Evaluation of Multifocality and Multicentricity With Breast Magnetic Resonance Imaging in Each Breast Cancer Subtype

Introduction

The purpose of this study was to evaluate whether diagnostic performance of breast magnetic resonance imaging (MRI) for detection of multifocality and multicentricity (MFMC) of breast cancer (BC) can be influenced by different histotypes or immunophenotypes in newly diagnosed patients with breast cancer.

不能触及肿块的多中心乳腺癌：临床病理分析

对１５例无肿块型乳腺癌进行临床及病理分析。这种乳腺癌术前绝大多数被诊断为乳腺增生。其临床特点表现为患者年轻；乳腺触诊无明确肿块，仅表现为区段乳腺增厚；个别病例有乳头溢液，乳腺Ｘ线片可发现腺体内有散在泥沙样钙化，但无肿块影；针吸细胞学检查阳性率低；冰冻切片检查有时也难以作出判断。病理特点主要是癌灶为多灶性的浸润性导管癌；癌灶小，分布广，但只局限在乳腺某一区段内；病变区的腺体都有增生背景。这种类型乳腺癌如能及时发现，预后较好。     

Risk Factors for Locoregional Failure in Patients With Inflammatory Breast Cancer Treated With Trimodality Therapy

PurposeTo compare patterns of local and regional failure between patients with inflammatory breast cancer (IBC) and non-IBC in patients treated with trimodality therapy.Materials and MethodsWe reviewed records of 463 patients with stage II/III breast cancer, including IBC, who completed trimodality therapy from January 1999 to December 2009.ResultsThe median follow-up was 46.3 months (range, 4-152 months). Clinical stage was 29.4% (n = 136) II, 56.4% (n = 261) non-IBC III, 14.2% (n = 66) IBC, 30.5% (n = 141) cN0/Nx, and 69.5% (n = 322) N1-N3c. All the patients received neoadjuvant therapy and mastectomy (98%, n = 456 with axillary dissection), and all had postmastectomy radiation therapy to the chest wall with or without supraclavicular nodes (82.5%, n = 382) with or without axilla (6%, n = 28). The median chest wall dose was 60.4 Gy. Patients with IBC presented with larger tumors (P < .001) and exhibited a poorer response to neoadjuvant therapy: after surgery, fewer patients with IBC were ypN0 (P = .003) and more had ≥ 4 positive nodes (P < .001). Four-year cumulative incidence of locoregional recurrence was 5.9%, with 25 locoregional events, 9 of which had a regional component. On multivariate analysis, triple-negative disease (hazard ratio [HR] 7.75, P < .0001) and residual pathologic nodes (HR 7.10, P < .001) were associated with an increased risk of locoregional recurrence, but IBC was not. However, on multivariate analysis, the 4-year cumulative incidence of regional recurrence specifically was significantly higher in IBC (HR 9.87, P = .005).ConclusionIn this cohort of patients who completed trimodality therapy, the patients with IBC were more likely to have residual disease in the axilla after neoadjuvant therapy and were at greater risk of regional recurrence. Future study should focus on optimizing regional nodal management in IBC.     

特殊类型乳腺癌动态增强MRI诊断价值

 目的　评价乳腺动态增强MRI诊断特殊类型乳腺癌的价值。方法　回顾性分析 13例经手术病理证实的几种特殊类型乳腺癌的动态增强MRI表现特征。结果　 6例多中心性乳腺癌、4例多灶性乳腺癌及 2例隐匿型乳腺癌具有特征性MRI表现 ,1例炎性乳腺癌病变广泛且形态多样 ,缺乏特征性。结论　乳腺动态增强MRI对多中心性、多灶性乳腺癌及隐匿型乳腺癌有重要诊断价值 ,对炎性乳腺癌的诊断需结合临床资料与急性乳腺炎鉴别     

Clinical Outcome of Isolated Locoregional Recurrence in Patients With Breast Cancer According to Their Primary Local Treatment

IntroductionThis study assessed the clinical outcome and prognostic factors in patients with breast cancer who presented with isolated locoregional recurrence (ILRR) as a first event.Materials and MethodsBetween 1970 and 2008, 2960 patients with pT1-2, N0-3, M0 primary invasive breast cancer had either breast-conserving therapy (BCT) using lumpectomy and radiation therapy (RT) (group A = 1849 patients) or mastectomy without RT (group B = 1111 patients). Out of groups A and B, 117 and 103 patients, respectively, developed ILRR as a first event. Those 220 patients served as the basis for this study. A multivariate analysis was performed to estimate the clinical outcome of both groups, taking into account clinically relevant variables for the primary tumor and ILRR.ResultsThe median follow-up after ILRR was 83 months. The median disease-free interval (DFI) was 79 and 38 months for groups A and B, respectively. The overall survival (OS) for group A was 81% and 69% at 5 and 8 years, respectively. For group B, it was 61% and 46%, respectively. The distant metastasis–free survival (DMFS) for group A was 84% at 5 years and remained 84% at 8 years. The DMFS for group B was 60% at 5 years and 52% at 8 years. In multivariate analysis, initial local treatment (BCT vs. mastectomy without RT), pathologic T stage, locoregional recurrence site (local vs. regional), and DFI (≤ 4 years vs. > 4 years) were significant prognostic variables for both OS and DMFS.ConclusionPatients with breast cancer who developed ILRR after BCT as their initial local treatment have better clinical outcome compared with those who had mastectomy without RT.     

乳腺癌术后早期发现复发转移方法的回顾性分析

目的：分析乳腺癌患者术后早期发现复发转移的方法。方法：回顾性分析126例早期乳腺癌术后发生复发转移患者的临床资料．包括最早发生复发转移的部位及其发现方法(症状、自查、医生查体和血液学、影像学检查)。结果：80例(63．5％)在常规随诊时发现复发转移，其中影像学或血液学检查发现65例(51．6％)，查体发现15例(11．9％)；28例(22．2％)经自查发现病变；仅18例(14．3％)因症状而就诊。结论：乳腺癌术后常规随诊是早期发现复发转移的主要方法．其中影像和血液学检查是必要的。     

Locoregional Interaction of Ixabepilone (Ixempra) After Breast Cancer Radiation

Background.

Radiation recall is an acute inflammatory reaction within a previously irradiated field triggered by chemotherapy administration. We observed a series of patients with unexpectedly severe reactions that included radiation recall and delayed healing when patients received the microtubule stabilizer ixabepilone (Ixempra; Bristol-Myers Squibb, Princeton, NJ) after radiation. We therefore decided to evaluate our experience in patients receiving ixabepilone following radiotherapy.

Methods.

We performed a retrospective chart review of all patients treated with curative intent in the Department of Radiation Oncology at the MD Anderson Cancer Center from 2008–2011 who received any ixabepilone after completion of external-beam radiation therapy. These patients received adjuvant ixabepilone on one of two protocols, either for locally advanced breast cancer or for metastatic breast cancer. In total, 19 patients were identified and their charts were subsequently reviewed for evidence of ixabepilone-related toxicity.

Results.

Of the 19 patients identified who received ixabepilone following radiation therapy, three (15.8%) had unexpectedly serious reactions in the months following radiation therapy. Complications included delayed wound closure and drain placement into the seroma, intense erythema, and delayed wound closure and grade 4 chest wall necrosis requiring latissimus flap and skin grafting. The average number of days between the end of radiation therapy and documentation of reaction was 99.

Conclusions.

Ixabepilone chemotherapy may induce radiation recall and delayed wound healing when used shortly after the completion of external-beam radiotherapy. Significant clinical interactions have not been previously reported and merit further evaluation.     

乳腺癌术后胸壁复发85 例分析

 目的　探讨乳腺癌术后胸壁局部复发因素及预后意义。方法　回顾性分析乳腺癌术后胸壁局部复发患者 85例。结果　本组患者占同期全部乳腺癌病例的 3.5 9% ,其中 5 5例 (6 4.7%复发发生在手术后 2年内 ,复发后 39例 (4 5 .9% ) ,2年内死亡。结论　临床分期晚、腋下淋巴结癌转移数多、原发灶见脉管癌栓患者术后胸壁复发率高 ;原发灶雌激素受体 (ER)及孕激素受体 (PR)阴性患者 ,复发多出现在术后第 1、2年内。对乳腺癌术后易复发的高危人群除应规范化治疗 ,还应实施适时胸壁放疗。     

Risk Factors Associated with Distant Metastasis and Survival Outcomes in Breast Cancer Patients with Locoregional Recurrence

Purpose

To decide the optimal treatment for breast cancer patients with locoregional recurrence (LRR), it is important to determine which group has the highest risk of subsequent distant metastasis (DM). We aimed to investigate the factors associated with DM in patients with LRR.

Methods

We reviewed the data of 208 patients with LRR as the first event after primary surgery for breast cancer at our institution between 1997 and 2010, to identify significant factors associated with DM. Subsequently, Kaplan-Meier curves and the Cox regression method were used to analyze the correlation between clinical factors and survival.

Results

DM occurred in 33.2% (68/208) of LRR patients. The median DM-free interval was 23 months. Some clinical factors were associated with DM in univariate analysis, including the type of primary surgery (p=0.026), tumor size (p=0.005), nodal status (p=0.011), and administration of initial adjuvant chemotherapy (p=0.001). In addition, regional rather than local recurrence and a disease-free interval (DFI; duration between primary surgery and LRR) ≤30 months were also significant (p<0.001 for both). However, only a shorter DFI reached significance in multiple logistic regression analysis. Cox regression analysis of DM-free survival showed that both a shorter DFI and regional recurrence were significant factors with hazard ratios of 2.1 (95% confidence interval [CI], 1.21-3.65) and 1.85 (95% CI, 1.04-3.28), respectively.

Conclusion

DFI was the most important factor associated with subsequent DM in patients with LRR as a first event of failure.     

Prognostic Factors Associated with Survival After Breast Cancer Recurrence

Factors associated with disease-free interval after the primary treatment and survival after a recurrence of breast cancer were studied in 331 female breast cancer patients treated in 1976 1980. Within five years after the primary treatment, recurrence occurred in 131 patients. the observation time of these patients after recurrence was from few weeks to twelve years. Twenty-nine patients were alive at the end of the follow-up. the average disease-free time was 2 years. the clinical stage of the disease in this material was not significantly associated with the disease-free interval. the median survival time after recurrence was 2.7 years when only breast cancer related deaths were included. Survival was significantly better for patients with primarily stage I disease than for patients with primarily stage II-IV disease. the size of the primary tumour was not significantly associated with survival after recurrence. the patients with loco-regional recurrence survived almost significantly better than those with distant recurrence. the disease-free time correlated positively with survival after a recurrence. the present study confirms the view that breast cancer includes several subgroups with a different type of clinical course.     

Conservative surgery in patients with multifocal/multicentric breast cancer

Purpose Many physicians recommend mastectomy in case of multifocal (MF) or multicentric (MC) breast cancer due to a theoretical risk of poor local control with less extensive surgery. We retrospectively evaluate outcome of patients with MF/MC cancers who had breast conservation with specific attention on local control and predictive factors of recurrence. Patients and methods Four hundred and seventy six patients with either MF (n = 421) or MC (n = 55) breast cancer, underwent breast-conserving surgery between 1997 and 2002 in a single institution. Median follow up was 73 months (range 11–118). Results Median age was 53 years (range 23–86). Invasive lobular carcinoma was found in 88 patients (18.5%) and mixed ductal-lobular cancer in 27 (5.7%) patients. Two hundred and sixty-seven patients (76.7%) had two identified tumor foci, 55 patients (15.3%) had three and 29 patients (8.0%) had four or more. Two hundred and sixty-one patients (55.3%) had nodal involvement. The 5-year cumulative incidence of local relapse was 5.1%. At the multivariate analysis, over-expression of HER2/neu and lack of both estrogen and progesterone receptors (HR: 3.2, 95% C.I. 1.01–10.0, and HR: 2.7, 95% C.I. 1.06–7.7, respectively) were associated with a higher ipsilateral breast cancer reappearance rate. Involvement of four or more lymph nodes and lack of estrogen and progesterone receptors (HR: 2.7, 95% C.I. 1.06–6.7, and HR: 4.7, 95% C.I. 2.1–10.4, respectively) were associated with poorer overall survival. Conclusions In selected patients with MF/MC breast cancer, wide conservative surgery is not associated with poor local disease control and can be considered whenever acceptable cosmetic results can be achieved.     

多西紫杉醇联合吡柔比星化疗治疗乳腺癌的效果及复发情况观察

目的观察多西紫杉醇联合吡柔比星化疗在乳腺癌患者治疗中的效果,及对不良反应发生率的影响。方法选取乳腺癌患者为研究对象,并根据其化疗药物的不同分为对照组和观察组,对照组给予紫杉醇联合吡柔比星进行化疗,观察组给予多西紫杉醇联合吡柔比星进行化疗。观察2组患者的治疗效果、不良反应发生率和复发率,比较2组患者治疗前后肿瘤标志物水平的差异。结果观察组治疗有效率为97. 50%,明显高于对照组的80. 00%,差异有统计学意义(χ^2=6. 135,P=0. 013)。2组患者治疗前肿瘤标志物水平无差别,治疗后,观察组患者的CEA、CA125、CA153水平低于对照组(t=11. 432、18. 876、3. 703,P <0. 001)。2组患者骨髓抑制、恶心呕吐、脱发、中性粒细胞减少、肝功能损害等不良反应发生率无差别(χ^2=0. 238,P=0. 626)。对照组1年复发率较观察组高,但差异无统计学意义(χ^2=1. 053,P=0. 305)。结论多西紫杉醇联合吡柔比星化疗对乳腺癌患者的化疗效果较好,且不会增加骨髓抑制等不良反应发生率,具有良好的应用价值。     

Survival and Pattern of Failure Following Locoregional Recurrence of Breast Cancer

This study analyzed prognostic factors at primary diagnosis and at first recurrence for impact on survival after isolated locoregional failure. The aims were: (1) assessment of prognostic factors for time to second locoregional failure, distant failure, and survival in isolated locoregional recurrence of breast cancer after mastectomy; and (2) investigation of the impact of a second locoregional failure on dissemination and survival.Between 1983 and 1985, 99 patients who had undergone mastectomy and then developed isolated local and/or regional recurrences, were treated with radical excision and radiotherapy; none of these patients had distant metastases. Survival and the times to second local failure and distant metastasis were analyzed according to potential prognostic factors.The median follow-up was 123 months; 38 patients were still alive. Median survival was 89 months and the 10-year survival rate was 38%, with no difference between local and regional recurrences. A total of 43 patients developed a second locoregional recurrence after a median of 73 months; primary tumour size and initial node status were significant independent prognostic factors. The annual hazard rates for recurrence were similar for patients developing local failure or systemic recurrence. The 10-year rate of dissemination was 49% for patients with locoregional control, compared with 51% for patients who had a second locoregional recurrence. The prognostic factors for survival were node status at mastectomy and haemoglobin level at first recurrence.The development of a second locoregional recurrence was not associated with an increased risk of dissemination or reduced survival. Differences in prognostic factors for locoregional control and distant metastases suggest that these recurrences represent different biological entities that require different treatment strategies. However, as the achievement of locoregional control had no influence on prognosis, the use of systemic adjuvant therapy may be warranted in a subset of these patients.     

Breast Cancer Recurrence According to Molecular Subtype

Background: To evaluate the location of tumor relapse and imaging modality for detection according to thebreast cancer subtype: luminal A, luminal B, HER2 positive luminal B, nonluminal HER2 positive, and triplenegative. Materials and Methods: A total of 1244 patients with breast cancer with known estrogen receptor (ER),progesterone receptor (PR), Ki-67 and human epidermal growth factor receptor 2 (HER2), who underwentbreast surgery from 2009 to 2012 were analyzed. Patients were classified into the following categories: luminalA (n=458), luminal B (n=241), HER2 positive luminal B (n=227), nonluminal HER2 positive (n=145) and triplenegative (n=173). A total of 105 cases of relapse were detected in 102 patients: locoregional recurrence (n=46),recurrence in the contralateral breast (n=28) and distant metastasis (n=31). Comparison of proportions wasused to determine the difference between subtypes. Results: Relapse rates by subtypes are as follows: luminal A23 of 458 (5.02%), luminal B 19 of 241(7.88%), HER2 positive luminal B 15 of 227 (6.61%), nonluminal HER2postive 19 of 145 (13.10%) and triple negative 29 of 173(16.76%). Luminal A tumors had the lowest rate ofrecurrence and had significantly lower recurrence rate in comparison with nonluminal HER2 postive (p=0.0017)and triple negative subtypes (p<0.0001). Compared with all other subtypes except nonluminal HER2 positive,triple negative tumors had the highest rate of tumor recurrence (p<0.01). Triple negatives were most likely todevelop contralateral recurrence against all subtypes (p<0.05). Detection rate of locoregional and contralateraltumor recurrence were 28.3% on mammography (n=17/60). Conclusions: Luminal A tumors are associatedwith a low risk of recurrence while triple negative lesions have a high risk. In case of triple negative tumors, thecontralateral breast has much more recurrence as compared with all other subtype. In terms of detection rates,breast USG was the best modality for detecting tumor recurrence, compared with other modalities (p<0.05).Subtyping of breast tumors using a molecular gene expression panel can identify patients who have increasedrisk of recurrence and allow prediction of locations of tumor recurrence for each subtype.