Twenty-Year Outcomes after Breast-Conserving Surgery and Definitive Radiotherapy for Mammographically Detected Ductal Carcinoma In Situ

Background

Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT).

Methods

Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86?% of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4?Gy to the lumpectomy cavity.

Results

A total of 129 cases were evaluated; the median follow-up was 19.3?years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2?% of which were invasive (n?=?16). Fourteen recurrences (66?%) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women <45?years of age (20?%/24?% vs. 5.1?%/8?%) at 10 and 20?years (p?=?0.02). The 5-, 10-, 15-, and 20-year actuarial rates of IBTR for this cohort were 8.7, 10.4, 12.1, and 16.3?% (IBTR), while overall survival at 5, 10, and 20 years was 97.6, 96.8, and 96.8?%, respectively.

Conclusions

Mammographically detected DCIS remains a clinically distinct subset of noninvasive breast cancer. With 20?year follow-up, local control and overall survival are excellent after BCT.     

Local Recurrence and Survival Among Black Women With Early-Stage Breast Cancer Treated With Breast-Conservation Therapy or Mastectomy

Background: Black women with breast cancer have significantly worse survival rates and receive diagnoses at relatively younger ages, compared with white patients with breast cancer, in the United States. Young age at diagnosis has been associated with increased risk for local recurrence (LR) after breast-conservation therapy (BCT). The goal of this study was to evaluate the impact of age and BCT on LR and survival rates among black patients with breast cancer.Methods: The records for 363 black women treated for breast cancer (excluding stage IV disease) at a comprehensive cancer center were reviewed.Results: Fifty-eight percent of patients (n = 211) had tumors 5 cm in diameter. Forty-two of these patients (19.9%) received BCT; the LR rate for this group was 9.8%. A total of 168 patients (79.6%) underwent mastectomy; the LR rate for this group was 8.9%. Data on the primary operation were unavailable for one patient. Five-year disease-free survival rates were similar for patients treated with BCT and those treated with mastectomy (88% and 73%, respectively). LR was associated with significant decreases in 5-year overall survival rates for both the BCT group (67% vs. 95%, P < .01) and the mastectomy group (43% vs. 76%, P < .01). LR and 5-year diseasespecific survival rates were similar for patients <50 years of age and patients 50 years of age, regardless of treatment.Conclusions: LR and survival rates are not compromised by the use of BCT among black American patients. LR is associated with an increased risk of breast cancer death, regardless of treatment type. Younger age at diagnosis was not associated with an increased rate of LR after BCT in this series.     

Breast-conserving therapy for primary Ductal Carcinoma in Situ in The Netherlands: A multi-center study and population-based analysis

ObjectiveThe aim of this study was to analyse the efficacy of breast-conserving therapy (BCT) for women with primary DCIS in a population-based setting.MethodsData were used from five Radiotherapy centres in The Netherlands from 2000 to 2010, all treated with BCT. Of all the cases, 59.2% received a boost of radiotherapy after their whole breast irradiation (WBI), irrespective of margin status.ResultsA total of 1248 cases with primary DCIS were analysed. The 10-years LRFS was 92.9%. Age ≤50 years and a positive margin were significantly related to local relapse free survival (LRFS). Having a boost had no impact on LRFS, showing a nearly equal recurrence pattern in patients with and without a boost. Separate analyses were done on patients who had received and not received a boost of radiotherapy after WBI. We noted 9.1% contra-lateral breast tumours. The 10-years disease specific survival (DSS) rate was 99.0%.ConclusionsDCIS of the breast and treated with BCT results in excellent LRFS and DSS. Primary surgical lumpectomy with negative margins followed by WBI seems to be the treatment of choice in DCIS treated with BCS with respect to IBTR.     

Outcomes After Breast Conservation Treatment with Radiation in Women with Ductal Carcinoma In Situ and Prior Nonbreast Malignancy

Abstract:  Management of ductal carcinoma in situ (DCIS) of the breast is controversial, as not all patients progress to invasive carcinoma. This report analyzes the outcomes after breast conservation treatment (BCT) with radiation in patients with DCIS following prior malignancy at another anatomic site. The study cohort was comprised of 14 women with DCIS who were treated between 1978 and 2003. The median age at diagnosis of DCIS was 54 years (mean 56; range 37–78) and for the prior nonbreast malignancy was 44 years (mean 47; range 27–76). All patients underwent breast conservation surgery followed by whole breast radiation and tumor bed boost. The median and mean follow-up times after treatment of DCIS were 8.0 and 9.1 years, respectively (range 2–18). The median and mean interval period between the prior malignancy and DCIS was 6.0 and 8.2 years, respectively (range 1–30). There was one (7%) local failure, two (14%) contralateral breast cancers, and one (7%) death from breast cancer that occurred 7 years after BCT following contralateral invasive breast cancer. In this cohort of 14 patients treated for DCIS of the breast after a prior nonbreast malignancy, treatment for DCIS resulted in a high rate of local control and should be considered for curative intent.     

Predictors of locoregional recurrence among patients with early-stage breast cancer treated with breast-conserving therapy

Background Our aim was to identify predictors of locoregional recurrence (LRR) in patients with early-stage breast cancer treated with breast-conserving therapy (BCT) and long-term follow-up. Methods From 1970 to 1994, 1153 patients with stage I to II breast cancer underwent BCT and radiotherapy at our institution. Patients with prior breast cancer or other primary malignancies were excluded. Clinical and pathologic characteristics evaluated were age, race, tumor size, stage, pathologic tumor margins, axillary nodal involvement, estrogen and progesterone receptor status, Black's nuclear grade, type of surgery, and use of adjuvant therapy. Results Of 1083 patients, 54% presented with stage I disease and 46% with stage II disease. Median age was 50 years, and median follow-up was 9 years. Axillary nodes were positive in 31% of the patients who underwent axillary dissection. LRR developed in 6%, LRR followed by systemic recurrence in 5%, and systemic recurrence alone in 13%, 76% had no evidence of recurrence at last follow-up. Age, tumor size, positive lymph nodes, and not receiving chemotherapy or hormonal therapy were independent predictors of LRR. Disease-specific survival among patients with LRR was similar to that among patients with no recurrence. Conclusions Multidisciplinary treatment strategies should be used to accomplish durable locoregional control after BCT. Presented at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.     

Optimal treatment of multiple ipsilateral primary breast cancers

INTRODUCTION: The success of breast-conservation therapy (BCT) for patients with multiple ipsilateral invasive breast cancers (MIBC) is sparsely documented. METHODS: A retrospective review of single-institution experience. Patients with 2 or more invasive cancers separated by normal breast tissue were included; patients with 1 invasive cancer with additional in situ lesions and those receiving neoadjuvant therapy were excluded. RESULTS: One hundred forty-nine patients were treated over 19 years. Fifty-eight (39%) patients underwent BCT. Preoperatively, multiple tumors were suspected in more mastectomy patients than BCT patients (75% versus 62%). Most patients had 2 tumors and 1 histology. Fifty-five percent of patients with tumors within 1 quadrant underwent BCT versus 10% of patients with tumors in more than 1 quadrant. One hundred eight patients underwent sentinel lymph node (SLN) biopsy. Twenty-seven percent (34) were SLN positive. There were no regional recurrences among the SLN-negative patients. Six patients recurred: 1 nodal, 1 local, and 4 distant. The locoregional BCT recurrence rate was 3.4%. DISCUSSION: MIBC patients can safely undergo BCT with low recurrence risk. SLNB can be performed with minimal risk of regional recurrence.     

Outcomes of breast-conservation therapy for invasive lobular carcinoma are equivalent to those for invasive ductal carcinoma

BACKGROUND: Breast-conservation therapy (BCT), including wide local excision and postoperative irradiation, is considered standard treatment for early-stage invasive ductal carcinoma (IDC). The use of BCT in patients with invasive lobular carcinoma (ILC) has been questioned because of concerns regarding ipsilateral breast recurrence and risk of bilateral breast cancer. We evaluated our institutional experience with BCT and compared treatment outcomes for ILC with those for IDC. METHODS: A review of our BCT database revealed 84 patients with ILC and 1,126 with IDC with stage I or II disease treated with BCT and radiation between 1976 and 1999. We evaluated local-regional recurrence, disease-specific survival, and contralateral breast cancer rates in both groups. RESULTS: The 5- and 10-year local-regional recurrence rates for the ILC group were 1% and 7%, respectively, and 4% and 9%, respectively, for the IDC group (P = .70). There were no significant differences in the 5- and 10-year disease-specific survival rates between the groups. Contralateral breast cancer occurred in 11.3% of patients with IDC and 11.9% of patients with ILC. CONCLUSIONS: BCT achieves similar local-regional control and survival outcomes in selected patients with ILC or IDC. Breast-conservation therapy is an appropriate treatment strategy for patients with early-stage invasive lobular carcinoma.     

Effective Local Control and Long-Term Survival in Patients with T4 Locally Advanced Breast Cancer Treated with Breast Conservation Therapy

Background: The presence of skin involvement has been accepted as a relative contraindication to breast preservation because it is believed to be associated with an increased local failure rate. This study was conducted to assess the outcome of a carefully selected group of patients who presented with breast cancer involving the skin and who had breast conservation therapy (BCT) following neoadjuvant chemotherapy.Methods: Between 1987 and 1999, 33 patients with stage IIIB or IIIC breast cancer completed treatment consisting of four cycles of neoadjuvant chemotherapy, lumpectomy, radiation therapy, and consolidative chemotherapy. Clinicopathologic factors were analyzed and patients were followed for locoregional and distant recurrence.Results: Initial median tumor size was 7 cm. All patients had skin involvement, defined as erythema, skin edema, direct skin invasion, ulceration, or peau dorange. Following chemotherapy, median pathologic tumor size was 2 cm. Complete resolution of skin changes occurred in 29 patients (88%). At median follow-up time of 91 months in surviving patients, 26 patients (79%) were alive without evidence of disease. The 5-year, disease-free survival rate was 70%, and the 5-year overall survival rate was 78%. The actuarial ipsilateral breast cancer recurrence rate was 6% at 5 years.Conclusions: Patients who present with T4 breast cancer who experience tumor shrinkage and resolution of skin changes with neoadjuvant chemotherapy represent a select group of patients who can have BCT. These patients have favorable rates of long-term local control and survival. Mastectomy is not mandatory for all patients with breast cancer who present with skin involvement.Presented at the 57^th Annual Society for Surgical Oncology Cancer Symposium in New York City, New York, March 18–21, 2004     

Breast cancer-specific mortality after invasive local recurrence in patients with ductal carcinoma-in-situ of the breast

BACKGROUND: Previous studies on the efficacy of primary treatments for ductal carcinoma-in-situ (DCIS) have focused on local recurrence rates. Our objective was to detail the outcomes of local invasive recurrence, distant recurrence, and breast cancer mortality in patients previously treated for DCIS. METHODS: Clinical, pathologic, and outcome data were collected prospectively for 1236 patients with pure DCIS accrued from 1972 through 2005. RESULTS: There were 150 recurrences (87 DCIS and 63 invasive). Invasive local recurrence after mastectomy was rare (0.5% of patients) and after breast preservation was more frequent (12.0% of patients). The 12-year probabilities of breast cancer-specific mortality after mastectomy and after breast preservation were 0.8% and 1.0%, respectively. The 12-year breast cancer-specific mortality and distant disease probability for the 63 patients with invasive recurrences were 12% and 15%, respectively. CONCLUSIONS: Regardless of initial treatment, most patients with invasive local recurrence after treatment for DCIS can be treated and cured.     

Is the systematic circumferential tumor cavity shaving a representative sample for the remaining mammary gland? About 75 cases

IntroductionThe conservative surgery is more and more indicated for breast cancer. However, we still fear local recurrence which is mostly due to residual tumors?. Several techniques have been used to minimize theses residual tumors; one of them is the systematic circumferential tumor cavity shaving (SCTCS).MethodsWe sampled 75 female patients who had conservative surgery with positive shaved margins in the anatomopathology examination and to whom a complementary treatment with mastectomy have been decided.ResultsThe median age was 48 years old. The median tumor size was 23 mm. In the histological examination of the tumors, 93% were invasive ductal carcinoma associated in 50% of the cases to the presence of ductal carcinoma in situ (DCIS) where all the lumpectomies had clear margin. For the SCTCS, 62,2% were DCIS and in 17,6% of the cases were invasive ductal carcinoma. A complementary treatment with mastectomy was indicated to all the patients. A residual tumor was detected in the remaining mammary gland in 47,7% of the cases out of which 50% were DCIS. Local recurrence happened in three patients (4,6%) after a median of follow up of 36 months. The overall survival and the disease free survival at five years were respectively 83,6% and 75,5%.ConclusionStandardized lumpectomy cavity shaving provides a backup to lumpectomy margins in conservative breast surgery but it can also be used as a sample for the remaining breast, helping to detect the residual tumor, and decreasing the rates of local recurrence after BCT.     

Impact of extensive intraductal component on recurrence and survival in patients with stage I or II breast cancer treated with breast conservation therapy

Background: The relationship between an extensive intraductal component (EIC) and recurrence and survival in patients with stage I or II breast cancer treated with breast conservation therapy has not been clearly defined. Methods: 133 patients with stage I or II breast cancer who underwent breast conservation therapy between 1978 and 1990 at The University of Texas M. D. Anderson Cancer Center were retrospectively studied. All pathology slides were reviewed to determine tumor size, nuclear grade, extent of intraductal component, number of positive lymph nodes, and histologic margins. EIC was defined as ductal carcinoma in situ (DCIS) occupying 25% or more of the area encompassed by the infiltrating tumor and DCIS present in grossly normal adjacent breast tissue. Results: 110 patients are alive, and 23 have died, with a median follow-up of 7 years; 85 of 133 patients had an intraductal component, but only 18 had an EIC. Locoregional control and disease-free and overall survival were not adversely affected by the presence of an EIC. Five of 133 patients had a locoregional recurrence, but only one had an EIC. Conclusions: EIC, if negative margins can be achieved, does not adversely affect disease-free or overall survival or local control rates.     

Does Breast Conservation Therapy in Young Women with Breast Cancer Adversely Affect Local Disease Control and Survival Rate? The M. D. Anderson Cancer Center Experience

Abstract: Historically, it was thought that young women with breast cancer had a poor prognosis and a high local disease recurrence rate after breast-conservation therapy. To determine the effect of breast-conservation therapy, the outcomes of young women with breast cancer who were treated at a single institution were retrospectively reviewed.
Between 1978 and 1993, 219 women ≤35 years of age with breast cancer were treated at the University of Texas M. D. Anderson Cancer Center and met the following criteria: no evidence of distant metastasis at the time of diagnosis, no prior treatment, and no concurrent cancers. The variables analyzed included demographics, type of surgery, TNM stage, use of adjuvant therapy, locoregional disease recurrences, distant metastases, and vital status. The median length of follow-up among surviving patients was 7.9 years (range, 1–17 years). Univariate analyses were performed using the log-rank test. Multivariate analyses were performed using the Cox proportional hazards model.
Seventy-nine patients underwent breast-conservation therapy (BCT) and 140 patients underwent modified radical mastectomy (MRM). Locoregional disease recurrences were identified in 27 cases: 12 in the BCT group and 15 in the MRM group. When patients were matched stage for stage, the type of local treatment did not correlate with the loco-regional recurrence rate (p = 0.236) or the disease-specific survival rate (p = 0.915). The five-year disease-specific survival rate was 84.2%. In the multivariate analysis, only TNM stage correlated with locoregional recurrence rate (p = 0.019) and disease-specific survival rate (p = 0.002).
This study shows no significant difference in locoregional recurrence rates or disease-specific survival rates in young women with breast cancer treated with BCT versus MRM.     

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast

Background: Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation. Methods: We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer. Results: Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate;P=.07, for multivariate) and initial presentation (P=.05, for univariate;P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease. Conclusions: Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.     

The 21-Gene Recurrence Score in Male Breast Cancer

Background

Given the limited data, systemic treatment of male breast cancer has been extrapolated from female patients. The 21-gene recurrence score (RS) assay estimates the risk of distant recurrence and chemotherapy benefit in early-stage, ER+/HER2? female breast cancer. We assessed the association between RS and type of treatment in male breast cancer.

Methods

We identified male patients with ER+/HER2? breast cancer and available RS results treated at our institution in 2006–2016. We collected data on clinicopathologic features, treatment, and outcome. The Institutional Review Board approved the study.

Results

The study cohort consists of 38 male breast cancer patients with a median age of 70 years. Median tumor size was 1.6 cm, and 81.6% (31) were node-negative. RS was low (≤ 17) in 26 (68.4%) cases, intermediate (18–30) in 9 (23.7%) cases, and high (≥ 31) in 3 (7.9%) cases, comparable to that in female patients at our institution. All patients underwent total mastectomy, and one received radiotherapy. Thirty-four (89.5%) patients received adjuvant endocrine therapy, mostly tamoxifen (81.6%; 31). Five (13.2%) patients with intermediate or high RS were treated with adjuvant chemotherapy. No locoregional recurrence was observed, and one patient developed distant recurrence (median follow-up 34 months).

Conclusions

The RS distribution in male breast cancers was similar to that in females treated at our institution. With limited follow-up, patients with low RS were spared chemotherapy and did not develop recurrence. Our results suggest that the RS may have a clinical utility in male breast cancer patients.

     

New trends in breast conservation therapy

Breast conservation therapy for early-stage invasive breast cancer provides survival equivalent to mastectomy. Careful patient selection and surgical technique are necessary to minimize local recurrence. Extensive studies of breast conservation therapy over the past 15 years have identified risk factors for local recurrence, and have proven that certain cases previously thought to be ineligible for lumpectomy (such as occult breast cancer, locally advanced breast cancer, macromastia, and cancer in pregnant patients), can be safely managed with modified BCT approaches. Recent trends in breast cancer management, such as expanded applications of induction chemotherapy, use of magnetic resonance imaging and ultra sound, and touch-prep cytology for intraoperative margin evaluation, can improve success rates for BCT. New developments with brachytherapy may also improve BCT availability by shortening duration of treatment. Innovations with minimally invasive tumor ablation techniques are investigational at present, but may obviate the need for surgical resections in selected patients in the future. Local recurrences that develop after breast conservation therapy should be managed aggressively, as long-term survival can frequently be achieved.     

Clinical Outcome after Selective Treatment of Patients Diagnosed with Ductal Carcinoma In Situ of the Breast

Background The effect of treatment of patients diagnosed with ductal carcinoma in situ (DCIS) of the breast was evaluated, and factors associated with local recurrence were assessed. Methods The study involved 504 patients treated by means of wide local excision alone (WLE) (n = 91), wide local excision and radiotherapy (WLE+RT) (n = 119), or mastectomy (n = 294) at the Netherlands Cancer Institute between 1986 and 2005. Clinical, pathological, and follow-up data were evaluated. Results The median time to follow-up was 6.7 years. The 8-year overall local recurrence rate was 12% after breast-conserving treatment (BCT) [15.6% after WLE and 8.8% after WLE+RT (P = 0.161)] and 0.9% after mastectomy (P < 0.0001). In total, 18 (66.7%) invasive local recurrences and 9 (33.3%) DCIS local recurrences occurred. The 8-year distant metastasis rate was 4% after BCT [4.3% after WLE and 4.2% after WLE+RT (P = 0.983)] and 0.9% after mastectomy (P = 0.048). Median tumor extent was 10, 15, and 35 mm for patients treated with WLE, WLE+RT, and mastectomy, respectively. Margins were involved in 6.4% of all patients. Factors associated with local recurrence were age younger than 40 years (HR 8.66), surgical margin involvement (HR 5.75), WLE (HR 26.77), and WLE+RT (HR 7.42). Conclusion BCT of DCIS bears the risk of residual disease progressing into invasive local recurrence and distant metastasis. A re-excision or mastectomy is therefore desired in all patients with unclear margins. Mastectomy treatment is associated with optimal local control and might be considered for patients younger than 40 years who are at high risk of local recurrence.     

Feasibility of Breast Conservation Therapy in Metachronous or Synchronous Bilateral Breast Cancer

Background: The optimal management of contralateral breast cancer (CC) in patients previously treated with breast-conserving therapy (BCT) is unclear, as is whether these patients continue to choose BCT as the preferred treatment of their second breast cancer.Methods: Of 1328 patients treated with BCT at The University of Texas M. D. Anderson Cancer Center between 1958 and 1994, 63 developed a contralateral breast cancer. We reviewed the charts of these patients retrospectively, and standard demographic and treatment variables were evaluated. Survival was analyzed by the Kaplan-Meier method and subgroups by ² analysis.Results: Twenty-nine percent of the patients had a family history of breast cancer. First breast cancers were detected by patient or physician in 67% of cases and by mammogram in 17% of cases, compared to 59% and 36%, respectively, of CC (P = .04). Median time to development of CC was 61 months. Sixty percent of the initial tumors were AJCC stage 0 or I with a median size of 2 cm, whereas 74% of the CC were stage 0 or I (P = .02), with a median size of 1.5 cm. Eighty-seven percent of patients chose BCT for treatment of CC. There were few treatment-related complications. Recurrence rates were not significantly different from those of patients undergoing BCT for the initial cancer (P = .47), and 5- and 10-year actuarial survival rates after the first cancer were 93% and 76%, respectively. Median follow-up was 134 and 56 months from the time of diagnosis of the initial cancer and CC, respectively.Conclusions: Because contralateral breast cancer often is detected at an early stage, there are few treatment-related complications, and the risk of recurrence is no different from that for the initial cancer, BCT is an acceptable and desirable option for appropriately selected patients with metachronous or synchronous bilateral breast cancers.Presented at the 51st Annual Cancer Symposium of The Society of Surgical Oncology, San Diego, California, March 26–29, 1998.     

Omitting radiation therapy in women with triple-negative breast cancer leads to worse breast cancer-specific survival

PurposeTo examine locoregional recurrence (LRR) and breast cancer-specific survival (BCSS) after breast-conserving therapy (BCT) or mastectomy (ME) with or without radiation therapy (RT) in triple-negative breast cancer (TNBC).Material & MethodsWe identified non-metastatic TNBC cases from a single institution database. BCT, ME with RT (ME + RT) and ME only were compared with respect to LRR and BCSS. Cox regression models were used to analyze the association between prognostic factors and outcome.Results439 patients fulfilled the inclusion criteria. Median follow-up was 10.2 years (interquartile range 7.9; 12.4 years). Patients in the BCT (n = 239), ME + RT (n = 116) and ME only (n = 84) group differed with respect to age, pT, pN, lymphovascular invasion, lymph node dissection and chemotherapy administration. Ten-year LRR rates were seven percent, three percent and eight percent for the BCT, ME + RT and ME only group, respectively. pN was associated with LRR. In multivariable analysis LRR were significantly lower in the ME + RT group compared to the BCT and the ME only group (p 0.037 and 0.020, respectively).Ten year BCSS was 87%, 84% and 75% for the BCT, ME + RT and ME only group, respectively. pT, pN, lymph node dissection, lymphovascular invasion and the administration of chemotherapy were associated with BCSS. In multivariable analysis BCSS was significantly lower in the ME only group compared to the BCT group and the ME + RT group (p 0.047 and 0.003, respectively).ConclusionTNBC patients treated with ME without adjuvant RT showed significant lower BCSS compared to patients treated with BCT or ME + RT and significant more LRR compared to ME + RT when corrected for known clinicopathological prognostic factors.     

Safe Negative Margin Width in Breast Conservative Therapy: Results from a Population with a High Percentage of Negative Prognostic Factors

Background

There remains a controversy in the literature regarding adequate width of negative surgical margins in breast conservative therapy (BCT). It is now advocated that no tumor on an inked margin is a safe negative margin. Majority of studies on the outcomes of BCT had patients with favorable prognostic factors. Pakistani population has a high expression of unfavorable prognostic factors. The objective of this study was to determine a safe negative margin width in Pakistani population that undergoes BCT.

Methods

A total of 603 patients with identifiable surgical margins underwent BCT from 1997 to 2009 in Shaukat Khanum Cancer Hospital. Patients were divided into close (≤2 mm), free (>2–10 mm), and wide (>10 mm) margin groups. Locoregional recurrence was defined as recurrence within the operated breast, ipsilateral axilla, or supraclavicular or internal mammary lymph nodes. Locoregional recurrence-free survival was calculated from the date of surgery to the date of locoregional recurrence. Five-year locoregional recurrence-free survival was determined for margin groups. Univariate and multivariate Cox proportional hazard analyses were performed to determine independent predictors of locoregional recurrence.

Results

A total of 415 (69 %) patients were <50 years of age. There were 82 (15 %) T3/T4, 337 (56 %) poorly differentiated, and 238 (39 %) ER/PR ?ve tumors. Nodal positivity was present in 314 (52 %) patients. The actual number of locoregional recurrences was 16 (12 %), 8 (3 %), and 10 (4.6 %), respectively (P = 0.002). Expected 5-year locoregional recurrence-free survival was 90, 97, and 96 %, respectively (P = 0.002). On multivariate analysis, tumor size, nodal involvement, and negative margin width were independent predictors of locoregional recurrence.

Conclusion

A negative margin width of 2 mm might represent an adequate negative margin width in the Pakistani population undergoing breast conservative therapy.     

Patterns of care for ductal carcinoma in situ of the breast: Queensland's experience over a decade

ObjectivesTo review management of ductal carcinoma in situ (DCIS) of the breast in Queensland, with reference to breast conserving surgery (BCS) and adjuvant radiation therapy (RT). In addition, we examined the incidence of invasive breast cancer recurrence and factors predictive of invasive recurrence.Materials and methodsA retrospective review of the Queensland Oncology Repository identified women with resected DCIS (TisN0) ± adjuvant RT between 2003 and 2012. Time to invasive breast cancer recurrence was analysed using the Kaplan Meier method. Median follow-up was 4.9 years.Results3038 women had surgery. 940 (31%) had mastectomy and 2098 (69%) underwent BCS. Of 2098 women having BCS, 1100 (52%) received BCS alone and 998(48%) received adjuvant RT. The use of RT significantly increased over the decade from 25% to 62% (p=<0.001). Clinicopathological factors associated with RT use on multivariate analysis included age ≤70, higher socioeconomic status, larger tumour size, higher nuclear grade and surgical margins ≤5 mm. Invasive breast cancer recurrence at 5 years was 1.7% [95% CI 1.0–3.0] in RT group versus 2.8% [95% CI 2.1–3.8] in BCS alone group. Factors associated with increased risk of invasive recurrence on multivariate analysis were age <40 and surgical margins ≤2 mm.ConclusionThe use of adjuvant RT in Queensland significantly increased between 2003 and 2012. Selection of patients for RT was based on clinicopathological factors associated with higher recurrence risk. Although longer follow-up is required, the selective use of radiation therapy after BCS is associated with a low rate of invasive breast cancer recurrence at 5 years.