Tubular carcinoma of the breast: an institutional experience and review of the literature

Tubular carcinoma of the breast is a variant of invasive ductal carcinoma that is well differentiated and characterized by an orderly tubular formation. Although often perceived to have a better prognosis, there continues to be questions regarding the extent of treatment required. A retrospective review of 44 patients diagnosed with tubular carcinoma of the breast from 1987 to 1999 was performed. All documented data regarding patient and tumor characteristics plus the extent of treatment were analyzed and compared. Lymph node metastases were present in 4 of 32 patients (13%) who had nodes examined. Tumor size correlated with axillary status, with tumors less than 15 mm having no axillary nodal involvement. No other factor influenced nodal status. In breast conservation patients without adjuvant radiation, 5% (1 of 20) had local recurrence versus 0% (0 of 13) of patients who received postoperative radiation. Ductal carcinoma in situ (DCIS) was associated with 52% of tubular cancers. Second breast cancers developed in 16% of cases. There was no difference in presentation or outcome for pure versus mixed tubular carcinoma. Overall mortality was 2%. Overall survival for patients with tubular carcinoma is quite good. Breast conservation treatment results in low rates of local recurrence for tubular carcinoma with or without the use of adjuvant radiation therapy. Pure tubular carcinomas had the same behavior and overall prognosis as mixed tubular carcinomas and should be classified together. Lymph node status did not influence disease-free or overall survival.     

乳腺小管癌11例诊治分析

目的 探讨乳腺小管癌的临床病理特性、预后及诊治方法.方法 回顾分析北京协和医院收治的11例乳腺小管癌的临床病理资料.结果 乳腺小管癌发病率占同期收治所有乳腺癌的0.4%.11例患者8例可触及肿块.6例患者行乳腺癌改良根治术,其中1例行双侧乳腺癌改良根治术,4例行保乳手术,1例行乳房单纯切除+前哨淋巴结活检术+腋窝淋巴结清扫术.2例伴腋淋巴结转移.免疫组化检查显示雌激素受体(ER)阳性者6例,孕激素受体(PR)阳性者7例.术后3例行单纯化疗,2例行单纯内分泌治疗,其他6例患者行联合辅助治疗.术后中位随访时间为34个月(1个月～7年),所有病例均无复发、转移或死亡.结论 乳腺小管癌恶性程度低,选择适当的尽量减少创伤的手术方式和辅助治疗对于改善患者生存,提高生活质量具有重要意义.     

乳腺小管癌11例诊治分析

目的 探讨乳腺小管癌的临床病理特性、预后及诊治方法.方法 回顾分析北京协和医院收治的11例乳腺小管癌的临床病理资料.结果 乳腺小管癌发病率占同期收治所有乳腺癌的0.4%.11例患者8例可触及肿块.6例患者行乳腺癌改良根治术,其中1例行双侧乳腺癌改良根治术,4例行保乳手术,1例行乳房单纯切除+前哨淋巴结活检术+腋窝淋巴结清扫术.2例伴腋淋巴结转移.免疫组化检查显示雌激素受体(ER)阳性者6例,孕激素受体(PR)阳性者7例.术后3例行单纯化疗,2例行单纯内分泌治疗,其他6例患者行联合辅助治疗.术后中位随访时间为34个月(1个月～7年),所有病例均无复发、转移或死亡.结论 乳腺小管癌恶性程度低,选择适当的尽量减少创伤的手术方式和辅助治疗对于改善患者生存,提高生活质量具有重要意义.     

乳腺小管癌11例诊治分析

目的 探讨乳腺小管癌的临床病理特性、预后及诊治方法.方法 回顾分析北京协和医院收治的11例乳腺小管癌的临床病理资料.结果 乳腺小管癌发病率占同期收治所有乳腺癌的0.4%.11例患者8例可触及肿块.6例患者行乳腺癌改良根治术,其中1例行双侧乳腺癌改良根治术,4例行保乳手术,1例行乳房单纯切除+前哨淋巴结活检术+腋窝淋巴结清扫术.2例伴腋淋巴结转移.免疫组化检查显示雌激素受体(ER)阳性者6例,孕激素受体(PR)阳性者7例.术后3例行单纯化疗,2例行单纯内分泌治疗,其他6例患者行联合辅助治疗.术后中位随访时间为34个月(1个月～7年),所有病例均无复发、转移或死亡.结论 乳腺小管癌恶性程度低,选择适当的尽量减少创伤的手术方式和辅助治疗对于改善患者生存,提高生活质量具有重要意义.     

老年乳腺癌术后辅助化疗对预后的影响

目的探讨老年乳腺癌的术后辅助化疗对预后的影响。方法收集80例Ⅰ~Ⅲ期≥65岁乳腺癌患者的资料,其中接受辅助化疗有47例,未接受辅助化疗有33例,分析两组的临床病理特点和预后特征。结果与未接受术后辅助化疗的患者比较,接受辅助化疗年龄轻的患者较多(P=0.005)、伴有合并症较少(P=0.040)、腋窝淋巴结转移率高(P0.001)、ER/PR阴性率高(P=0.029)、接受放疗概率高(P=0.005);而在肿瘤组织学分级、肿瘤大小、HER2表达、手术方式、内分泌治疗无明显区别(P0.05)。中位随访期为73个月,辅助化疗组与未辅助化疗组相比,无病生存率(DFS)无明显区别(78.7%vs 90.9%,P=0.147),总生存率(OS)也无明显区别(83.0%vs93.9%,P=0.098)。结论老年乳腺癌患者术后辅助化疗的获益不明显,但对于年纪较轻、伴有合并症较少且伴有腋窝淋巴结转移、ER/PR阴性等高风险因素的患者,应全面综合评估患者的耐受性和获益程度选择术后辅助化疗。     

An update on prognosis in breast cancer patients with extensive axillary disease

Abstract:  Lymph node (LN) status is the most important factor in predicting survival in breast cancer. Historically, patients with 10 or more positive LN have been thought to have a particularly poor prognosis, which has in the past been used to alter therapeutic recommendations. Studies conducted both prior to and after the use of anthracycline-based chemotherapy demonstrate poor survival. We hypothesized that the current survival rate is considerably higher. All patients with breast cancer treated at our institution between July 1991 and December 2005 with at least 10 positive axillary LN were identified. A multivariate Cox proportional hazards model was performed using age, number of positive nodes, and primary tumor characteristics. Of 55 patients identified, two were excluded for incomplete follow-up information. The median patient age was 53; median follow-up was 5-years. The overall 5-year survival rate was 71.9%. On univariate analysis estrogen receptor (ER) status (p = 0.0001), progesterone receptor status (p = 0.004), use of adjuvant chemotherapy (p = 0.01), T-stage (p = 0.03), and adjuvant hormonal therapy (p = 0.002) were statistically significant for survival. In the multivariate analysis, only ER status and the use of adjuvant chemotherapy remained significant for survival. ER negativity conferred a hazard ratio of 12.6 (95% confidence interval: 3.7–43.2) and the use of adjuvant chemotherapy had a hazard ratio of 0.14 (95% confidence interval: 0.04–0.46). In our study, patients with at least 10 positive axillary LN had a 5-year survival of 71.9% which may be due to the improvements in local and systemic therapy.     

Prognostic Implications of Pathological Lymph Node Status After Preoperative Chemotherapy for Operable T3N0M0 Breast Cancer

Background: Although preoperative chemotherapy has become the standard of care for inoperable locally advanced breast cancer, its role for downstaging resectable primary tumors is still evolving. The purpose of this study was to determine whether the prognostic information from an axillary node dissection in patients with clinical T3N0 breast cancer was altered by preoperative chemotherapy compared with surgery de novo.Methods: Between 1976 and 1994, 91 patients with clinically node-negative operable T3 breast cancer received doxorubicin-based combination chemotherapy on protocol at one institution. Fifty-three patients received both preoperative and postoperative chemotherapy (PreopCT), and 38 received postoperative chemotherapy only (PostopCT). All patients underwent axillary lymph node dissection as part of their definitive surgical treatment. There were no differences between the PreopCT and PostopCT groups in median age (51 vs. 49 years), median tumor size at presentation (6 cm vs. 6 cm), tumor grade, or estrogen receptor status (estrogen receptor negative 38% vs. 32%). The median follow-up time was 7 years.Results: Patients in the PreopCT group had fewer histologically positive lymph nodes (median, 0 vs. 3, P < .01), and a lower incidence of extranodal extension (19% vs. 42%, P 5 .02). By univariate analysis, the number of pathologically positive lymph nodes (P < .01) and extranodal extension (P < .01) were predictors of disease-specific survival in PreopCT patients. Multivariate analysis showed that extranodal extension was the only independent prognostic factor in PreopCT patients (P < .01). Overall, PreopCT and PostopCT patients had similar 5-year disease-free survival rates (66% vs. 57%); however, PreopCT patients had worse disease-free (P 5 .01) and diseasespecific survival (P 5 .04) when survival was compared after adjustment for the number of positive lymph nodes. Furthermore, PreopCT patients with 4–9 positive lymph nodes had a lower 5-year disease-free survival rate than PostopCT patients with 4–9 positive nodes (17 vs. 48%, P 5 .04).Conclusions: Axillary lymph node status remains prognostic after chemotherapy. Pathologically positive lymph nodes after preoperative chemotherapy are associated with a worse prognosis than the same nodal status before chemotherapy.     

Treatment of Pure Tubular Carcinoma of the Breast

Abstract: A retrospective study of 63 cases of tubular breast carcinoma was performed to address issues of optimum therapy; in particular, the extent of surgery, the need for axillary lymph node dissection, and the need for postoperative radiation therapy. The patient's mean age at presentation was 57 years. The primary lesions were treated by local excision in 61% of cases and by some form of mastectomy in the remainder. Twenty-one patients were treated with radiation therapy after local excision. Axillary lymph node dissection was performed on 39 patients. The primary lesions ranged in size from 3 to 21 mm (mean 8 mm). Fifteen lesions were larger than 10 mm. Two patients had axillary lymph node metastases (5% of those were treated by axillary lymphadenectomy). These patients were 2 of 15 that had lesions larger than 10 mm. Therefore 13.3% of patients with tumors 10 mm or larger metastasized to axillary lymph nodes. In those two cases, the size of the primary tumor was 11 mm and 14 mm. All patients were free of disease at last follow-up (mean follow-up 4 years, 9 months; median follow-up 4 years). The study demonstrates excellent prognosis for patients with tubular breast carcinoma, regardless of the extent of the surgery, performance of axillary lymph node dissection, or administration of postoperative radiation therapy. Local excision may be adequate to control the primary disease and axillary lymph node dissection may not be necessary in patients with small lesions.     

Outcomes of patients with invasive mucinous and tubular carcinomas of the breast

Invasive tubular carcinoma (ITC) and invasive mucinous carcinoma (IMC) of the breast are rare histologic subtypes of breast cancer associated with favorable prognoses. The aim of our study was to investigate the outcomes for these rare subtypes using the National Cancer Database. Female patients diagnosed with ITC or IMC between 2005 and 2014 were analyzed. The primary outcome was overall survival (OS), and we analyzed its association with adjuvant therapy. 2735 patients with ITC and 5602 patients with IMC were identified. ITC presented in younger patients (57 vs. 67 years), had smaller tumors (size <1 cm, 63.1% vs. 25.4%), earlier stage, and less node-positive disease (5% vs. 8.6%), compared with IMC. Older age, government insurance, lower income, treatment in a community cancer program, large tumor size, positive nodal status, and without endocrine therapy were associated with worse OS with either subtype on multivariate analysis. No OS benefit was found for node-positive ITC that received adjuvant chemotherapy compared with those who did not. (5-year OS of 96.0% vs. 91.3%, p = 0.17).OS was improved for IMC that received adjuvant chemotherapy (10-year OS: 82.5% vs. 60.1%, p = 0.008) and endocrine therapy (10-year OS: 86.6% vs. 81.2%, p < 0.001). We concluded that ITC has favorable clinicopathological characteristics and prognosis, even with node-positive disease. ITC and IMC may need to be evaluated independently when administering adjuvant treatment plans.     

Male breast cancer: management and follow-up recommendations

National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but similar guidelines on male breast cancers are less recognized. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer compared to established guidelines for female patients. After Institutional Review Board approval, a prospective breast database from 1990 to 2009 was queried for male patients. Medical records were examined for clinico-pathological factors and follow-up. The 5-year survival rates with 95% confidence intervals were estimated using Kaplan-Meier method and Greenwood formula. Of the 19,084 patients in the database, 73 (0.4%) were male patients; 62 had complete data. One patient had bilateral synchronous breast cancer. The median age was 68.8 years (range 29-85 years). The mean/median invasive tumor size was 2.2/1.6 cm (range 0.0-10.0 cm). All cases had mastectomy (29 with axillary node dissection, 23 with sentinel lymph node biopsy only, 11 with sentinel node biopsy followed by completion axillary dissection). Lymph node involvement occurred in 25/63 (39.7%). Based on NCCN guidelines, chemotherapy, hormonal therapy, and radiation are indicated in 34 cases, 62 cases, and 14 cases, respectively. Only 20/34 (59%) received chemotherapy, 51/62 (82%) received hormonal therapy, and 10/14 (71%) received post-mastectomy radiation. Median follow-up was 26.2 months (range: 1.6-230.9 months). The 5-year survival estimates for node positive and negative diseases were 68.5% and 87.5%, respectively (p = 0.3). Despite the rarity of male breast cancer, treatment options based on current female breast tumors produce comparable results to female breast cancer. Increased awareness and a national registry for patients could help improve outcomes and tailor treatment recommendations to the male variant.     

Is there a role for axillary dissection for patients with operable breast cancer in this era of conservatism?*

Background: The trend in breast cancer surgery is toward more conservative operative procedures. The new staging technique of sentinel node biopsy facilitates the identification of pathological node‐negative patients in whom axillary dissection may be avoided. However, patients with a positive sentinel node biopsy would require a thorough examination of their nodal status. An axillary ­dissection provides good local control, and accurate staging and prognostic information to inform decisions about adjuvant therapy. In addition, the survival benefit of axillary treatment is still debated. The objectives of the present study were to examine the pattern of lymph node metastases in the axilla, and evaluate the merits of a level III axillary dissection. Methods: Between June 1997 and May 2000, 308 patients underwent a total of 320 level III dissections as part of their treatment for operable invasive breast cancer. The three axillary levels were marked intraoperatively, and the contents in each level were submitted and examined separately. The patterns of axillary lymph node (ALN) metastases were examined, and factors associated with ≥4 positive nodes, and level III ALN metastases were evaluated by univariate and multivariate analyses. Results: An average of 25 lymph nodes were examined per case (range: 8?54), and using strict anatomical criteria, the mean numbers of ALN found in levels I, II and III were 18 (range: 2?43), 4 (range: 0?19), and 3 (range: 0?11), respectively. Axillary lymph node involvement was found in 45% of the cases (143/320). Of the 143 cases, 78% (n = 111) had involvement of level I nodes only, and 21% (n = 30) had positive ALN in levels II and, or, III, in addition to level I. Involvement of lymph nodes in level II or III without a level I metastasis was found in two cases only (0.6%). By including level II, in addition to level I, in the dissection, four cases (1%) were converted from one to three positive nodes to ≥4 positive nodes (P = 0.64). By the inclusion of level III to a level I and II dissection, three cases (1%) were converted from one to three positive nodes to ≥4 positive nodes (P = 0.74). Involvement of lymph nodes in level III was found in 22 cases (7%), and 51 cases (16%) had ≥4 positive nodes. Palpability of ALN, pathological tumour size, and lymphovascular invasion (LVI), were sig­nificantly associated with level III involvement and ≥4 positive nodes by univariate and multivariate analyses. The frequencies of level III involvement and ≥4 positive nodes in patients with palpable ALN were 22% and 42%, respectively. The corresponding frequencies in patients with a clinically negative axilla, and a primary tumour which was >20 mm and LVI positive, were over 14% and 31%, respectively. Conclusion: Level III axillary dissection is appropriate for patients with palpable ALN, and in those with a tumour which is >20 mm and LVI positive, principally to reduce the risk of axillary recurrence. Staging accuracy is achieved with a level II dissection, or even a level I dissection alone based on strict anatomical criteria. Sentinel node biopsy is a promising technique in identifying pathological node‐positive patients in whom an axillary clearance provides optimal local control and staging information.     

Use of trastuzumab in Australia and New Zealand: results from the National Breast Cancer Audit

Background: Trastuzumab increases disease‐free and overall survival in HER‐2‐positive, early breast cancer. In 2007, the National Breast and Ovarian Cancer Centre recommended that patients with HER‐2 positive cancers (node positive or node negative tumours >1 cm) be offered adjuvant trastuzumab with chemotherapy. The aim of this study was to evaluate recent trends in trastuzumab therapy in Australia and New Zealand. Methods: Following data were obtained from the National Breast Cancer Audit for patients treated between 2006 and 2008: tumour size, number of cases recorded per surgeon per year, location of hospital, HER‐2 receptor status, age, lymph node status, chemotherapy and trastuzumab treatment. Results: Data were available from 23 290 patients. During the study period, the percentage of breast cancers tested for HER‐2 rose from 77% to 91%. Patients over 70 had fewer HER‐2 tests than their younger counterparts. Fourteen percent of tumours were HER‐2 positive; the proportion treated with trastuzumab in 2006, 2007 and 2008 was 50%, 66% and 74%, respectively. Significantly more node‐positive patients (77%) were given trastuzumab than node‐negative patients (52%). All the patients prescribed trastuzumab also received chemotherapy. Patients under 70 years, patients treated in Australia and patients treated by higher caseload surgeons were more likely to be prescribed trastuzumab than those over 70, patients in New Zealand and patients treated by lower caseload surgeons. Conclusions: Trastuzumab‐prescribing trends conform to the published guidelines. However, older patients and those with HER‐2 positive, node‐negative tumours >1 cm may be undertreated in some cases.     

Neo‐Adjuvant chemotherapy and its affects to the axilla—Can we safely downgrade axillary surgery to mirror the approach in the breast

The use of neo‐adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast‐conserving surgery is well‐established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo‐adjuvant chemotherapy were identified over a seven‐year period between 2010 and 2017. Surgical plans were compared with pre‐ and post‐chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51 years, and Grade 3, ER‐positive, and Her2‐negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo‐adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.     

Pathologic Tumor Response of Invasive Lobular Carcinoma to Neo‐adjuvant Chemotherapy

Abstract: Neo‐adjuvant chemotherapy is used for locally advanced breast cancer patients with significant variation in tumor response. Our objective is to determine the clinicopathologic effect of neo‐adjuvant chemotherapy on invasive lobular carcinoma. A review of a single‐institution data base of women diagnosed with breast cancer identified 30 patients from 1999 to 2009 with operable invasive lobular carcinoma who received neo‐adjuvant chemotherapy. Patient demographics and clinicopathologic data were reviewed. Cases were reviewed by a single pathologist (NNE). Residual cancer burden class was determined for each case. Median patient age was 50 years (range 25–79). All tumors were hormone receptor positive and clinical stage II or III carcinomas. Most patients (53.3%) had combination anthracycline‐ and taxane‐based chemotherapy. Therapy‐related changes were noted within the tumor bed in 25 (83.3%) patients. Six (30%) of 20 patients with residual axillary disease had therapy‐related nodal changes. There were 11 patients with moderate residual disease (class II) and 18 (60%) with extensive (class III); there were no complete pathologic responses (class 0). Only one patient (3.3%) converted from mastectomy to breast‐conserving surgery. Four (13.3%) patients developed distant metastases; all had pleomorphic‐type, clinical stage III tumors with residual cancer burden III classification and developed distant disease in the 2 years after surgery (range 0–26 months). Median follow‐up time was 29.5 months (range 7–132). Patients with locally advanced pleomorphic‐type lobular carcinoma appear to develop early post‐treatment metastatic disease. Neo‐adjuvant chemotherapy did not appear to have significant impact on the surgical treatment of patients with invasive lobular carcinoma.     

基于SEER数据库乳腺浸润性筛状癌临床病理特征及预后因素分析

目的探讨乳腺浸润性筛状癌的临床病理特征、预后及相关影响因素。方法选择2010—2016年美国国立癌症研究监测、流行病学和最终结局(SEER)数据库中诊断为乳腺浸润性筛状癌的388例病例资料,回顾性分析其临床病理特征与生存情况,及其预后影响因素。结果在388例病人中,287例(74.0%)为T1期,321例(82.7%)为N0期,374例(96.4%)接受手术治疗,204例(52.6%)接受放疗,85例(21.9%)接受化疗。病人3、5年总体生存率分别为94.4%、88.4%。单因素分析显示,年龄、婚姻状态、T分期、M分期、手术、放疗是影响乳腺浸润性筛状癌病人生存预后的相关因素(P<0.05)。多因素分析显示,年龄、T分期、M分期、放疗是影响乳腺浸润性筛状癌病人预后的独立危险因素(P<0.05)。结论影响浸润性筛状癌病人预后的独立危险因素包括年龄、T分期、M分期。放疗对浸润性筛状癌病人的生存率是否有益仍需对浸润性筛状癌进一步深入研究。     

Outcome of small invasive breast cancer with no axillary lymph node involvement

Abstract: The prognosis and need or not for adjuvant therapy in patients with small breast tumors (≤1 cm N0) is the subject of controversy as regards the clinical benefit obtained, toxicity, and the economical costs generated. A retrospective analysis was made of 238 patients with early‐stage breast cancer (pT1 ≤ 1 cm N0M0) diagnosed between January 1993 and May 2008. As regards the systemic adjuvant treatments provided, (a) 122 (51%) received no treatment, (b) 102 (43%) received hormone therapy, (c) 9 (4%) chemotherapy, and (d) 5 (2%) received both hormone therapy and chemotherapy. An analysis was made of disease‐free survival (DFS) and breast cancer‐specific survival in our series of patients, and of their correlation to clinicopathological factors (age, tumor size, histological grade, estrogen receptor (ER) expression, HER‐2 overexpression, and systemic adjuvant therapy). The median follow‐up of this cohort was 63 months (range 5–145). Some type of relapse was recorded in 4.2% of the patients (six patients presented local recurrence in all cases subjected to rescue treatment with surgery and/or radiotherapy, three patients developed distant metastases, and one patient presented a resected local recurrence followed by systemic relapse). The 5 year DFS was 96%, and the 5 year breast cancer‐specific survival was 99.6%. A univariate analysis was made of the clinicopathological variables and their association to DFS. None of the variables was seen to be significantly correlated to shorter DSF except for an association between HER‐2 overexpression and poor outcome borderline significance (p = 0.07). The prognosis of our pT1 ≤ 1 cm N0M0 tumors was excellent, although the absence of systemic adjuvant therapy in one‐half of the patients.     

Casting-type calcifications with invasion and high-grade ductal carcinoma in situ: a more aggressive disease?

HYPOTHESIS: Women with breast cancer who have casting-type microcalcifications associated with multifocal invasion and extensive ductal carcinoma in situ (DCIS) form a subset of patients with a poor prognosis. Our study aims to identify the mammographic and pathologic features of this group. DESIGN: Women with casting-type microcalcifications, multifocal invasion, and extensive DCIS were identified from our tumor board registry. Mammographic features, tumor characteristics, treatment, and survival rates were evaluated. Invasive tumors were limited to 14 mm or smaller. SETTING: University medical teaching hospital and breast cancer specialty clinic. RESULTS: Of the 984 patients with breast cancer treated at our center, 15 patients were identified who had extensive casting-type calcifications and DCIS. Twelve of these patients also had multifocal invasive breast cancer. All had casting-type microcalcifications occupying more than 1 breast quadrant. All but 1 of the patients were treated using mastectomy with sentinel node biopsy or axillary node dissection. All but 1 patient had extensive grade 3 DCIS. Invasive tumors were negative for estrogen receptor and progesterone receptor expression in half of the patients, and 60% were positive for the HER-2-neu receptor. Positive axillary lymph nodes were found in 33% of patients, and 75% received adjuvant chemotherapy. After a median follow-up period of 20.5 months (range, 6-72 months), 1 patient had died and 1 had distant metastases. Of the 3 patients who had DCIS without invasion, 1 experienced a recurrence with infiltrating ductal carcinoma. CONCLUSIONS: In women with small multifocal breast cancers with extensive casting calcifications and DCIS, the incidence of positive lymph nodes was 33%, with a tendency for poor tumor markers. These women appear to be at substantial risk for systemic disease; lymph node sampling and adjuvant systemic therapy are recommended.     

Treatment of the axilla in early breast cancer: past, present and future

Background: The optimal treatment of the axilla in early breast cancer is controversial. The present study reviews the pattern and predictors of regional recurrence (RR) and prognosis after RR in patients with early breast cancer treated by conservative surgery and radiotherapy (CS + RT). Implications of the results on current practice and future directions are explored. Methods: Between 1979 and 1994, 1158 patients with stage I or II breast cancer were treated with CS + RT at Westmead Hospital. Two groups of patients were compared: 782 patients who underwent axillary dissection (axillary surgery group) and 229 patients who received radiotherapy (axillary RT group) as the only axillary treatment. At least 10 lymph nodes were dissected in 82% of the axillary surgery group. Of the women in the RT group, 90% received RT to the axilla and supraclavicular fossa (SCF) only and 10% also received RT to the internal mammary chain (IMC). Results: With a median follow‐up period of 79 months for the axillary surgery group and 111 months for the axillary RT group, 27 patients developed a RR (2.8% and 2.2%, respectively). Seven patients (0.9%) in the axillary surgery group and three patients (1.3%) in the axillary RT group developed a RR in the axilla (P, not significant). Of the patients with SCF recurrences, 14 (1.8%) were in the axillary surgery group and one (0.4%) in the axillary RT group (P, not significant). One patient in the axillary surgery group developed concurrent axillary and SCF recurrences, while a patient in the axillary RT group developed an IMC recurrence. Twenty (74%) of the 27 patients with a RR developed a concurrent or subsequent distant relapse (30% and 44%, respectively). In the pathologically node‐positive patients, the axillary recurrence rate was higher in those who had less than five nodes removed (17%) than those who had 10 or more nodes removed (0%; P = 0.01). The SCF recurrence rate was higher in patients with four or more positive axillary nodes (9.5%) than in those with 0–3 positive nodes (1.5%; P = 0.003). Conclusion: Adequate treatment of the axilla by surgery or RT alone is associated with a low rate of RR. The incidence of distant relapse was substantial in patients who developed a RR, which gives emphasis to the importance of optimizing local–regional control.     

The case for the omission of axillary staging in invasive breast carcinoma that exhibits a predominant tubular growth pattern on preoperative biopsy

True invasive tubular breast carcinoma (TBC) is unlikely to metastasize to axillary nodes, yet it is routinely subjected to sentinel lymph node biopsy (SLNB), even if the diagnosis was suspected preoperatively. The positive predictive value (PPV) of core biopsy for TBC and the incidence and predictors of axillary metastasis in invasive breast carcinomas identified as tubular‐rich on core biopsy are unknown. Prospective patient and tumor data regarding postoperatively confirmed TBCs, and tubular‐rich carcinoma identified on preoperative core biopsy between January 2005 and May 2016 was analyzed retrospectively. Axillary metastasis occurred in only 4.2% (4/95) of TBCs, all of which measured >15 mm pathologically. In 11.1% (11/99) of TBCs, the initial core biopsy was either indeterminate/suspicious or ductal carcinoma in situ (DCIS); therefore, their true tubular histotype and size were ascertained following operative excision and before SLNB. Nine were ≤15 mm, and all were node‐negative. Only 63.9% (46/72) of tubular‐rich core biopsies were confirmed as TBCs; the remaining 36.1% (26/72) were well‐differentiated invasive nontubular carcinomas. None of the preoperative patient or tumor features were predictive of true TBC on multivariable analysis; 10.1% (7/69) of carcinomas identified as tubular‐rich on core biopsy (regardless of their true histotypes) were node‐positive; 23.1% (6/26) in nontubular and 2.3% (1/43) in true tubular carcinomas. Preoperative ultrasound size >15 mm was associated with axillary metastasis in 40.0% (4/10) compared to 5.7% (3/53) in those ≤15 mm (OR = 11.11, 95% CI = 1.99‐62.04; multivariable P = .010). Axillary metastasis in TBC is dependent on pathological size; therefore, a case is made for omitting SLNB in small true TBCs confirmed following excision. Preoperative tubular‐rich core biopsy is not adequately diagnostic of TBC; however, it selects carcinomas that are well‐differentiated, small, and unlikely to metastasize to the axilla, thus allowing for the selective omission of SLNB.