the Prevention of Contralateral Breast Cancer

This paper describes the accrual of the controlled clinical trial with fenretinide for the prevention of contraiateral breast cancer. Accrual screened 4,030 potentially eligible patients of whom 1,815 were randomized. Two strategies of recruitment were used, i.e. retrospective and prospective. In the retrospective accrual, the medical staff reviewed the records of breast cancer patients who had received curative surgery to select those who fulfilled the eligibility criteria of the study. For the prospective recruitment operated, patients were contacted after the beginning of the trial. The study started in March 1987 and accrual closed on July 31,1993. The planned accrual period was extended by 19 months. The yearly accrual tended to decrease with time. This was mainly due to the end of the retrospective recruitment and to the introduction of adjuvant chemotherapy, a reason for exclusion from the trial, also for patients with negative axillary nodes. The known accrual difficulties of chemoprevention studies proved also to be true for the high-risk population of this trial.

Breast Cancer in Childhood

A case of breast cancer in a 8-year old girl is described, and 23 cases of breast cancer in children previously reported in the literature are analysed. The principal characteristics of breast cancer in children, unlike breast cancer in adults, seem to be a better prognosis, not depending on the surgical procedure (excision, simple mastectomy or radical mastectomy) and the frequent secretive appearance of the neoplasm, always of ductal origin.

Patterns of Relapse and Survival in Operable Breast Carcinoma with Positive and Negative Axillary Nodes

The medical records of 716 consecutive patients with infiltrating mammary carcinoma and treated during a 4-year period (January 1964-January 1968) were reviewed. Patients were randomized between conventional radical or extended radical mastectomy. No postoperative radiotherapy or other specific treatments were given without documented evidence of recurrence. The intent of this retrospective analysis was to identify, on a clinical basis, the high-risk groups that could be candidates for systemic adjuvant treatment. The most reliable prognostic discriminant was found to be the histological status of axillary lymph nodes. The 10-year relapse rate for patients with negative axillary nodes (N−) was 27.9 % compared to 75.5 % for patients with positive axillary nodes (N+). The corresponding 10-year survival rates were 81.9 % and 39.6 %, respectively. The number of involved nodes was also of particular prognostic importance (relapse rates at 10 years: 1 to 3 nodes, 66.5 %; more than 3 nodes, 83.6 %; survival rates: 53.7 % and 25.6 %, respectively). Other clinical variables (location of primary tumor and menopausal status) failed to significantly affect the results of mastectomy, except for the extent of primary tumor in N+ patients. In this subgroup, relapse and survival rates were directly proportional to tumor size. In both groups, the highest incidence of recurrence was detected in distant organs and tissues, and it progressively increased with time. In contrast, 77.3 % of all local-regional recurrences were documented during the first three years from radical surgery.

A Case of Postmastectomy Lymphangiosarcoma

A case of postmastectomy lymphangiosarcoma of the arm, arising 13 years after the operation, is described. A singular character of the case was the absence of lymphedema in the affected arm.

Malignant Mesenchymal Tumors of the Thyroid

16 cases of malignant mesenchymal tumors of the thyroid (7 polymorphous sarcomas, 3 hemangioendotheliomas, 3 reticulum cell sarcomas, 4 fibrosarcomas) observed at the National Cancer Institute, Milan, between 1938 and 1968 are presented. They account for 3.3% of all malignant thyroid tumors during that period. More frequent after the age of 50, the cases reported showed marked malignancy and a rapidly fatal course. Only 2 cases of fibrosarcoma, one in a 15-year old boy and the other in a 35-year old man, were clinically cured 13 and 16 years respectively after radiosurgical treatment.

Clinical Staging and Treatment of Lymphosarcoma and Reticulum Cell Sarcoma

The Committee for the Study of Malignant Lymphomas of the National Cancer Institute of Milano in cooperation with the Institute of Radiology, University of Milano presents a new clinical classification for lymphosarcoma and reticulum cell sarcoma as well as the method of treatment adopted in these Institutes. For primary lymph node lesions the staging is identical to that already proposed for Hodgkin's disease. Stage I: disease limited to a single peripheric lymphatic region. Within this stage two groups can he distinguished: a) involvement of one single lymph node or few nodes limited to a small area of the region (unifocal lesions); b) involvement of many nodes spread throughout the region (uniregional lesions). Stage II: disease limited to two contiguous peripheric lymphatic regions, or to few deep nodes (mediastinal, retroperitoneal). Stage III: disease limited to two non contiguous peripheric lymphatic regions, or to many peripheric and/or deep (mediastinal, retroperitoneal) regions, provided the involvement is either above or below the diaphragm. Stage IV: generalized disease with involvement of lymph nodes above and below the diaphragm, or involvement of one or more lymphatic regions with concomitant involvement of visceral organs, bones, marrow, nervous system and skin. For primary pharyngeal lesions the T.N.M. nomenclature has been adopted. T1: unifocal lesion (e.g. nasopharynx, tonsil, uvula); T2: multifocal lesions (e. g. nasopharynx and tonsil, tonsils, tonsil and base of the tongue); T3: unifocal lesion with extension beyond the anatomical confine of the site of origin (e. g. base of the skull, paranasal sinuses, jaw, orbit); T4: multifocal lesions with extension beyond the anatomical confine of the site of origin. N0: no adenopathy; N1: ipsilateral contiguous adenopathy (submental and/or cervical); N2: bilateral contiguous adenopathy; N3: bilateral contiguous and/or supravicular adenopathy (unilateral or bilateral); N4: distant adenopathy. M–-: absence of metastases; M+: presence of metastases (visceral, osseous, nervous, cutaneous). The remaining primary extranodal lesions (visceral, osseous, cutaneous, etc.) are classified as local, regional and diffuse. Systemic symptoms and signs (fatigue, fever, night sweats, more than 10% weight loss, itching, anemia, leukocytosis, lymphocytopenia, high erythrosedimentation rate) must be recorded in each case to evaluate prognosis and proper treatment but are not important for staging the disease. In all stages with primary lymph node lesions endolymphatic radiotherapy with Lipiodol F I131 is indicated (10 ml in each foot with 2–5 mc/ml giving a tissue-dose of 15-20,000 rads). This is considered as radical as well as prophylactic treatment for those lymph nodes adequatelly filled with the contrast medium. In case of non filling or incomplete filling of part of the lymph node chains, treatment will be completed with external radiation therapy. Stage I and II are treated with radical radiation therapy. No prophylactic radiotherapy is given. If systemic symptoms and signs are still present after radiotherapy a course with anticancer drugs will be administered. Radiation therapy is given with high voltage or Co60 units. In radical treatments tumor doses of at least 3,000 rads within 3–4 weeks are administered to all involved lymphatic regions. In stage III radical radiotherapy follows a course of chemotherapy. In stage IV chemotherapy is the treatment of choice. Palliative radiotherapy is given to any bulk of tumors, wherever the location, when specific symptoms can be attributed to the masses. For primary pharyngeal lesions the primary focus (T1, T2, T3, T4) is always treated with radical radiation therapy (Co60 unit) which includes in the whole Waldeyer's ring. Prophylactic radiotherapy (Co60 unit with doses not less than 3,000 rads in 3–4 weeks) is given in N0 to the ipsilateral and in N1 to the contralateral submental and cervical lymphatic regions. In N1 and N2 the lymph node bearing areas are given radical radiation therapy. In N3 are irradiated prophylactically also the contralateral submental, cervical and supraclavicular lymphatic regions if clinically free of disease. Endolymphatic radiotherapy is performed only in T1 T2 T3 T4, N3 N4, M–- or M+ cases; otherwise diagnostic lymphangiography is performed and when pathologic nodes are present or suspected they are irradiated with Co60. Chemotherapy is given after the course of radiotherapy in N2 cases only if radical treatment has not been accomplished, while is always administered in combination with radical radiotherapy in N3 cases, and is considered the treatment of choice with palliative radiation therapy in N4 and M+ cases. The drug of choice is methyl-bis-(β-chloro-ethyl)-amine HCl (HN2) 0.4 mg/kg i.v. (single dose) for those patients who did not receive any previous course of chemotherapy. Otherwise, as well as during the course of the disease and in maintenance therapy, other polyfunctional alkylating agents, but chiefly chlorambucil (0.1–0.2 mg/kg/die, p. o.), vinblastine (0.10–0.15 mg/kg/week, i.v.), alone or every two weeks in combination with small daily doses of chlorambucil (5 mg/die, p. o.), methylhydrazine, hydroxyurea, and corticosteroids will be administered according to each clinical situation. Relapses in oropharynx can be treated with intraarterial infusions of amethopterine, vinblastine and cyclophosphamide. Radical surgery followed by a course of radiotherapy is reserved for primary lymphatic involvement only in specially selected patients in Stage I with unifocal lesions. Primary involvement of stomach, small bowel and colon is treated by surgical extirpation and radiotherapy. Splenectomy, lobectomy or pneumonectomy is indicated when these viscus are the only site of involvement. During pregnancy radiation therapy is not administered below the diaphragm and chemotherapy is not given during the first 4 months. The need for one internationally accepted clinical classification for lymphosarcoma and reticulum cell sarcoma is stressed.

Oophorectomy for Advanced Breast Cancer

A series of 168 cases of bilateral oophorectomy in patients with advanced breast cancer operated on during the 4 years 1962-65 at the National Cancer Institute of Milan is studied. There was no criterion of selection apart from the limit of 5 years after menopause; indeed, only 3 patients exceeded that limit. Post-operative mortality (5 cases) was 3%. The clinical success rate was 31.9% (52 cases) with a mean regression period of 13 months 10 days and a mean survival of 20 ½ months. The subjective successes numbered 25 with a mean period of wellbeing of 9 months 6 days and a mean survival of 16 months. The mean survival of the 87 patients who did not benefit from oophorectomy was 6 months 10 days. The success rate has been studied with reference to the chronological and physiological age of the patients, the duration of the free interval, tumor stage at first examination, site and distribution of metastases, cancer familiarity, the degree of estrogenic stimulation according to the karyo-pyknotic index, duration of menstrual life, parity, lactation and any previous hormonal therapy. The results obtained may be summarised as follows: 1) oophorectomy yields a clinical success rate of around 40% in patients who fit at least one of the following conditions: premenopausal women of over 35 or women in menopause for under a year; free interval of over two years; lesions confined to the soft tissues or to the skeleton or the presence of only nodular metastases in the lungs; a high degree of estrogenic stimulation, menstrual life exceeding 35 years; and primiparity; 2) the following are adverse conditions: age under 35; state of menopause exceeding a year; free interval of under two years; presence of pleuropulmonary lymphangitic metastases or of several groups of metastases; low degree of estrogenic stimulation; menstrual life of under 35 years; numerous pregnancies with subsequent lactation, and failure of hormonal therapy; 3) the operation is contraindicated, because never or hardly ever successful, in women in menopause for over a year without signs of estrogenic stimulation, in patients with extensive hepatic metastases and in those with cerebral metastases; 4) cancer familiarity, generic or specific, tumor stage at the time of surgical or of primary radiotheraphy and the presence or absence of ovarian metastases have no influence upon the results of ovariectomy. Oophorectomy is not only the first-line treatment for advanced carcinoma of the breast in patients in premenopause and in menopause for under a year but it is also a sound criterion for secondary treatment, since, as a rule, only patients who have responded to oophorectomy benefit (over 60% of these cases) from further endocrine theraphy, whether additive or ablative.

A Case of Laterocervical Ectopic Thyroid

A case of a woman 31 years old, with ectopic thyroid tissue located in the lateral side of the neck is reported. The thyroid tissue, 2 x 3 cm in size, was 8 cm far from the thyroid border, was devoid of lymphatic tissue, and did not show radioiodine uptake. The metastatic character of the tissue was excluded. In this case, the ectopic laterocervical thyroid tissue was considered to originate as a peduncolate mass which was detached from the thyroid.

Adriamycin in Combination and in Combined Treatment Modalities

The paper reviews the current strategic approach of the Istituto Nazionale Tumori of Milan with adriamycin (ADM) in combination with other drugs as well as in combined treatment modalities for various neoplasias of adults and children. The preliminary results obtained during the past four years in malignant lymphomas, acute leukemias, carcinoma of the breast, and neuroblastoma are reported. With the exception of the group of malignant lymphomas treated with a quintuple drug regimen (MABOP), none of the patients admitted the different trials had received chemotherapy. Most studies were controlled with random allocation to two different combinations. Cross over was carried out on relapse. In advanced Hodgkin's disease, non-Hodgkin's lymphomas, mammary carcinoma, soft tissue sarcomas, embryonal carcinoma of testicle, ovarian carcinoma, and multiple myeloma the main purpose of the study was to develop two independent non cross resistant combinations to be used sequentially in subsequent trials. There is a preliminary evidence that this is being obtained in Hodgkin's disease (ABVD vs. MOPP), in non Hodgkin's lymphomas (ABP vs. CVP) and carcinoma of the breast (ADM + VCR vs. CMF). In the other groups the patients were too few to permit conclusions. In acute lymphoblastic leukemia, in the leukemic phase of non-Hodgkin's lymphomas as well as in the group of solid tumors of children, combination chemotherapy and combined treatment modalities were not designed in a controlled fashion. ADM was introduced in all treatments because of its definite activity when employed as a single agent in refractory disease. Few therapeutic results are as yet available since most studies were started in 1974. However, the remission rate observed in the limited group of acute leukemias treated with ADM + VCR + prednisone is worth noting. The wide spectrum of activity of ADM justifies its use in several protocols of combination chemotherapy and in combined treatment modalities. With both full and reduced regimens drug tolerance was good, and in practically all studies more than 80 % of the optimal dose of ADM could be administered. All trials were properly designed to avoid a total dose of ADM exceeding 550–600 mg/m2 since cardiomyopathy (reversible) was observed in 2 patients after 600 mg/m2.

Intranodular Treatment with BCG of Cutaneous and Subcutaneous Metastases of Malignant Melanoma

A fresh preparation of BCG (Istituto Vaccinogeno Antitubercolare, Milano) having a bacterial charge of 0.5 mg/ml was injected intranodularly in cutaneous and subcutaneous metastases of malignant melanoma of 22 patients. A total of 85 nodules were treated. Caseous necrosis was observed in 17 patients equal to 68 nodules. The side-effects were modest and cleared up in a short time. The results obtained were localized at the treated nodules, without giving rise to a therapeutic action on those not injcted. The evolution of the disease was not modified.

Solitary Plasmocytoma of the Thyroid

A case of a man 53 years old with a solitary plasmocytoma of the thyroid is described. The nodule was 5 x 7 cm in size, and did not show uptake of I131. No sistemic clinical and laboratory signes were present. The patient was treated with total thyroidectomy and postoperative telecobaltotherapy. The case is the seven described in the medical literature.

Evaluation of the Risk of Multiple Primaries in Malignant Cutaneous Melanoma

The evaluation of the risk of a second primary melanoma has been done on a series of 521 cases of malignant melanoma observed at the National Cancer Institute of Milan from September 1967 to December 1974. It has been found that a malignant melanoma patient is about 900 times more likely to have a second primary than an individual in the general population is likely to contract the disease. The risk is age and sex dependent.

Surgical Treatment of Intestinal Complications after Radiotherapy and Surgery for Malignant Lymphoma and Carcinoma of the Testis

The aim of this paper is the analysis of the complications occurred after surgical and radiological procedures, for staging and treatment of malignant lymphomas and testicular carcinoma with an evaluation of the possible efficacy of their surgical treatment. At the Istituto Nazionale dei Tumori of Milan during the period 1970-1976, 718 patients with malignant lymphomas were staged with laparosplenectomy; 444 of them received radiotherapy on the abdominal area. Laparosplenectomy was not performed on other 123 cases that were irradiated as well on the abdominal area. Retroperitoneal lymphadenectomy or explorative laparotomy were carried out in 98 patients with carcinoma of the testis and 46 of them received adjuvant radiotherapy; other 29 were irradiated without previous surgical procedures. After surgery alone morbidity and mortality rate were 2.7% and 0.73% respectively. The mortality/morbidity ratio was 26%. The incidence of complications after radiotherapy alone was 3.3%. No deaths followed the treatment. Combined treatment had a morbidity rate of 5.5% and mortality rate of 2%. The mortality/morbidity ratio was 37%. Complications were treated mainly by surgery: out of 50 interventions, 22 were intestinal resections. New secondary complications were however frequent (more than 50% after intestinal resection) especially in patients originally treated with laparosplenectomy or retroperitoneal dissection plus radiotherapy.

Proposal for a Clinical Classification of Liver Metastases

The lack of a worldwide-accepted classification of liver metastases makes it difficult to compare data on natural history and results from different treatments. The increasing interest in aggressive multimodal therapies for hepatic metastases prompted us to review the chief prognostic factors and the main published classifications in order to propose a new clinical classification, whose principal application concerns metastases from colorectal adenocarcinomas. Following the general rules of the TNM classification, liver metastases are classified by expressing with letters and numbers the parameters selected for their prognostic importance, clinical applicability and objectivity. H (hepatic) is the letter that indicates the liver is the site of metastasis. Synchronous metastases are indicated by H, metachronous by rH (r = recurrent). The extent of liver involvement is defined: H1, liver involvement less than 25%; H2, from 25 to 50%; H3, more than 50%. Site of metastases is defined by s (single), m (multiple to one surgical lobe), b (to both lobes), i (infiltration of important structures). The alteration of liver functions is indicated by F. The presence of cirrhosis is noted by C.

Intravenous Administration of BCG in Advanced Melanoma Patients

From June 1975 to August 1977, 19 patients with distant metastases of malignant melanoma of the skin that were no longer responsive to chemotherapy were treated with BCG given intravenously. A single dose of lyophilized Pasteur BCG ranging from 2×107 to to 3×108 viable units was given in 500 ml of saline infused in 5 to 6 h. Seven of the 16 evaluable patients benefited from treatment; 3 showed an objective regression of more than 50% of the original tumor volume, and 4 an arrest of tumor growth. The objective regressions lasted from 2 to 5 months, and 1 case had an arrest of tumor growth for 29 months. The regression rate was related to the BCG dosage: 2×108 viable units appears to be the dosage that gives severe but reversible toxicity and is able to induce objective regression. The most responsive lesions were skin and subcutaneous deposits (5 of 7) and lung metastases (1 of 4). Toxic effects seem to be related to the number of bacilli injected. In the group of 10 cases treated with less than 108 units, toxicity was modest: 4 patients had fever (up to 38.5 °C) that lasted a few days, and in 3 cases it was associated with shivering during the infusion period and weakness. One case only had vomiting and jaundice. Toxicity was severe in the 9 patients that were treated with a dosage higher than 108: patients had fever and weakness for at least 4 days and shivering during the infusion. Two had adrenal insufficiency and 7 had liver enlargement and jaundice with return to normality by day 21. In the whole series 8 patients had leucopenia and 5 thrombocytopenia for 2 to 3 days: only 1 patient required blood and platelet transfusion. No significant variations in immunoglobulin levels were observed. No variations of PPD or BCG skin tests were observed after treatment. Three patients expired; the first, treated with 6×107 units, had an intercurrent disease (autopsy showed a heart infarction); the second, treated with 1.8×108, showed a rapid growth of lung metastases and died 15 days after treatment; the death of the third patient was probably due to anaphylactic shock. All 3 patients had been previously treated with BCG, given by scarification or intranodular injection.

Thyroid Function in Patients with Cancer of the Breast

In 47 patients with operable cancer of the breast the thyroid activity has been studied with the following tests: a) radioactive iodine uptake, 3 and 24 hours after the administration of 50 μc of I131; b) conversion rate; c) hormonal index, i. e. the quantity of protein bound radioiodine in 1 liter of plasma, evaluated as a percentage of the administered dose. The thyroid function was studied immediately before Halstead operation as well as one, three, and twelve months later. From the data obtained it appears that a) breast cancer patients show a thyroid radioiodine uptake higher than the controls, either at the 3rd or at the 24th hour, b) after the removal of the breast, the uptake decreases, reaching normal values 12 months after the operation, c) the conversion rate does not show any difference from the controls either before or after the operation, d) the hormonal index is considerably higher than normal values before operation, and in spite of a lowering after radical mastectomy, it is still higher one year later. The data seem to show that breast cancer patients have a higher metabolic activity of the thyroid gland, without clinical signs of hyperthyroidism. After removal of the carcerous breast the thyroid activity slowly decreases. However, the conversion rate is not modified as compared to the control patients. Further confirmation of the present preliminary results should be obtained by a comparative evaluation of the results either in patients with other types of tumors, or in patients subjected to surgical procedures for non-tumorous lesions.

Stage I Melanoma of the Limbs. Immediate versus Delayed Node Dissection

553 patients with stage I malignant melanoma of the limbs entered a prospective randomized clinical trial carried out by the W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma from September 1967 to January 1974. 286 patients were submitted to wide excision of primary and node dissection at the time as appearance of regional lymph node metastases and 267 to wide excision and immediate node dissection. Survival was identical in the 2 groups. Different subsets of patients were evaluated to assess whether some groups of patients may benefit from immediate node dissection. As regards sex, females and a significantly higher survival rate than males (p < 0.05), but results were not improved by immediate node dissection. Maximum diameter and elevation of primary melanoma were significantly related to survival but also in these cases immediate node dissection did not achieve better results. 63 patients had an excisional biopsy of their melanoma within 4 weeks before final treatment. This procedure did not worsen survival and also in this case immediate node dissection did not improve survival. 273 cases were classified according to histologic type: survival of superficial spreading and nodular melanoma was not different at a statistically significant level after the 2 treatment modalities. 325 cases were considered classifiable according to Clark's levels, out of these 165 were submitted to immediate node dissection. Neither level III nor level IV cases showed higher survival rate after immediate node dissection. Maximum tumor thickness according to Breslow was evaluated in 338 cases: 188 were submitted to wide excision and immediate node dissection. In no clusters of thickness did the enlarged surgical procedure achieve better results. The authors conclude that there is good evidence that in stage I melanoma of the extremities delayed dissection is as effective as the immediate one in the control of the disease if the patient can be kept under strict clinical control. Immediate node dissection is advisable if the quarterly follow-up is not guaranteed, at least for melanomas thicker than 2 mm.

Breast conservation following neoadjuvant therapy for breast cancer in the modern era: Are we losing the opportunity?

The main rationale for neoadjuvant therapy for breast cancer is to provide effective systemic treatment while surgically down-staging the cancer. This down-staging was initially to convert inoperable patients to operable and later to increase rates of breast conservation in patients initially deemed mastectomy only candidates. Unexpectedly, in recent neoadjuvant trials lower rates of breast conservation have been observed than in past decades, despite remarkable advances in systemic therapies, which have increased pathologic complete response rates. These results point to factors aside from response and eligibility for breast conservation that may lead surgeons and/or patients to recommend and choose mastectomy. Here, we aim to examine the surgical benefits offered by the modern era neoadjuvant therapy and explore factors that have contributed to this decrease in breast conservation rates. If the main benefit of neoadjuvant therapy is to increase the opportunity for breast conservation, then our review suggests that to optimize less invasive surgical approaches, we will need to address both surgeon and patient-level variables and biases that may be limiting our ability to identify patients appropriate for less aggressive options. As an oncology community, we must be aware of the surgical overtreatment of breast cancer, especially in a time where systemic therapies have remarkably improved outcomes and responses.

Extensive Frozen Section Examination of Axillary Sentinel Nodes to Determine Selective Axillary Dissection

As experience accumulates on the use of sentinel node biopsy in breast cancer, it is becoming clear that the method can reliably predict the state of the axilla and thus be used to decide whether to perform complete axillary dissection. Ongoing controlled trials will soon provide definitive evidence on the latter point. The key issue regarding sentinel node biopsy is pathologic evaluation of the biopsied node, which should be done intraoperatively whenever possible. In our initial experience with a conventional intraoperative frozen section method, the false-negative rate was 19% compared to examination of permanent sections of the biopsied node. We therefore devised a new intraoperative method in which pairs of sections are obtained every 50 mm for the first 15 sections and every 100 mm for any remaining node, which essentially samples the entire node; the method takes about 40 minutes. Sentinel node metastases were found in 119 of 295 (40%) of T1N0 breast cancer patients examined by this new method. This high rate of positivity indicates that the new method is reliable. In all cases, metastases were identified on hematoxylin-eosin (HE)-stained sections, although in 4% of positive cases the HE sections were doubtful, and cytokeratin immunostaining on the adjacent section was useful for confirming malignancy. Of 295 patients, 8 (2.7%) had a negative sentinel node but another axillary node metastasis. In conclusion, we found that extensive intraoperative frozen section examination of sentinel nodes correctly predicts a metastasis-free sentinel node in 95.4% of cases (negative predictive value), it is therefore suitable for identifying patients in whom axillary dissection might be avoided. Immunocytochemical staining for cytokeratins or other epithelial markers may be helpful for reducing the risk of missing micrometastatic foci.

Risk factors associated with recurrence after nipple-sparing mastectomy for invasive and intraepithelial neoplasia

BACKGROUND

To identify risk factors of recurrence in a large series of patients with breast cancer who underwent a nipple-sparing mastectomy (NSM).

PATIENTS AND METHODS

Breast-related recurrences and local recurrences (LR) in the breast and the nipple areola complex (NAC) were studied. Cumulative incidences of events were estimated through competing risk analysis. Multivariate Cox regression models were also applied.

RESULTS

We identified 934 consecutive NSM patients during 2002-2007. Median follow-up was 50 months. In 772 invasive carcinoma patients, the rate of LR in the breast and in the NAC was 3.6% and 0.8%, respectively. In the 162 patients with intraepithelial neoplasia, the rate of LR in the breast and in the NAC was 4.9% and 2.9%, respectively. The significant risk factors of LR in the breast for the group A were grade, overexpression/amplification of HER2/neu and breast cancer molecular subtype Luminal B. In group B, the risk factors of LR in the breast and in the NAC were age (<45 years), absence of estrogen receptors, grade, HER2/neu overexpression and high Ki-67.

CONCLUSIONS

The LR rate after NSM in our series was low. Biological features of disease and young age should be taken into account when considering NSM in breast cancer patients.

Assessment of pulmonary fibrosis after radiotherapy (RT) in breast conserving surgery: comparison between conventional external beam RT (EBRT) and intraoperative RT with electrons (ELIOT)

The aim of this study was to assess the frequency and the grade of RT-induced pulmonary fibrosis in patients who underwent EBRT compared to patients who underwent ELIOT. One-hundred-seventy-eight patients enrolled in a prospective randomized phase III trial to compare the efficacy of ELIOT (a single dose of 21 Gy prescribed at the 90% isodose) versus EBRT (50 Gy to the whole breast plus a 10 Gy boost to the tumour bed), underwent a spiral 16-detector row Computed Tomography (CT) examination to assess RT-induced pulmonary fibrosis: 83 patients in the EBRT arm and 95 in the ELIOT arm. All patients (age range 48-75 years) were affected by unicentric infiltrating carcinoma of the breast with diameter < 2.5 cm. This study was approved by our Institutional Ethical Committee and informed consent was obtained from each patient. Two observers, blinded to patient's randomization, independently evaluated each CT examination and assigned a fibrosis score (Grades 0 to 3). Inter-observer agreement for the fibrosis score was evaluated and a consensus between observers was obtained. Differences in fibrosis score between the two arms were evaluated by Chi Square test and Odds Ratio (OR) with 95% Confidence Intervals (CI). Pulmonary fibrosis was diagnosed in 42 patients (23.6%): 38 (90%) were in the EBRT arm and 4 (10%) in the ELIOT arm (p < 0.0001); twenty-six of them were Grade 1 (one ELIOT), fifteen were Grade 2 (three ELIOT) and one was Grade 3. The post-radiotherapy risk in the EBRT arm to develop at least Grade 1 fibrosis was 19 times higher than in the ELIOT one (OR: 19.20; 95%CI: 6.46-57.14) and 6 times higher to develop at least Grade 2 (OR: 5.70; 95%CI: 1.56-20.76). In conclusion, CT detected pulmonary fibrosis in patients treated with ELIOT is significantly less frequent compared to patients treated with EBRT.

IART (Intra-Operative Avidination for Radionuclide Therapy) for accelerated radiotherapy in breast cancer patients. Technical aspects and preliminary results of a phase II study with 90Y-labelled biotin

BACKGROUND

Breast conserving surgery (BCS) plus external beam radiotherapy (EBRT) is considered the standard treatment for early breast cancer. We have investigated the possibility of irradiating the residual gland, using an innovative nuclear medicine approach named IART(®) (Intra-operative Avidination for Radionuclide Therapy).

AIM

The objective of this study was to determine the optimal dose of avidin with a fixed activity (3.7 GBq) of (90)Y-biotin, in order to provide a boost of 20 Gy, followed by EBRT to the whole breast (WB) at the reduced dose of 40 Gy. Local and systemic toxicity, patient's quality of life, including the cosmetic results after the combined treatment with IART(®) and EBRT, were assessed.

METHODS

After tumour excision, the surgeon injected native avidin diluted in 30 ml of saline solution into and around the tumour bed (see video). Patients received one of three avidin dose levels: 50 mg (10 pts), 100 mg (15 pts) and 150 mg (10 pts). Between 12 to 24 h after surgery, 3.7 GBq (90)Y-biotin spiked with 185 MBq (111)In-biotin was administered intravenously (i.v.). Whole body scans and SPECT images were performed up to 30 h post-injection for dosimetric purposes. WB-EBRT was administered four weeks after the IART(®) boost. Local toxicity and quality of life were evaluated.

RESULTS

Thirty-five patients were evaluated. No side effects were observed after avidin administration and (90)Y-biotin infusion. An avidin dose level of 100 mg resulted the most appropriate in order to deliver the required radiation dose (19.5 ± 4.0 Gy) to the surgical bed. At the end of IART(®), no local toxicity occurred and the overall cosmetic result was good. The tolerance to the reduced EBRT was also good. The highest grade of transient local toxicity was G3, which occurred in 3/32 pts following the completion of WB-EBRT. The combination of IART(®)+EBRT was well accepted by the patients, without any changes to their quality of life.

CONCLUSIONS

These preliminary results support the hypothesis that IART(®) may represent a valid approach to accelerated WB irradiation after BCS. We hope that this nuclear medicine technique will contribute to a better management of breast cancer patients.

Analysis of local and regional recurrences in breast cancer after conservative surgery

BACKGROUND

A minority of patients treated conservatively for breast cancer will develop local or regional recurrences. Our aim was to determine how their occurrence may be linked to the evolution of the disease.

PATIENTS AND METHODS

We analyzed 2784 women treated for early-stage breast cancer by quadrantectomy and whole-breast irradiation in a single institution. We evaluated the prognostic factors associated with local, regional and distant recurrences and the prognostic value of local and regional recurrences on systemic progression.

RESULTS

After a median follow-up of 72 months, we observed 33 local events, 35 regional events and 222 metastases or deaths as first events (5-year cumulative incidence 1.1%, 1.2% and 7.6%, respectively). Size, estrogen receptor status, Her2/Neu and Ki-67 were associated with all three types of events, while axillary status and vascular invasion were associated only with the occurrence of metastases or death. Young age increased the risk of local recurrence. Local and regional recurrences were associated with an increased risk of systemic progression: hazard ratios 2.5 [95% confidence interval (CI) 1.1-5.8] and 5.3 (95% CI 3.0-9.5), respectively.

CONCLUSIONS

Local and regional recurrences after breast-conserving surgery are rare events. They are markers of tumor aggressiveness and indicators of an increased likelihood of distant metastases.

Nipple sparing mastectomy with nipple areola intraoperative radiotherapy: one thousand and one cases of a five years experience at the European institute of oncology of Milan (EIO)

In order to reduce mutilation, nipple-areola complex (NAC) conservation can be proposed for the treatment of breast cancer when mastectomy is indicated. To reduce the risk of retro areolar recurrence, a novel radiosurgical treatment combining subcutaneous mastectomy with intraoperative radiotherapy (ELIOT) is proposed. One thousand and one nipple sparing mastectomies (NSM) were performed from March 2002 to November 2007 at the European institute of oncology (EIO), for invasive carcinoma in 82% of the patients and in situ carcinoma in 18%. Clinical complications, aesthetic results, oncological and psychological results were recorded. A comparison was performed between the 800 patients who received ELIOT and the 201 who underwent delayed one-shot radiotherapy on the days following the operation. The median follow up time was 20 months (range 1-69) for a follow up performed in 83% of the patients. The NAC necrosed totally in 35 cases (3.5%) and partially in 55 (5.5%) and was removed in 50 (5%). Twenty infections (2%) were observed and 43 (4.3%) prostheses removed. The median rate of the patients for global cosmetic result on a scale ranging from 0 (worst) to 10 (excellent) was 8. Evaluation by the surgeon in charge of the follow-up gave a similar result. Only 15% of the patients reported a partial sensitivity of the NAC. Of the fourteen (1.4%) local recurrences, ten occurred close to the tumour site, all far from the NAC corresponding to the field of radiation. No recurrences were observed in the NAC. In a group of patients characterized by a very close free margin under the areola, no local recurrence was observed. Overall, 36 cases of metastases and 4 deaths were observed. No significant outcome difference was observed between the 800 patients receiving intraoperative radiotherapy (ELIOT) and the 201 patients receiving delayed irradiation.

Unavoidable mastectomy for ipsilateral breast tumour recurrence after conservative surgery: patient outcome

BACKGROUND

In the case of ipsilateral breast tumour recurrence (IBTR) after breast-conserving surgery (BCS), a second conservative surgical approach maybe considered in some motivated patients whereas in others mastectomy is unavoidable.

PATIENTS AND METHODS

From 1997 to 2004, 282 patients presented at the European Institute of Oncology with an operable invasive IBTR after BCS. One hundred and sixty-one (57%) underwent a second conservative surgery, whereas 121 patients (43%) were given a mastectomy and represent the study population. We investigated the prognosis and determined predictive factors of outcome.

RESULTS

Median time from primary breast cancer to IBTR was 41 months (range 5-213). Recurrences were T2-T4 and/or multifocal in 83 cases (68.6%). With a median follow-up of 5 years after mastectomy, 5-year overall survival (OS) and disease-free survival (DFS) were 73.3% [95% confidence interval (CI) 65.0% to 81.6%] and 50.4% (95% CI 40.9% to 59.8%), respectively. At the multivariate analysis, early onset of IBTR, presence of vascular invasion and Ki67 >or=20 of the recurrent tumour were found to significantly affect both DFS and OS.

CONCLUSIONS

In women who need mastectomy for IBTR, early onset of the relapse, high proliferation index and presence of vascular invasion represent the worst prognostic factors.

Correlation between administered treatment and patient's living will

Respecting the wishes of an adequately informed patient should be a priority in any health structure. A patient with advanced or terminal cancer should be allowed to express their will during the most important phases of their illness. Unfortunately, this is seldom the case, and in general instructions regarding an individual’s medical care preferences, i.e., their ‘living will’, expressed when healthy, often change with the onset of a serious illness.

At the European Institute of Oncology (IEO), a clinical study is ongoing to verify whether, during clinical practice, the patient is adequately informed to sign an ‘informed consent’, in a fully aware manner, that will allow the patient and doctor to share in the decisions regarding complex treatment strategies (living will). A further aim of the study is to verify if health workers, both in hospital and at home, respect the patient’s will.

The observational study ‘Respecting the patient’s wishes: Correlation between administered treatment and that accepted by the patient in their Living Will’ was approved by the IEO Ethical Committee in April 2008.

The value of radiotherapy on metastatic internal mammary nodes in breast cancer. Results on a large series

The 'regional nodal mapping', is a fundamental step to stage breast carcinoma. In addition to the axillary nodes status, the involvement of internal mammary nodes is an important prognostic factor. Six hundred and sixty-three patients with breast carcinoma, mainly in the inner quadrants, underwent a biopsy of internal mammary nodes. Positive internal mammary nodes were found in 68 out of 663 cases (10.3%) representing 27.2% of all cases with regional node metastases (250). When histologically proven metastases were detected, radiotherapy was administered to the internal mammary nodes chain. In 254 cases, the surgeon's exploration was guided by a gamma probe. Out of these cases, 28 (11.0%) showed metastatic involvement. Out of the other 409 cases, not radioguided, 40 showed positive nodes (9.8%). Patients with internal mammary metastases treated with radiotherapy and appropriate systemic treatment showed an excellent survival (95% at 5 years), a result which is in opposition to the previous experience, which stated that invasion of internal mammary nodes is an ominous prognostic sign. We assume that this excellent result is due to radiotherapy to internal mammary nodes and we propose that exploration of internal mammary nodes should be part of the staging process of carcinomas of the medial part of the breast.

Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases

BACKGROUND

When the conservative treatment is not recommended, Nipple Sparing Mastectomy (NSM) is proposed more and more frequently for the surgical treatment of breast cancer. The risk of local recurrence behind the nipple areolar complex (NAC) is the main limiting factor of the NSM procedure. To minimize such risk, we proposed in 2002 a intraoperative radiotherapy of the preserved NAC.

PATIENTS AND METHODS

From March 2002 to November 2006, 579 cases (in 570 patients) of NSM were performed for carcinoma. The median follow up time was 19 months (Range: 1-60). The subcutaneous mastectomy was performed through an incision removing a portion of the skin overlying the tumour. An extemporaneous histological examination was performed on the retroareolar glandular tissue. If the histology was positive the patient was not considered eligible. Then an intraoperative radiotherapy with electrons (ELIOT) of 16 Gy in one shot was delivered on the NAC area. An immediate breast reconstruction was done using implants in most cases and in several cases a musculocutaneous flaps, usually in large breast. The number of local recurrences was recorded and the correlation between their occurrence and the clinical and histological criteria were analysed using the Gray test statistical method in a competing framework.

RESULTS

In 516 cases the negative retroareolar frozen section biopsy was confirmed by the final histology, while in 63 cases, the final histology showed foci of carcinoma. Seven out of these 63 cases underwent a secondary NAC removal. In the 56 cases which preserved areolas we did not observe any local recurrence after 19 months follow up. The probability of retro areola positive histology increases with the tumour size. and was not related to the nodal status. The rate of local relapses was 0.9% per year. We didn't find any significant difference in the local relapse rate according to different patient's and tumour's features. Most relapses were located close to the tumour bed but never in the NAC area.

CONCLUSION

Our study confirms that the local recurrence rate in the NSM completed with local radiotherapy on the NAC is not higher than the usual rate observed in the literature and the preservation of the NAC does not increase the risk. The absence of local recurrence in the region where a portion of glandular tissue has been purposely preserved is a good argument in favour of ELIOT.

Full-dose intra-operative radiotherapy with electrons (ELIOT) during breast-conserving surgery: experience with 1246 cases

Background:

Previous studies showed that after breast-conserving surgery for breast cancer, radiotherapy may be applied to the portion of the breast where the primary tumour was removed (partial breast irradiation (PBI), avoiding the irradiation of the whole breast. We developed a procedure of PBI consisting of a single high dose of radiotherapy of 21 Gy with electrons equivalent to 58–60 Gy in fractionated doses, delivered during the surgical session by a mobile linear accelerator, positioned close to the operating table.

Patients and methods:

From July 1999 to December 2006, 1246 patients with primary carcinoma of less than 2.5-cm maximum diameter, mostly over 48 years, were treated with electron intra-operative radiotherapy (ELIOT) at a single dose of 21 Gy.

Results:

After a follow-up from 0.3 to 94.7 months (median 26), 24 (1.9%) patients showed a local recurrence and 22 developed distant metastases. Sixteen patients died, seven from breast carcinoma and nine from others causes. The five-year crude survival was 96.5%. Six (0.5%) developed severe breast fibrosis, which resolved in 2–3 years. An additional 40 patients suffered for mild fibrosis. Cosmetic results were good.

Conclusions:

Electron intra-operative radiotherapy is a safe method for treating conservatively operated breasts and avoids the long period of post-operative radiotherapy, greatly improving the quality of life and reduces the cost of radiotherapy. ELIOT markedly reduces the radiation to normal surrounding tissues and deep organs. Results on short- and medium-term toxicity are good. Data on local control are encouraging.

Is avoiding post-mastectomy radiotherapy justified for patients with four or more involved axillary nodes and endocrine-responsive tumours? Lessons from a series in a single institution

BACKGROUND

Current guidelines for post-mastectomy radiotherapy (PMRT) derive largely from extrapolating information from multicentre trials. The aim of this study was to describe outcomes of patients who underwent mastectomy without radiotherapy in a single institution.

PATIENTS AND METHODS

650 patients had total mastectomy and axillary dissection without PMRT between 1997 and 2001. Median follow-up was 65 months.

RESULTS

5-year cumulative incidence of loco-regional recurrence (LRR) was 6.8% (3.0, 8.1, 9.9% in node negative, 1-3, > or =4 positive nodes, respectively). At the multivariate analysis, positive lymph nodes and endocrine non-responsive tumours were found to shorten LRR disease-free survival. In patients with positive hormone receptors, 5-year cumulative incidence of LRR disease-free survival were 2.3%, 7.6% and 7.6% for node negative, 1-3 and > or =4 positive lymph nodes, respectively. The same figures were 5.9%, 10.3% and 20.0% in patients with endocrine non-responsive tumours.

CONCLUSIONS

patients with endocrine-responsive tumours treated by mastectomy and complete (level III) axillary dissection have a low risk of LRR even if four or more positive lymph nodes are involved, thus giving rise to doubts on the use of PMRT in this subset of patients. On the other hand, PMRT might play a role for patients with negative hormone receptors and four or more positive nodes.