局部晚期乳腺癌新辅助化疗预后因素分析

目的 探讨术前接受长春瑞滨联合表柔比星(VE)方案治疗的局部晚期乳腺癌的预后影响因素.方法 回顾分析2001年9月至2006年5月术前接受3个周期VE方案化疗的119例局部晚期乳腺癌患者的临床病理资料.所有患者均经术前空心针活检证实为浸润性乳腺癌,新辅助化疗后接受手术治疗.术后根据新辅助化疗的临床疗效,再继续接受3个周期VE或标准的环磷酰胺+表柔比星+氟尿嘧啶(CEF)方案辅助化疗及局部区域放射治疗和相应的内分泌治疗.分析新辅助化疗前及术后临床病理资料与预后的关系.结果 新辅助化疗后临床完全缓解27例(22.7%),部分缓解78例(65.5%);肿瘤原发灶病理完全缓解(pCR)22例(18.5%).本组115例(96.6%)获得随访,随访时间9～76个月,中位时间63.4个月.无局部复发转移患者共72例(60.5%).5年无病生存率为58.7%,5年总生存率为71.3%.多因素分析显示,新辅助化疗前Ki-67(pre-Ki-67)高表达(P=0.012)、化疗后Ki-67(post-Ki-67)高表达(P=0.045)、化疗后病理未完全缓解(P=0.034)与无病生存时间的降低有关;pre-Ki-67高表达(P=0.017)、post-Ki-67高表达(P=0.001)、pre-ER阴性(P=0.002)、化疗后病理未完全缓解(P=0.034)与总生存时间的降低有关.结论 pre-Ki-67、post-Ki-67及pre-ER的表达水平和新辅助化疗后肿瘤原发灶病理状况是接受术前3个周期VE新辅助化疗局部晚期乳腺癌的独立预后因素.     

Impact of a Raised Body Mass Index on Breast Cancer Survival in Relation to Age and Disease Extent at Diagnosis

Abstract: The prognostic value of Body Mass Index (BMI) on breast cancer outcome is controversial and previous studies from this unit have not shown any significant relation to survival. The aim of this study was to re‐examine any impact of a raised BMI on recurrence and survival related to age and disease stage at the time of diagnosis. Breast cancer patients (2,298) were reviewed and divided in groups by BMI. Recurrence Free Survival (RFS), Breast Cancer Specific Survival (BCSS), and Overall Survival (OS) were compared by Kaplan–Meier life table analysis. Known prognostic factors including BMI were tested for independent prognostic significance in a Cox’s regression model. Obese patients (417) had on average larger tumors (median 2.3 versus 2.1 cm, p < 0.01). A trend to an increased positive node status (37% versus 33%) was not significant, p = 0.18. Seven‐year RFS was 82% versus 77% in the obese, p < 0.01, BCSS was 87% versus 85%, p = 0.046 and OS 81% versus 77%, p = 0.02. BMI was independently associated with RFS in multivariate analysis (HR: 1.43, p < 0.01). In subgroup analysis, survival differences were most prominent in patients with node positive disease and in patients <60‐years old. Breast cancer outcome was worse in patients with a raised BMI and this risk was greater in younger patients and in those with node positive disease. The difference may be related to diagnosis at a more advanced stage in the obese but there was also an independent effect of BMI on survival.     

Detection of disseminated tumor cells in locally advanced breast cancer patients before primary systemic therapy

AimTo assess the prevalence and prognostic power of disseminated tumor cells (DTC) in patients with locally advanced breast cancer (LABC) before primary systemic therapy (PST).Materials and methodsLABC patients attending our Breast Unit were studied between 2002 and 2012, all of them being considered for PST. To determine the presence of DTC, posterior iliac crest aspirates were obtained and marrow samples were processed by gradient separation with Ficoll (Lymphoprep^®) and immunohistochemical staining using the antiCK A45-B/B3 (EPIMET) antibody. Clinicopathologic variables were recorded before and after PST to assess response. Disease-free survival (DFS) and overall survival (OS) were determined after follow-up. The presence of DTC as a predictor of response to PST and as a prognostic tool for OS and DSF was evaluated.ResultsDTC were observed in 26% of 47 patients included in the study. PST consisted of chemotherapy in 94% and hormone therapy in 6%. Breast-conserving therapy was attained in 33%. Mean follow-up was 68 months. Complete clinical response (CR) after PST was seen in 26%, disease recurrence in 38%, and cancer-related death in 8%; tumor size and negative estrogen receptors were significant predictors of CR and mastectomy was associated with DFS. Persistent axillary disease after PST and previous recurrence were predictive of OS. DTC were detected more often in patients who did not achieve CR and those who presented recurrence. DTC detection was a significant prognostic factor for a worse OS (OR = 7.62; CI95%: 1.46–39.61; p = 0.009) and a decreased survival time (62 versus 82 months, p = 0.004).ConclusionPresence of DTC before PST was found in a significant number of patients with LABC. DTC were found to be a significant prognostic factor for cancer-related death. DTC could be a surrogate predictor of response to PST and also of disease recurrence in LABC patients.     

Inflammatory breast cancer: results of antracycline-based neoadjuvant chemotherapy

Abstract: Twenty-three patients with inflammatory breast cancer treated with a combined modality approach including anthracycline-based induction chemotherapy-surgery-chemotherapy-radiotherapy were reviewed. Twelve patients (52.2%) received FAC (5-fluorouracil, adriamycin, cyclophosphamide) and 11 patients (47.8%) were treated with FEC (5-fluorouracil, epirubicin, cyclophosphamide) induction chemotherapy for three cycles every 3 weeks. Surgery was followed by the initial chemotherapy or second-line chemotherapy for an additional six cycles to complete nine cycles and radiotherapy, respectively. The median overall survival (OS) time was 27 months and the median disease-free survival (DFS) was 13 months. Furthermore, patients treated with FAC induction chemotherapy have been found to have longer median OS and DFS periods compared to patients with FEC induction chemotherapy in both univariate and multivariate analysis. In conclusion, the superiority of doxorubicin-containing chemotherapy over epirubicin-containing chemotherapy should be established in larger randomized studies and more effective chemotherapeutic agents such as taxans are required for better survival rates in inflammatory breast cancer patients.      

High-Dose Chemotherapy with Peripheral Blood Stem Cell Support for Operable Locally Advanced Noninflammatory Carcinoma of the Breast

▪ Abstract: The purpose of this study was to determine outcomes for patients with operable noninflammatory stage IIIA/B locally advanced breast cancer (LABC) with positive axillary lymph nodes receiving high-dose chemotherapy (HDC) with peripheral blood stem cell (PBSC) support. One hundred fifteen patients with LABC who were no evidence of disease (NED) after initial surgery received standard dose induction chemotherapy, chemotherapy for mobilization of PBSC, and high-dose cyclophosphamide, thiotepa, and carboplatin with PBSC support for adjuvant therapy. Following hematopoietic recovery, all patients were scheduled to receive radiation therapy and tamoxifen was administered if the primary tumor was estrogen receptor/progesterone receptor (ER/PR) positive. Eighty-eight percent of patients were admitted to the hospital following HDC for a median of 11 days (range 3–26) and 12% were treated entirely as outpatients. There was one treatment-related death (0.9%) from infection occurring on day 8 after HDC. Forty-four (38%) have relapsed at a median of 20 months (range 10–55) from diagnosis, 11 (10%) with local-regional and 33 (28%) with metastatic disease. The probabilities of overall (OS) and event-free survival (EFS) for all 115 patients at 3 years were 0.73 and 0.61, respectively, with a median follow-up of 42 months (range 10–89) from diagnosis. In univariate and multivariate analyses, no factors could be identified that were statistically predictive for OS or EFS. However, there were trends for patients with ER/PR-negative primary tumors to have worse OS (p = 0.16) and EFS (p = 0.10) than patients with ER/PR-positive tumors. This adjuvant combined modality strategy incorporating HDC is safe and compares favorably to historical studies of neoadjuvant or adjuvant treatment for LABC. Further attempts to improve outcomes of patients with LABC receiving HDC are warranted. ▪     

The interaction of estrogen receptor status and race in predicting prognosis for stage I breast cancer patients

As part of a multi-institutional breast cancer data base, 501 stage I, node negative patients have been followed prospectively with a median of 89 months. Patients were treated by a modified radical mastectomy without postoperative therapy. Estrogen receptor (ER) content of the primary tumor was determined in all cases. For the entire patient group at 10 years, the disease-free survival (DFS) rate is 72% and the overall survival (OS) rate is 85%. Both ER value and race (black versus white) were found to be significant prognostic variables for DFS (p = 0.008 and 0.02, respectively) and for OS (p = 0.0001 and 0.01, respectively). ER positive patients had a better DFS and OS rate compared with ER negative patients (74% versus 66% and 90% versus 68%, respectively). Black patients had significantly worse DFS and OS rates compared with white patients (64% versus 74% and 75% versus 86%, respectively). Statistical interaction between the ER and race variables was apparent when comparing the similar DFS for ER positive white (75%), ER negative white (72%), and ER positive black (73%) patients in contrast to a DFS of less than 42% at 10 years for the ER negative black patients. An analysis of the data for the ER negative black patients suggested that the postmenopausal ER negative black patients are at particularly high risk of recurrence and death from breast cancer.     

Long-Term Survivals of Stage IIB Osteosarcoma: A 20-Year Experience in a Single Institution

Background

The purpose of this study is to evaluate the disease-free survival (DFS) and overall survival (OS) of patients with stage IIB osteosarcoma at a single institution for 20 years and to compare the results according to the chemotherapy protocols.

Methods

From Jan 1988 to Nov 2008, 167 patients with osteosarcoma were treated at our hospital and among them, 117 patients (67 males and 50 females) with stage IIB osteosarcoma were evaluable. Their mean age was 22.6 years (range, 8 months to 71 years). Seventy-eight cases underwent the modified T10 (M-T10) protocol (group 1), 23 cases underwent the T20 protocol (group 2) and 16 cases underwent the T12 protocol (group 3). The DFS and OS were calculated and compared according to the chemotherapy protocols.

Results

At a mean follow-up of 78.9 months, 63 patients were continuously disease-free (63/117), 6 patients were alive after having metastatic lesions, 7 patients died of other cause and 41 patients died of their disease. The 5- and 10-year OS rates were 60.2% and 44.8%, respectively and the 5- and 10-year DFS rates were 53.5% and 41.4%, respectively. There was no significant difference of the OS and DFS between the chemotherapy protocols (p = 0.692, p = 0.113).

Conclusions

At present, we achieved success rates close to the internationally accepted DFS and OS. We were able to achieve the higher survival rates using the M-T10 protocol over the 20 years. However, there was no significant difference of results between the chemotherapy protocols. We think the M-T10 protocol will achieve more favorable results in the near future.     

Young women with locally advanced breast cancer who achieve breast conservation after neoadjuvant chemotherapy have a low local recurrence rate

Women with locally advanced breast cancer (LABC) who are breast conservation (BCT) candidates after neoadjuvant chemotherapy have the best long-term outcome and low local-regional recurrence (LRR) rates. However, young women are thought to have a higher risk of LRR based on historical data. This study sought to evaluate LRR rates in young women who undergo BCT after neoadjuvant chemotherapy. We identified 122 women aged 45 years or younger with American Joint Committee on Cancer (AJCC) Stage II to III breast cancer, excluding T4d, treated with neoadjuvant chemotherapy from 1991 to 2007 from a prospective, Institutional Review Board-approved, single-institution database. Data were analyzed using Fisher eExact test, Wilcoxon tests, and the Kaplan-Meier method. Median follow-up was 6.4 years. Fifty-four (44%) patients had BCT and 68 (56%) mastectomy. Forty-six per cent were estrogen receptor-positivity and 28 per cent overexpressed Her2. Mean pretreatment T size was 5.6 cm in the BCT group and 6.7 cm in the mastectomy group (P = 0.04). LRR rates were no different after BCT compared with mastectomy (13 vs 18%, P = 0.6). Higher posttreatment N stage (P < 0.001) and AJCC stage (P = 0.008) were associated with LRR but not pretreatment staging. Disease-free survival was better for patients achieving BCT, with 5-year disease-free survival rates of 82 per cent (95% CI, 69 to 90%) compared with 58 per cent (95% CI, 45 to 69%) for mastectomy (P = 0.03). Young women with LABC who undergo BCT after neoadjuvant chemotherapy appear to have similar LRR rates compared with those with mastectomy. This suggests that neoadjuvant chemotherapy may identify young women for whom BCT may have an acceptable risk of LRR.     

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。     

The Integrated Evaluation of the Results of Oncoplastic Surgery for Locally Advanced Breast Cancer

The optimal surgical management of locally advanced breast cancer (LABC) remains undefined. The aim of the study was to obtain long‐term results of oncoplastic surgery in terms of overall survival, loco‐regional recurrence, and quality of life in case of LABC. Prospective cohort study enrolled 60 patients with stage III breast cancer. Forty‐two (70%) patients received neo‐adjuvant chemotherapy, 28 patients were considered suitable for surgery as initial treatment option. Type II oncoplastic surgery was performed for all patients: hemimastectomy and breast reconstruction with latissimus dorsi flap – for 29 (48.3%), lumpectomy – 31 (51.7%), and reconstruction with subaxillary flap for four (6.7%), with bilateral reduction mammoplasty – 14 (23.3%) and with J‐plastic – 13 (21.7%) patients. Adjuvant chemotherapy and hormonal therapy followed surgery for all, except one, patients. Sequential radiotherapy was administered for all patients. The mean period of follow‐up was 86 months. Postoperative morbidity rate was 5%. Local‐regional recurrence was detected in six (10%) patients. After reoperation no local relapse was diagnosed. However, three of these patients had systemic dissemination of the disease. Distant metastasis was detected in 23 (38.3%) patients. Distant metastasis‐free survival at 5 years was 61.7%. Fourteen patients died (23.3%). A total of 87.2% of the patients had good and excellent esthetic outcome. Oncoplastic breast‐conserving surgery can be proposed for selected patients with LABC with acceptable complication, local recurrence rate, and good esthetic results.     

Primary chemo-radiotherapy in the treatment of locally advanced and inflammatory breast cancer

BackgroundThe best management of large, diffuse or inflammatory breast cancers is uncertain and the place of radiotherapy and/or surgery is not clearly defined.MethodsA cohort of 123 patients with non-metastatic locally advanced or inflammatory breast cancer 3 cm or more in diameter or T4, was treated between 1989 and 2006. All patients received primary chemotherapy followed by radiotherapy, 40 Gy in 15 fractions with 10 Gy boost. Patients with ER positive tumours received Tamoxifen. Assessment was carried out 8 weeks post-treatment and surgery was reserved for residual or recurrent disease.ResultsFor each stage there were T2/3: 63, T4b: 31 and T4d: 29 patients. 80 had complete clinical response (65%) but 18 patients were never free of inoperable local disease. 25 patients had residual operable disease at assessment and 12 patients who initially had a complete response developed operable local recurrence (LR). 37 Patients (30%) had surgery at a mean of 15 months post diagnosis. At 5 years, overall survival (OS) of the two surgical groups was not significantly different from those 68 patients who had complete remission without surgery, p = 0.218, HR 1.46 (0.80–2.55). Surgery as an independent variable to predict survival was not significant on a Cox proportional hazards model (p = 0.97). LR in the surgical groups was 13.5% vs 17.5% in the non-surgical patients. The median OS was 64.5 months and disease-free survival (DFS) was 52.5 months. 5-Year OS was 54% and DFS survival 43%.ConclusionIn patients with a complete or partial response to chemo-radiotherapy for locally advanced or inflammatory breast cancer, reserving surgery for those with residual or recurrent local disease did not appear to compromise survival. This finding would support examination of this treatment strategy by a randomised controlled trial.     

Outcome of pN0 Triple‐Negative Breast Cancer with or without Lymph Node Irradiation: A Single Institution Experience

The optimal management of patients with pathologically node‐negative triple‐negative breast cancer (pN0 TNBC) remains unclear. We hypothesized that lymph node irradiation (LNI; internal mammary chain/periclavicular irradiation) had an impact on outcomes of pN0 TNBC. A cohort of 126 consecutive patients with pN0 TNBC treated between 2007 and 2010 at a single institute were included. All radiotherapy (breast/chest wall, ±LNI) was delivered adjuvantly, following completion of surgery ± chemotherapy. Tumors were reviewed and histologic features were described. Tissue microarrays were constructed and tumors were assessed by immunohistochemistry using antibodies against ER, PR, HER2, Ki‐67, cytokeratins 5/6, 14, epidermal growth factor receptor and androgen receptor. Patients were divided into two groups for statistical analysis: LNI (LNI+) or no LNI (LNI?). We focused on disease‐free survival (DFS), metastasis‐free survival (MFS), and overall survival (OS). Fifty‐seven and 69 patients received or not LNI, respectively. Median age was 52 (range [25–76]) and 55 (range [29–79]) in LNI+ and LNI? group (p = 0.23). LNI was associated with larger tumors (p = 0.033), central/internal tumors (33 versus 4, p < 0.01) and more chemotherapy (86% versus 59.4% p < 0.01). The median follow‐up was 53.5 months. The rate of first regional relapse (associated or not with distant relapse) was low in both groups. There was no difference in 4‐year DFS (82.2% versus 89.9%; p = 0.266), MFS (87.0% versus 91.1%; p = 0.286) and OS (85.8% versus 89.9%; p = 0.322) between LNI+ and LNI? group, respectively. In univariate analysis, only clinical size (T >10 mm versus ≤10 mm), histologic size (pT >10 mm versus ≤10 mm) and grade 3 (versus grade 2) were found to be significantly associated with shorter DFS. Omission of LNI in patients with pN0 TNBC does not seem to result in poorer outcome. Further studies are needed to specifically evaluate LNI in pN0 TNBC with histologic grade 3 and/or (p)T >10 mm.     

Addition of adjuvant tamoxifen to cyclophosphamide,methotrexate and 5-fluorouracil for premenopausal women with oestrogen receptor-positive breast cancer

OBJECTIVE: To study the value of adjuvant tamoxifen (TAM) in premenopausal women with oestrogen receptor (ER)-positive breast cancer who received adjuvant cyclophosphamide, methotrexate and 5-fluorouracil (CMF) polychemotherapy. METHODS: Four hundred and two premenopausal ER-positive breast cancer patients who received CMF chemotherapy between January 1990 and December 1999 were retrospectively studied. Disease-free survival (DFS) and overall survival (OS) were used to evaluate the clinical value of TAM therapy. The relationships between nodal status and TAM were also analysed. RESULTS: After a mean of 41 months of follow-up, 43 (13.7%) patients died of breast cancer and 68 (19.9%) patients suffered recurrence. There was a significant difference between TAM and non-TAM treatment groups for DFS (p=0.0058), but no significant difference for OS. For node-negative patients, there was no significant difference between the TAM and non-TAM treatment groups for either DFS or OS. For node-positive patients, the difference between TAM and non-TAM treatment groups was significant for both DFS and OS (p=0.0497 and p=0.0285, respectively). CONCLUSION: TAM resulted in additional benefit to premenopausal patients with node-positive ER-positive breast cancer who received the CMF polychemotherapy regimen.     

经尿道二次电切在pT1期非肌层浸润性膀胱癌的预后价值研究

目的评估常规二次经尿道膀胱肿瘤切除术（STURBT）对初诊T₁期非肌层浸润性膀胱癌（NMIBC）患者远期预后的价值。 方法本研究回顾性分析了在我院接受治疗的256例pT₁期NMIBC患者,接受经尿道膀胱肿瘤电切术（TURBT）患者126例,接受二次TURBT（STURBT）的患者130例。通过查阅病历资料和随访的方式评估两种手术方式的预后疗效。我们记录了两组患者疾病复发及死亡情况。最后,总的疾病复发率（DRR）、疾病特异性死亡率（DSM）及2年、4年和6年无复发生存率（RFS）和总生存率（OS）作为两组对比分析指标。 结果两组患者随访时间为6年,相比较TURBT组,STURBT组的DRR（42.1% vs 61.9%,P=0.001）和DSM（23.1% vs 35.7%,P=0.026）均显著降低;4年和6年的RFS（59.2% vs 44.4%,P=0.018;55.4% vs 38.1%,P=0.006）明显升高;6年OS（76.2% vs 64.3%,P=0.038）也明显升高。利用Kaplan-Meier法构建的RFS、OS曲线显现出差异有统计学意义（RFS：P=0.001;OS：P=0.029）,STURBT组RFS、OS均优于TURBT组。 结论pT₁期NMIBC患者STURBT的预后价值,不仅对患者RFS有利,而且对长期OS有利。     

Fluorouracil, doxorubicin, and cyclophosphamide followed by tamoxifen as adjuvant treatment for patients with stage IV breast cancer with no evidence of disease

We conducted a single-institution study to determine whether local therapy plus six cycles of chemotherapy with 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) followed by 5 years of tamoxifen is superior to local treatment alone in terms of disease-free survival (DFS) and overall survival (OS) in patients with stage IV breast cancer with no evidence of disease (stage IV-NED breast cancer). Patients with breast cancer were eligible if they had histologic proof of a locoregional or distant recurrence that had been curatively resected, irradiated, or both and had no other evidence of disease. Patients who had received prior anthracycline therapy were not eligible. All patients received six cycles of intravenous FAC, with cycles repeated every 3 weeks. After completion of chemotherapy, patients whose tumors had not previously demonstrated resistance to tamoxifen and had positive or unknown estrogen receptor status received tamoxifen 20 mg by mouth daily for 5 years. Patients in this study were compared with a historical control population (patients with stage IV-NED breast cancer who never received systemic therapy) as well as with the patients in two previously reported trials of chemotherapy for stage IV-NED disease. Forty-seven patients were registered, but only 45 were evaluable. There was a highly statistically significant difference ( p < 0.001) in OS and DFS among the four groups, with patients in our most recent study having the best OS and DFS at 3 years compared with the control group (84% vs. 55% and 66% vs. 11%, respectively). When patients in all four groups were analyzed together in search of prognostic factors, we found that patients whose primary tumors had negative axillary lymph nodes had a statistically significant improvement in OS and DFS ( p < 0.01) compared with patients with positive axillary lymph nodes. No survival differences were found between patients with positive and those with negative hormone receptor status. This study demonstrates a benefit in terms of OS and DFS for patients with stage IV-NED breast cancer who receive doxorubicin-based adjuvant chemotherapy. The benefit was greater on patients with node-negative primary tumors. In patients with stage IV-NED disease, doxorubicin-based chemotherapy should be considered standard treatment after adequate local control is achieved.     

Validation of the seventh edition of the American Joint Committee on Cancer tumor‐node‐metastasis (AJCC TNM) staging in patients with stage II and stage III colorectal carcinoma: analysis of 2511 cases from a medical centre in Korea

Aim The sixth and seventh editions of the American Joint Committee on Cancer (AJCC) tumor‐node‐metastasis (TNM) system for patients with stage II and stage III colorectal carcinoma (AJCC‐6 and AJCC‐7) were compared. Method Between 2000 and 2007, 2511 stage II/III colorectal carcinoma patients received primary surgical resection at the Asan Medical Center (Seoul, Korea). All patients were staged using AJCC‐6 and AJCC‐7 TNM systems. Patients with synchronous or other cancers, those given preoperative chemotherapy or radiotherapy and those in whom fewer than 12 lymph nodes were resected, were excluded. Overall survival (OS) and disease‐free survival (DFS) were compared. Results Of 2511 patients, 255 (10.2%) had different stages in the AJCC‐6 and AJCC‐7. For the AJCC‐7, the 5‐year OS by stage was 94.2% for stage IIA, 88.8% for stage IIB, 83.5% for stage IIC, 91.8% for stage IIIA, 81.8% for stage IIIB and 72.0% for stage IIIC. The OS and the DFS were not significantly different for the new substages IIB (n = 57) and IIC (n = 34) (P = 0.34 and P = 0.87, respectively). For the 187 patients with stage T3N2a cancer, the OS and the DFS were significantly different from stage IIIB other than T3N2a (P = 0.008 and P = 0.01, respectively) and there were no statistically significant differences in OS between the T3N2a group and the IIIC group (P = 0.46). Conclusion The study indicates that AJCC‐7 has better prognostic validity than AJCC‐6 for staging of patients with stage II and stage III colorectal carcinoma.     

Predictors of disease‐free survival in rectal cancer patients undergoing curative proctectomy

Objective To identify the factors that affect the disease‐free survival (DFS) of rectal cancer patients. Method Patients from an IRB approved rectal cancer database were reviewed (1990–2000). All patients underwent either abdominoperineal resection or low anterior resection using total mesorectal excision with curative intent. Univariate and multivariate analyses were performed to analyse the factors that influenced DFS. Results A total of 304 patients were reviewed (mean age 64, 52% male). Seventy‐seven per cent of patients received neoadjuvant therapy (28.6% short‐course radiation therapy (RT), 35.5% long‐course RT, 12.5% chemo‐RT). The radial margin was involved with tumour in 5.2% of patients (final pathology). The overall survival rate was 85.2% with a mean follow‐up time of 33 ± 26 months. The mean time to death was 34.8 ± 26.8 months. Local recurrence (± distant recurrence) occurred in 4%. Anastomotic leaks occurred in 3.6% of patients. Overall pathologic stage, pathologic T stage, nodal status, the use of adjuvant chemotherapy, tumour fixation, involvement of the radial margin, the presence of mucin, and lymphatic and perineural invasion (PNI) were predictors of DFS by univariate analysis. Of note, anastomotic leaks and obstructing cancers did not influence DFS. Using multivariate analysis with backward elimination, overall pathologic stage, radial margin status, adjuvant chemotherapy, and PNI predicted the DFS. Conclusion Major predictors of DFS in rectal cancer are the overall pathologic stage, adjuvant chemotherapy, radial margin status and PNI. Radial margin status may be a marker of tumour aggressiveness and should be considered in deciding on adjuvant chemotherapy.     

Prognostic impact of triple negative phenotype in conservatively treated breast cancer

To evaluate overall survival (OS), disease-free survival (DFS), and local-recurrence free survival (LRFS) rates in a subgroup of patients affected by breast cancer expressing a particular phenotype (estrogen receptor negative, progesterone receptor negative, and Human Epidermal Growth Factor receptor 2 negative) known as "triple negative" (TN). Data of 387 women affected by early breast cancer who underwent whole-breast radiotherapy after conservative surgery with or without chemotherapy and/or hormone therapy between January 2002 and December 2008, in the Department of Radiotherapy at Regional Cancer Center, were retrospectively evaluated. Chi-squared test was used to compare prognostic factors (age, histology, tumor size, nodal status, grading, and adjuvant therapy) between TN patients and non-TN patients. OS, DFS, and LRFS rates were analyzed using Kaplan--Meier proportional log-rank test; impact of prognostic factors on poor outcome was evaluated using Cox regression stepwise method on univariate and multivariate analysis. Mean follow-up time was 57.6 months (range13.7-109.7). TN patients were more likely to have ≥T2 tumors (p = 0.0003), grade 3 tumors (p = 0.0001) and to receive chemotherapy as adjuvant therapy (p =< 0.0001). TN patients had lower 5-years-OS (p = 0.039) and lower 5-years-DFS (p = 0.003) compared with non-TN patients. No difference in 5-years LRFS was found (p = 0.49). After multivariate analysis, TN status was found to be a predictive factor for OS (p = 0.004) and for DFS (p = 0.01), but not for LRFS (p = 0.8). TN patients have lower survival when compared with non-TN patients, but similar LRFS rates. These patients can be treated in a conservative surgical protocol, but should receive more aggressive and tailored adjuvant therapies.     

Contralateral Axillary Nodal Metastases: Stage IV Disease or a Manifestation of Progressive Locally Advanced Breast Cancer?

Background

Contralateral axillary nodal metastases (CAM) is classified as stage IV disease, although many centers treat CAM with curative intent. We hypothesized that patients with CAM, treated with multimodality therapy, would have improved overall survival (OS) versus patients with distant metastatic disease (M1) and similar OS to those with locally advanced breast cancer (LABC).

Methods

Using the NCDB (2004–2016), we categorized adult patients with node-positive breast cancer into three study groups: LABC, CAM, and M1. Kaplan-Meier curves were used to visualize the unadjusted OS. Cox proportional hazards models were used to estimate the association of study group with OS.

Results

A total of 94,487 patients were identified: 122 with CAM, 12,325 with LABC, and 82,040 with M1 (median follow-up 63.6 months). LABC and CAM patients had similar histology and rates of chemotherapy and endocrine therapy receipt. However, the CAM group had significantly larger tumors, more estrogen-receptor expression, higher T-stage, and more mastectomies than the LABC group. Compared with M1 patients, CAM patients were more likely to have grade 3 and cT4 tumors. Patients with CAM and LABC had similar 5-year unadjusted OS and significantly improved OS vs M1 patients. After adjustment, LABC and CAM patients continued to have similar OS and better OS vs M1 patients.

Conclusions

CAM patients who receive multi-modal therapy with curative intent may have OS more comparable to LABC patients than M1 patients. Out data support a reevaluation of whether CAM should remain classified as M1, as N3 may better reflect disease prognosis and treatment goals.

     

Beyond Palliative Mastectomy in Inflammatory Breast Cancer—A Reassessment of Margin Status

Background: Inflammatory breast cancer is a locally advanced tumor with an aggressive local and systemic course. Treatment of this disease has been evolving over the last several decades. The aim of this study was to assess whether current therapies, both surgical and chemotherapeutic, are providing better local control (LC) and overall survival (OS). We also attempted to identify clinical and pathologic factors that may be associated with improved OS, disease-free survival (DFS), and LC.Methods: A 25-year retrospective review performed at the City of Hope National Medical Center identified 90 patients with the diagnosis of inflammatory breast cancer.Results: Of the 90 patients identified with inflammatory breast cancer, 33 received neoadjuvant therapy (NEO) consisting of chemotherapy followed by surgery with radiation (n = 26) and without radiation (n = 7). Fifty-seven patients received other therapies (nonNEO). Treatments received by the nonNEO group consisted of chemotherapy, radiation, mastectomy, adrenalectomy, and oophorectomy, alone or in combination. The median follow-up was 28.9 months for the NEO group and 17.6 months for the nonNEO group. Borderline significant differences in the OS distributions between the two groups were found (P =.10), with 3- and 5-year OS for the NEO group of 40.0% and 29.9% and for the nonNEO group of 24.7% and 16.5%, respectively. DFS and LC were comparable in the two groups. Lower stage was associated with an improved OS (P < .05). The 5-year OS for stage IIIB was 30.9%, compared to 7.8% for stage IV. In those patients with stage III disease who were treated with mastectomy and rendered free of disease, margin status was identified by univariate analysis to be a prognostic indicator for OS (P < .05). The 3-year OS, DFS, and LC for patients with negative margins were 47.4%, 37.5%, and 60.3%, respectively, compared to 0%, 16.7%, and 31.3% in patients with positive margins.Conclusions: This study suggests that in patients with inflammatory breast cancer and nonmetastatic disease, an aggressive surgical approach may be justified with the goal of a negative surgical margin. Achievement of this local control is associated with a better overall outcome for this subset of patients. The ability to obtain negative margins may further identify a group of patients with a less aggressive tumor biology that may be more responsive to other modalities of therapy.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 17–21, 1997.