Isolated skin recurrence following salvage mastectomy for intramammary recurrence (after initial breast conservation therapy): is it a fatal event?

Aims

The authors analyzed the outcome of patients with Isolated Skin Recurrence After Salvage Mastectomy (ISRASM) performed after conservative treatment for breast carcinoma, taking into account initial tumor characteristics, intramammary recurrence (first recurrence) characteristics, local skin recurrence (second recurrence) characteristics, and the type of treatment at each stage of the breast cancer continuum.

Methods

Forty-two patients who had ISRASM between 1976 and 2007 were included in this retrospective study. Twenty-six factors were studied in univariate and multivariate analyses.

Results

Mean Overall Survival (OS) was 70.3 (±4.1) months. The 5-year OS rate was 66.6%. 31% of patients did not present any recurrence, 52% had locoregional recurrence and 14% metastatic recurrence following ISRASM. Univariate analysis showed that 4 prognostic factors were significantly related to OS and/or Disease-Free Survival (DFS): (1) initial chemotherapy after primary breast cancer (P = 0.09 and 0.01 respectively), (2) presence of emboli at the site of intramammary recurrence (first recurrence) (P = 0.02 and 0.03), (3) interval between first and second surgery of less than 3 years (P = 0.09 and 0.0003), and (4) inflammatory skin involvement at ISRASM (P = 0.005 and 0.17). Multivariate analysis showed that presence of emboli at the site of intramammary recurrence was significantly related to OS and that an interval between first and second recurrence of less than 3 years was significantly related to DFS.

Conclusion

Our results show that ISRASM affects a group of breast cancer patients with predominantly local rather than metastatic disease. Prognostic factors depend on characteristics at initial breast cancer, first recurrence and second recurrence. Evidence-based guidelines are still required for ISRASM management.     

Risk factors and outcome of early recurrence after resection of small hepatocellular carcinomas

Background

This study aimed to clarify risk factors for early recurrence and examine the subsequent outcome in patients undergoing potentially R0 resection of small hepatocellular carcinomas (HCCs) (≤2 cm in greatest dimension).

Methods

Eighty-nine patients were divided into 2 groups as follows: 26 patients suffering from recurrence within 2 years of surgery (early recurrence group) and 63 patients who were disease-free for at least 2 years (disease-free 2Y group).

Results

Only 7 of 63 patients (11%) from the group that was disease-free for at least 2 years died during the 5-year period after surgery, whereas 13 of 26 patients (50%) from the early recurrence group died. Multivariate analysis showed that the preoperative maximum removal rate of technetium-99m-diethylenetriamine pentaacetic acid-galactosyl human serum albumin and microscopic vascular invasion were independent predictors of the early recurrence of small HCC.

Conclusions

Early recurrence of small HCC is the leading cause of death within 5 years after R0 resection. The preoperative hepatic functional reserve influences early recurrence, even in patients with small tumors.     

Clinical characteristics of women presenting with skin-only recurrence of breast cancer

Background

Locoregional failure after breast cancer treatment is usually heralded as a significant risk factor for systemic recurrence. However, locoregional recurrence may have different presentations, some of which may represent a more benign course. An example of this is the phenomenon of isolated chest wall recurrence (CWR). Given the paucity of data describing the clinical outcomes of women who recur this way, we sought to review the natural history and prognosis of patients presenting with this specific presentation.

Methods

Women who previously underwent primary treatment for breast cancer and subsequently developed an isolated CWR were identified. Histologic and treatment data as it related to their primary diagnosis and demographic data were obtained by chart review. Modalities of treatment for isolated CWR were also collected.

Results

We identified 17 patients who experienced an isolated CWR from January 1987 to May 2005. The median age at original diagnosis was 61 years (range 33-94 years). Median time to isolated CWR was 20 months (range 6-134). Eleven patients were treated with primary resection, 12 with radiotherapy, and 3 with a combination of hyperthermia and electron beam radiation. Ten patients went on to receive endocrine therapy, 6 received chemotherapy, and 2 were observed. Ten of these patients (58%) experienced a second event and for this group the median time to second event was 24 months (range 8-109). Median overall survival was 80 months (range 3-134) for the entire cohort.

Conclusions

Patients experiencing a chest wall recurrence may have a benign course suggesting this may be an indolent presentation of local regional recurrence. The proper therapy of these patients may require further study.     

Outcome of multiple-wire localization for larger breast cancers: do multiple wires translate into additional imaging, biopsies, and recurrences?

Background

Breast conservation is possible in breast cancer patients whose mammographic lesions are large enough to require multiple localizing wires for excision.

Methods

A retrospective review of 112 patients who underwent multiple-wire and 160 controls who underwent single-wire lumpectomy for breast cancer. Rates of in-breast recurrence, metastasis, and additional imaging and biopsy procedures were calculated.

Results

The median follow-up was 24 months. One multiple-wire and 2 single-wire patients developed in-breast recurrences (P = .84). No distant metastases developed among the multiple-wire patients. Additional follow-up imaging was obtained in 29% of multiple-wire and 22% of single-wire cases (P = .1). Seven (6%) of the multiple-wire and 11 (6%) of the single-wire cases underwent biopsy (P = .94).

Conclusions

We found no increased risk of early local recurrence, metastasis, or additional imaging or biopsies in patients requiring multiple-wire localization for lumpectomy. Breast conservation should be considered a safe option even for patients with mammographically extensive lesions.     

Four-year clinical update from the American Society of Breast Surgeons MammoSite brachytherapy trial

Background

We present a 4-year update on the efficacy, cosmetic results, and complications of MammoSite breast brachytherapy in patients enrolled in the American Society of Breast Surgeons registry trial.

Methods

A total of 1,449 breasts in 1,440 patients with early stage breast cancer undergoing breast-conserving therapy were treated with adjuvant, accelerated partial breast irradiation (APBI) (34 Gy in 3.4-Gy fractions) delivered with the MammoSite device. The median follow-up period for the entire group was 36.1 months.

Results

The 3-year actuarial rate of ipsilateral breast tumor recurrence was 2.15%. The 3-year actuarial rate of axillary recurrence was .36%. Complication rates were as follows: infection, 9.5%; seroma, 26.8% (symptomatic seroma, 12.7%); and fat necrosis, 2.0%. The percentages of breasts with good or excellent cosmetic results were as follows: 12 months, 95%; 24 months, 94%; 36 months, 94%; and 48 months, 91%.

Conclusions

Locoregional control, complications, and cosmetic outcomes from MammoSite APBI at the 4-year update are acceptable and similar to results seen with other forms of APBI.     

Radiofrequency ablation of unresectable liver tumors: factors associated with incomplete ablation or local recurrence

Background

Radiofrequency ablation (RFA) of liver tumors is associated with a risk of incomplete ablation or local recurrence.

Methods

One hundred sixty-eight patients with 311 unresectable liver tumors were included. Effects of different variables on incomplete ablation and local recurrence were analyzed.

Results

There were 132 hepatocellular carcinomas and 179 liver metastases. Tumor size was 24 (±13) mm. Two hundred twenty-six tumors were treated percutaneously, and 85 through open approach (associated with liver resection in 42 cases). There was no mortality. Major morbidity rate was 7%. Incomplete ablation and local recurrence rates were 14% and 18.6%. Follow-up was 29 months. On multivariate analysis, factors associated with incomplete ablation were tumor size (>30 mm vs ≤30 mm, P = .004) and approach (percutaneous vs open, P = .0001). Factors associated with local recurrence were tumor size (>30 mm vs ≤30 mm, P = .02) and patient age (>65 years vs ≤65 years, P = .05).

Conclusions

RFA is effective to treat unresectable liver tumors. However, there is a risk of incomplete ablation when percutaneously treating tumors >30 mm. When tumor ablation is completely achieved, the main factor associated with local recurrence is tumor size >30 mm.     

Long-term follow-up results of breast cancer patients with sentinel lymph node biopsy using periareolar injection

Background

Areolar injection for sentinel lymph node biopsy (SLNB) in breast cancer surgery has been adopted by many institutions. However, only one study has reported the follow-up results for patients whose SLNB was performed with this injection method alone.

Methods

Three hundred eighty patients with breast cancer underwent SLNB with periareolar injection of both blue dye and radiotracer. The follow-up consisted of a physical examination every 3 months and annual mammography.

Results

Of 380 patients with SLNB, 261 were found to have negative sentinel lymph nodes so that no ALND was performed. At a median follow-up of 39 months (range 13-74), 2 of the 261 patients developed axillary recurrence for an axillary relapse incidence of .77%. Five-year distant disease-free survival was 96.9%, and overall survival was 99.4%.

Conclusions

The incidence of axillary recurrence for the areolar injection method was low and consistent with that reported in other observational studies using other injection methods.     

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.     

Pelvic/retroperitoneal salvage lymph node dissection for patients treated with radical prostatectomy with biochemical recurrence and nodal recurrence detected by [11C]choline positron emission tomography/computed tomography

Background

The management of patients with clinical recurrence of prostate cancer after radical prostatectomy (RP) remains challenging.

Objective

To determine whether the removal of positive lymph nodes at [11C]choline positron emission tomography/computed tomography (PET/CT) scan may have an impact on the prognosis of patients with biochemical recurrence (BCR) and nodal recurrence after RP.

Design, setting, and participants

Prospective analysis of 72 patients affected by BCR after RP associated with a nodal pathologic [11C]choline PET/CT scan.

Intervention

Patients underwent salvage lymph node dissection (LND).

Measurements

Biochemical response (BR) to treatment was defined as prostate-specific antigen (PSA) <0.2 ng/ml at 40 d after salvage LND. Kaplan-Meier and Cox regression analyses addressed time to and predictors of clinical recurrence (CR) after salvage LND, respectively.

Results and limitations

Overall, 56.9% of patients achieved BR. Mean and median follow-up after LND were 39.4 and 39.8 mo, respectively. The 5-yr BCR-free survival rate was 19%. Preoperative PSA <4 ng/ml (hazard ratio [HR]: 0.12; p = 0.005), time to BCR <24 mo (HR: 7.52; p = 0.005), and negative lymph nodes at previous RP (HR: 0.19; p = 0.04) represented independent predictors of BR. Overall, 5-yr CR-free and cancer-specific survival were 34% and 75%, respectively. At multivariable analyses, only PSA >4 ng/ml (HR: 2.13; p = 0.03) and the presence of retroperitoneal uptake at PET/CT scan (HR = 2.92; p = 0.004) represented independent preoperative predictors of CR. Similarly, the presence of pathologic nodes in the retroperitoneum (HR: 2.78; p = 0.02), higher number of positive lymph nodes (HR: 1.04; p = 0.006), and complete BR to salvage LND (HR: 0.31; p = 0.002) represented postoperative independent predictors of CR. Main limitations consisted of the lack of a control group and the heterogeneity of patients included in the analyses.

Conclusions

Salvage LND is feasible in patients with BCR after RP and nodal pathologic uptake at [11C]choline PET/CT scan. Biochemical response after surgery can be achieved in a consistent proportion of patients. Although most patients invariably progressed to BCR after surgery at longer follow-up, 35% of patients showed the absence of CR at 5 yr.     

Impact of initial surgical margins and residual cancer upon re-excision on outcome of patients with localized breast cancer

Background

A significant proportion of patients undergoing breast conservation therapy require additional operations to obtain clear margins. The aim of this study was to assess the impact of initial margins and residual carcinoma found on second surgery on the outcomes of breast cancer patients.

Methods

In this retrospective study, Cox proportional-hazard regression analysis was performed to evaluate data from 437 patients with stage I to IIIA breast cancer who underwent initial breast-conserving surgery between 1994 and 2004.

Results

The distant recurrence rate was higher among patients with initial positive margins than among those with initial negative margins (15.5% vs 4.9%; hazard ratio, 3.6; 95% confidence interval 1.5-8.7; P = .003). For patients who had underwent second surgery, the finding of a residual invasive carcinoma was associated with increased risk for distant recurrence (22.8% vs 6.6%; hazard ratio, 3.5; 95% confidence interval, 1.8-7.4; P = .0001).

Conclusion

Invasive residual carcinoma found during subsequent surgery after initial compromised margins is an important prognostic marker for distant recurrence.     

Surgical treatment in Paget's disease of the breast

Background

The aim of this study was to evaluate the outcomes of surgical treatment of Paget's disease of the breast, with special emphasis on magnetic resonance imaging (MRI) and sentinel node biopsy (SNB).

Methods

The study included 58 consecutive patients with Paget's disease treated from 1995 to 2006.

Results

Twenty-five patients had ductal carcinoma in situ, and 31 had invasive carcinoma. MRI was performed in 14 patients, with positive findings in 7 patients, 5 of whom had negative findings on conventional imaging. The overall mastectomy rate was 76%. Eighteen patients underwent SNB, and 26 patients underwent full or partial axillary clearance. Fourteen patients had no axillary surgery. One patient had local recurrence after breast conservation, and another had axillary recurrence after negative results on SNB. Six patients had distant metastases. Four patients died of breast cancer.

Conclusions

Paget's disease is frequently associated with peripheral or multicentric cancer. MRI may be helpful when considering breast conservation or omitting axillary nodal staging.     

Risk factors for intrahepatic recurrence after hepatectomy for hepatocellular carcinoma

Background

Long-term survival after hepatectomy for hepatocellular carcinoma is still poor because of tumor recurrence especially in the liver remnant. The risk factors for intrahepatic recurrence after liver resection are studied in our cohort of patients.

Methods

A retrospective analysis from a prospective database was performed on 76 consecutive successful hepatectomies for hepatocellular carcinoma.

Results

Twenty-two patients had intrahepatic recurrence. The following were not found to be risk factors for recurrence: age, sex, race, number of segments resected, and mean operating time. By using multivariate analysis, serum aspartate transaminase level, more than 1 hepatocellular carcinoma nodule, and presence of tumor thrombi were found to be significant risk factors.

Conclusion

Patients who with these risk factors should undergo close follow-up to detect recurrence early; treatment with reresection, chemoembolization, or radiofrequency ablation can be considered.     

The use of positron emission tomography in detecting hepatoblastoma recurrence--a cautionary tale

Purpose

The use of positron emission tomography (PET) with [18F] fluorodeoxyglucose (FDG) in the detection of recurrences has been well established in many tumor types. Here the authors present their experience using this modality in the evaluation of posttreatment hepatoblastoma patients.

Methods

The authors conducted a retrospective review on patients with hepatoblastoma diagnosed from 1996 to 2003. FDG-PET imaging was performed together with measurement of alpha-fetal protein (AFP) during posttreatment follow-up.

Results

Sixteen patients (8 boys and 8 girls) were identified in this series. The mean age was 23.5 months (range, 5 months to 4 years). Three posttreatment patients had PET results suggestive of tumor recurrence. One of these patients had normal AFP level and suspected recurrence in the caudate lobe. Radiologic-guided biopsy was performed 3 times, and there was no evidence of tumor. The other 2 patients underwent further liver resections because of mildly raised AFP levels. The histology of these showed regenerative liver tissue only with no hepatoblastoma recurrence.

Conclusions

Although PET has been gaining popularity as a tool in the detection of tumor recurrences worldwide, it has been shown in this series that PET may not be useful in hepatoblastoma patients, and caution must be taken in the interpretation of positive results.     

Factors associated with improved outcome after surgery in metastatic breast cancer patients

Background

Recent studies suggest local surgical therapy improves survival in metastatic breast cancer (MBC). We evaluate the difference in outcome in patients with MBC after mastectomy versus breast conservation (BCT) and factors that influence outcome.

Methods

In a retrospective review of our prospective database, we identified patients who presented with MBC (1990 to 2007). Patient surgery type and clinicopathologic factors were reviewed. We compared OS between pts dependent on surgery and clinicopathologic factors.

Results

Of the 566 patients with MBC, 154 (27%) underwent removal of the primary tumor. Surgery was associated with an improved OS (33%) versus no surgery (20%) (P = 0.0015). Of those undergoing local therapy; mastectomy was associated with a 37% OS vs BCT with a 20% OS (P = 0.04).

Conclusions

Our study confirms that removal of the primary tumor in MBC is associated with improved overall survival. It appears that mastectomy is associated with a significantly improved overall survival.     

Tubular carcinoma of the breast: results of a large contemporary series

Background

Tubular carcinoma (TC) of the breast is an uncommon subtype associated with a favorable prognosis. This study aimed to assess recent trends and prognostic features in the treatment of TC.

Methods

We performed a retrospective review of cases of TC of the breast treated between 1997 and 2004.

Results

We identified 111 cases of TC of the breast. The median patient age at diagnosis was 55 years, and the median follow-up period was 72 months. Breast-conservation surgery was performed in 75% (83 of 111) of patients. Axillary staging was performed in 80% (89 of 111). Nine (8.1%) were found to be node-positive. Node positivity was associated with larger tumor size (P = .003). All node-positive tumors were greater than 1 cm. One patient developed an in-breast recurrence. No patient developed distant metastases or died from breast cancer.

Conclusions

In this series of TC, the locoregional recurrence rate was low and no patient developed distant metastases. Surgical staging of the axilla may not be necessary in lesions measuring 1 cm or less.     

Clinical importance of micrometastasis in sentinel lymph nodes

Introduction

We evaluated the incidence of micrometastasis and nonsentinel lymph node metastasis as well as local and axillary recurrence rates after level I-II axillary lymph node dissection.

Materials and methods

Patients (n = 760) with early-stage breast cancer underwent sentinel lymph node biopsy, and 45 patients (6.0%) with micrometastasis (0.2-2.0 mm) were included in this study. Data concerning tumor, patients’ characteristics and adjuvant treatments were recorded.

Results

The median age was 46 (26-67) years, median breast tumor size was 20 (1-50) mm, and median number of excised sentinel lymph nodes were 2 (1-5). All patients with micrometastasis underwent further level I-II axillary lymph node dissection. Eleven of 45 (24.4%) patients with micrometastasis in their sentinel lymph node biopsy had nonsentinel lymph node metastasis after an axillary lymph node dissection. There was no factor related to nonsentinel lymph node metastasis. Stage migration occurred in 4 of 45 patients (8.8%) due to the detection of micrometastases or macrometastases in nonsentinel lymph nodes.

Discussion

The classical treatment after detection of micrometastasis in sentinel lymph nodes is further axillary dissection. However, nonrandomized, nonprospective studies with 4-5 years follow up showed 0.6% axillary recurrence without further axillary lymph node dissection, although we still need the results of randomized controlled studies.     

Thyroglossal duct infections and surgical outcomes

Purpose

Thyroglossal duct cysts (TGDC) are the most common head and neck congenital anomalies in children and often present as infected neck masses. The authors reviewed their experience with TGDC to determine if preoperative infection was related to postoperative complications, including recurrence and postoperative infection.

Methods

The medical records of 99 patients undergoing excision of TGDC from January 1991 to July 2002 were reviewed. Factors thought to be associated with recurrence (age, history of infection, drainage, abscess, and operative procedure) were analyzed.

Results

Ninety-nine patients made up the study group. The mean age at operation was 5.0 years (range, 6 months to 16 years) with a male to female ratio of 1.6:1. TGDC recurred in 12.1% (12 of 99) of these patients. There was no gender difference for those with and without recurrence. The presence of an abscess or cellulitis preoperatively (22 of 99 patients) did not correlate with recurrence (NS). In addition, postoperative infection occurred in 13 of 99 patients and also was independent of preoperative infection. However, postoperative infection clearly was associated with an increased risk of TGDC recurrence. Seven of 87 patients without recurrence had a postoperative infection, whereas 6 of 12 of those who had a recurrence had a postoperative infection (P < .001). The mean follow-up was 3.7 years and was comparable for the 2 groups (recurrence v. resolution). Twelve patients successfully underwent a second procedure for recurrence.

Conclusions

In this large series of TGDC, preoperative infection occurred in approximately 1 of 5 patients and was not predictive of recurrence. Although postoperative infection did not correlate with the presence of preoperative infection, it was clearly associated with a statistically significant incidence of recurrent disease.     

More than 150 consecutive open umbilical hernia repairs in a major Veterans Administration Medical Center

Background

The purpose of this study was to determine the rate of surgical site infection for open elective umbilical hernia repairs and to identify the factors related to an increased risk of infection and/or recurrence.

Methods

A retrospective analysis of 152 open elective umbilical hernia repairs between 2003 and 2007 was performed.

Results

Overall, 19% of repairs became infected. Both high ASA classification (P = .01) and mesh repair (P = .01) significantly predicted wound infection, whereas age >60 years, body mass index >30, smoking, immunosuppression, diabetes, and hernia size did not. Only 2 of 17 infected mesh repairs required removal of the mesh. The recurrence rate was 1.5% for mesh and 9.2% for suture repairs.

Conclusions

Umbilical hernia repair is associated with a high rate of infection, and most superficial mesh infections can be treated with antibiotics alone. In addition, mesh repair of umbilical hernias decreased the rate of recurrence but increased the risk of infection compared with suture repairs.     

Does magnetic resonance imaging accurately predict residual disease in breast cancer?

Background

The accuracy of magnetic resonance imaging (MRI) in identifying residual disease after breast conservation therapy (BCT) is unclear.

Method

Review of an institutional database identified patients with positive or close (≤2 mm) margins undergoing MRI before re-excision. Histopathologic correlation was performed.

Results

Forty-three women underwent MRI after BCT. MRI suggested residual disease in 29 patients, of whom 20 (69%) had residual carcinoma pathologically. Nine patients had false-positive MRI as seen by benign pathology findings. Fourteen MRIs indicated no residual disease, of which 6 had residual disease pathologically. The sensitivity and positive predictive value of MRI was 77% and 69%, respectively. MRI conducted within 28 days of the original surgery was 85% sensitive. MRI performed after 28 days was 69% sensitive.

Conclusions

MRI is able to detect residual disease among most patients undergoing re-excision. False-positive results may be caused by inflammatory processes that resemble residual disease.     

Scientific Presentation Award: The impact of magnetic resonance imaging on surgical treatment of invasive breast cancer

Background

The purpose of this study was to examine the relationship between magnetic resonance imaging (MRI) and surgical treatment of invasive breast cancer (IBC).

Method

The IBC patients treated from January 2003-June 2008 were reviewed by a single institution.

Results

A total of 814 patients were treated, out of which 562 (69%) underwent breast conservation therapy (BCT), 151 (19%) chose mastectomy alone (M), and 101 (12%) chose mastectomy with reconstruction (M+ R). The mean age was comparatively low in M + R patients (P ≤ 0.001). The mean tumor size was the lowest in BCT patients (P ≤ 0.001). MRI use increased with no significant difference in type of surgery as noted by year. In multivariate analysis, type of surgery was significantly associated with tumor size, multifocality, age, and MRI use. The factors associated with MRI performance were: multifocality, younger age, tumor size, lobular histology, body mass index, and genetic testing.

Conclusions

The use of MRI in IBC patients has increased over the past 5 years, without any observable impact on surgical treatment. Similar factors are associated with mastectomy and MRI performance.