Results of conservative treatment of breast cancer at ten and 15 years.

The ten-year survival of patients at the Cleveland Clinic treated by operations less than radical mastectomy was 45% compared with 43% in identically staged patients of the "National Cancer Registry" treated predominantly by radical mastectomy. The five and ten-year survival rates of patients treated by simple operations was higher than that of a similar group of patients treated by radical operations, but at 15 years there was no difference. The late deaths from cancer in the patients treated conservatively occurred in patients with favorably staged cancers who never had local recurrences and most of whom had no involvement of nodes. The incidence of local recurrence was no higher after simple operations than after the radical procedure. The ten-year incidences of local recurrence and of death from cancer were the same after partial mastectomy as after total mastectomy. It is pointed out that differences in staging the cancers and in reporting the survival rates invalidate comparisons of results from different institutions. The figures presented suggest that conservative operations and radical operations give the same survival rates at ten and at 15 years.     

Role of surgery in the treatment of inflammatory breast carcinoma

Twenty-eight patients with inflammatory carcinoma of the breast have been retrospectively reviewed. Overall 5 year survival was 25 percent. There was a trend toward improved survival in patients who received chemotherapy which did not achieve statistical significance. Sixteen patients underwent mastectomy as part of their treatment. These patients had a 48 percent 5 year survival which was significantly better than the survival in patients who did not undergo mastectomy. Furthermore, mastectomy resulted in better control of the local disease. Of 12 patients who did not undergo mastectomy, local control was initially obtained in only 2, and both of these patients suffered local recurrence within 1 year. Our data support the conclusion that mastectomy be combined with preoperative and postoperative multiagent cytotoxic chemotherapy in the treatment of inflammatory carcinoma of the breast. More precise staging may permit better prognostic stratification of patients with this highly malignant cancer.     

Male breast carcinoma

Fifty men with primary breast carcinoma were seen between the years 1938 and 1983 at the University of Iowa Hospitals and Clinics. In most patients, there was a significant delay between the onset of symptoms and seeking medical advice (mean, 21 months; range, 1-156). The vast majority of patients were treated by simple, modified radical, or radical mastectomy. Ten patients underwent incisional or excisional biopsy with or without radiation because of locally advanced disease or distant metastases. Survival was comparable in the groups of patients treated with simple mastectomy (mean, 70 months), modified radical mastectomy (mean, 61 months), and radical mastectomy (mean, 78 months). Local recurrence occurred in 25 per cent of all patients, and this rate was not dependent on the operation performed. The data suggest that modified radical mastectomy is adequate therapy for local control and staging of the disease without reducing survival from that observed after radical mastectomy.     

16a. The management of early cancer of the breast

Summary The results of clinical trials for early cancer of the breast were aBeBed in terms of survival, morbidity, and the rate of local recurrance. Simple mastectomy appeared to be the operation of choice because survival following this procedure was equal to that following more radical operations, but the morbidity was leB. Partial mastectomy was found to be an unsatisfactory method of treatment. Simple mastectomy should be combined with removal of the lower axillary nodes to allow accurate staging of the disease.[/p]Postoperative radiotherapy did not influence survival, but did increase morbidity. It may be best to restrict its use to the treatment of local recurrance. Improvement in survival figures may be seen by use of adjuvant chemotherapy, or by more widespread use of screening programmes.     

Sarcoma of the breast]

Sarcoma of the breast represents only 0.2-1% of all mammary malignancies. This study reports 5 such cases, including 2 osteosarcomas, 1 fibro-, 1 lipo-, and 1 malignant fibrous sarcoma. The treatment used was mastectomy in 3 cases with excision of axillary lymph nodes. The remaining 2 patients were treated by simple mastectomy whereby 1 of these received a immediate reconstruction with a prosthesis. 1 patient demonstrated local recurrence and died. The remaining 4 patients did not develop neither metastases nor local recurrence and are still alive after an observing period between 12 months up to 17 years. Today, first-line treatment is wide local excision or simple mastectomy. Excision of the axillary lymphatics, adjuvant radiotherapy, and chemotherapy have been disappointing in the treatment of breast sarcoma.     

Scientific Presentation Award. Patterns of local breast cancer recurrence after skin-sparing mastectomy and immediate breast reconstruction

BACKGROUND: Local recurrence rates after skin-sparing mastectomy and immediate reconstruction are similar to recurrence rates after conventional mastectomy. We investigated the pattern of local recurrences and risk factors associated with them. METHODS: We identified 206 patients who underwent 210 skin-sparing mastectomies with immediate reconstruction from 1998 to 2006 in our database. RESULTS: Eleven patients had local recurrences (5.3%). Nine developed in the quadrant of the corresponding primary tumor. There were no significant differences between patients who recurred and those who did not with respect to tumor size/stage, margin status, estrogen receptor/progesterone receptor/Her2neu status, lymph node metastases, or radiation therapy (P > .05). Patients with grade 3 invasive tumors or high-grade ductal carcinoma in situ were more likely to recur than patients with grade 1 or 2 invasive tumors or low- or intermediate-grade ductal carcinoma in situ (P = .0035). Those patients who recurred had a significantly decreased overall survival compared to patients who did not recur (P = .0006). CONCLUSIONS: Skin-sparing mastectomy and immediate reconstruction has a low local recurrence rate. Recurrences occur most commonly in the same quadrant as the primary tumor and treatment approaches include surgery, chemotherapy, and radiation therapy. Local recurrence portends a poorer overall survival.     

乳腺癌再手术的探讨

目的探讨乳腺癌手术后局部复发、腋窝淋巴结转移或可疑转移者的预防及再手术的可行性。方法对1994年6月～2003年4月我院收治的再次手术的23例乳腺癌病人临床资料加以分析并随访。结果全组病例腋窝淋巴结再清扫17例有淋巴结转移,占74%。其中,12例原改良根治术中淋巴结阳性者8例;4例原Halsted根治术淋巴结阳性者3例;4例原单纯乳房切除术中,淋巴结阳性3例;原象限切除加腋窝淋巴结清扫和象限切除术各1例,淋巴结均有阳性发现;原单纯乳房切除加前哨淋巴结活检术中,淋巴结阳性1例。再次手术者中,发现原切口疤痕或胸肌有残留或复发癌6例。17例曾行腋窝清扫病人中,经手术再清扫共得淋巴结283枚,平均每例16.6枚。结论恰当的手术方式、规范化的切除范围、精细的手术操作和无瘤技巧是预防和减少局部复发转移的重要措施。对局部复发、腋窝淋巴结转移或可疑转移者再补作手术有助于控制和减少局部病情的发展,改善病人的生存质量。     

Effectiveness of mastectomy by response to induction chemotherapy for control in inflammatory breast carcinoma

Background: Controversy exists as to the treatment regimen necessary to best provide optimal local control for inflammatory breast carcinoma (IBC). This study was conducted to determine if mastectomy combined with radiotherapy offered any advantages over radiotherapy alone in patients with IBC who had been treated with doxorubicin-based combination chemotherapy. Methods: A retrospective review of 178 women treated for IBC on doxorubicin-based multimodality therapy protocols between January 1974 and September 1993 was performed. Clinical and histologic response to treatment, time to local recurrence, survival, and ultimate control of local disease were analyzed. Kaplan-Meier analysis was used to examine survival and relapse times, and Fisher's exact test was used to test differences in treatment outcomes. Significance was determined at p≤0.05. Results: Median follow-up was 89 months (range 22 to 223 months). Locoregional disease persisted in seven patients and recurred in 44 patients who had been rendered disease free at a median time of 10 months. The mortality rate after a local recurrence (LR) was 98%, and all patients but one with LR developed systemic metastases. Response to induction chemotherapy influenced the incidence of LR, and the amount of residual disease found on histologic examination of mastectomy specimens was highly prognostic for local failure. Patients who underwent mastectomy in addition to radiotherapy had a lower incidence of LR than did patients who received radiotherapy alone (16.3% vs. 35.7%, p=0.015). Conclusions: The addition of mastectomy to combination chemotherapy plus radiotherapy improved local control in patients with IBC. The addition of mastectomy to chemotherapy plus radiotherapy improved distant disease-free and overall survival in patients with a clinical complete or partial response to induction chemotherapy. Patients who had no significant response to induction chemotherapy received no survival or local disease-control benefit from the addition of mastectomy to their treatment regimen. These patients should be considered for entry into clinical trials of new treatment regimens. Presented at the 49th Annual Cancer Symposium of The Society of Surgical Oncology, Atlanta, Georgia, March 21–24, 1996.     

乳腺分叶状肿瘤14例的诊断和治疗

目的：探讨乳腺分叶状肿瘤的临床病理特点、治疗原则和影响预后的因素。方法：回顾1993年6月至2001年2月收治的14例乳腺分叶状肿瘤患者的临床资料。结果：14例患者平均年龄35岁，按WHO分类标准，其中良性5例，交界性5例，亚性4例。7例行局部切除术，4例行乳腺单纯切除术，3例行乳腺癌改良根治术。随访11例，平均随访时间19个月（6-96个月），1例行乳腺癌改良根治术后2年死于远处转移，3例行局部切除术后复发。结论：保证1-2cm切缘的扩大局部切除术是治疗乳腺分叶状肿瘤的首选方案。     

Adenoid cystic carcinoma of the breast. Data from the Connecticut Tumor Registry and a review of the literature.

The case records of the Connecticut Tumor Registry were reviewed from 1952-1982. There were 37 cases of adenoid cystic carcinoma of the breast (ACC) from a total of 40,350 invasive breast tumors. Patient survival, complications, and pathologic sections were reviewed. Only 14 of 27 surgical pathology slides available for review could be confirmed histologically as ACC. All patients were white females with a mean age of 64 years. The tumor remained localized to the breast in all cases. Nine patients had either radical or modified radical mastectomy, four patients had either simple mastectomy or lumpectomy, and one patient refused treatment. There was no evidence of axillary node involvement, metastases, or local recurrence after excision. At the time of follow-up, nine patients were alive and disease free and four died of disease unrelated to their breast cancer. The one patient who died of breast cancer had a radical mastectomy and survived 11.7 years after diagnosis. It is concluded that ACC has a favorable biologic behavior characterized by a prolonged clinical course and good prognosis. Simple mastectomy is all that is required as initial treatment, and a chest x-ray and thorough physical examination looking for local recurrence is all that is needed for follow-up.     

Multimodality treatment of locally advanced breast carcinoma

Forty patients with 41 locally advanced breast lesions at stages IIIA and IIIB and the inflammatory stage were treated with combined-modality therapy from July 1980 to August 1985. Treatment included induction chemotherapy consisting of three cycles of fluorouracil, doxorubicin hydrochloride, and cyclophosphamide, followed by mastectomy in those patients whose lesions were operable (n = 28), and resumption of chemotherapy. Nine patients received postoperative radiation therapy. The mean follow-up was 34 months. Greater than 50% reduction in tumor size was achieved in 72% of patients after three cycles of chemotherapy. Overall, local control was achieved in 85% of patients with 59% survival and 53% disease-free survival, while 10% of patients developed local recurrences. Excluding lymphedema of the upper extremity (n = 2) and inflammatory carcinomas (n = 4), local control was achieved in 96% of patients, with 75% survival and 68% disease-free survival, while 4% of patients developed local recurrences. The rate of disease-free survival was 71% in patients with partial response to chemotherapy, contrasted with 43% in patients who did not respond or only minimally responded to chemotherapy. Actuarial five-year survival, based on life-table analysis, was calculated to be 46% for the group overall, 58% for the group excluding lymphedema of the upper extremity and inflammatory carcinoma, and 56% for the 28 patients undergoing mastectomy.     

Local Recurrence After Mastectomy for Ductal Carcinoma In Situ

Abstract: Local recurrence after mastectomy for invasive cancer generally carries a poor prognosis. Local recurrence after mastectomy for ductal carcinoma in situ (DCIS) is rare and its impact on survival is unknown. Sixty-eight patients were treated with mastectomy for DCIS at the Fox Chase Cancer Center between 1985 and 1996, and only one of these developed a chest wall recurrence. An additional five patients treated with mastectomy at other institutions and referred to Fox Chase after local recurrence were also identified. These six patients had only DCIS as their primary pathology. Four of the six patients were premenopausal (median age 42 years). The median interval to local recurrence was 5.0 years (2.8–9.3 years). The median follow-up from initial diagnosis was 10.5 years (4.3–26.7 years) and 5.2 years (1.4–17.6 years) from recurrence. All of the recurrences were invasive and treatment included wide local excision with radiotherapy in all of the patients followed by adjuvant chemotherapy for the premenopausal patients. None of the patients had metastatic disease at presentation. The disease-free survival from initial recurrence was 83% and 63% at 5 and 10 years, respectively. The 5- and 10-year survival following local recurrence was 80%. One patient died 3.6 years after recurrence with metastatic disease, while a second patient developed metastatic disease 11.8 years after her initial recurrence. The remaining four patients are alive (NED), ranging from 1.4 to 10.7 years following their local recurrence. Local recurrence following mastectomy for DCIS is rare, usually invasive, and may have a long interval to failure. Salvage using conventional multimodality therapy appears to result in long-term survival.     

A population-based study of breast cancer-specific survival following mastectomy and immediate or early-delayed breast reconstruction

Abstract: Immediate breast reconstruction allows for improved patient psychosocial outcomes after mastectomy. We used the Surveillance, Epidemiology, and End Results (SEER) database to study the breast cancer‐specific survival of patients treated with immediate or early‐delayed breast reconstruction after mastectomy. Population‐level de‐identified data was abstracted from the SEER database. All female patients treated with mastectomy for a diagnosis of ductal and/or lobular breast cancer between 1998 and 2002 were included. Breast cancer‐specific survival was reported as hazard ratios using multivariate analysis to control for patient demographic and oncologic covariates. Demographic covariates included age, race, marital status, income, education, and county metropolitan status; oncologic covariates included tumor stage, histology, grade, lymph node status, hormone receptor status, receipt of radiation therapy, and unilateral or bilateral mastectomy. A total of 52,249 patients were included in the study. Patients treated with mastectomy and reconstruction had a significantly lower hazard of death (HR 0.73, p < 0.0001) compared with patients treated with mastectomy only. Black patients had a significantly increased hazard of death (HR 1.42, p < 0.0001) compared with white patients. Receipt of radiotherapy did not significantly associate with hazard of death (HR 1.03, p = 0.3494). Additionally, bilateral mastectomy did not significantly associate with hazard of death (HR 0.98, p = 0.763). Our analysis shows that patients who undergo breast reconstruction after mastectomy have a higher breast cancer‐specific survival than those undergoing mastectomy alone, when controlling for demographic and oncologic covariates. Further research is required to understand the nature of this relationship.     

Full-thickness chest wall resection for recurrence of breast malignancy

We present outcomes in 13 consecutive patients with solitary, local chest wall recurrence subsequent to mastectomy for breast malignancy who were operated on in 1983--2001. All patients underwent full-thickness chest wall resection (FTCWR) and immediate reconstruction. The mean chest wall defect area was 108 cm(2). The choice of reconstruction method was individualized. The reconstruction was accomplished with the patient's own tissues, in three cases supported by artificial mesh. Most commonly we used the contralateral breast or myocutaneous flap. We did not observe postoperative complications. The tissues used for the reconstruction provided sufficient stiffness of the rib cage. In all specimens the surgical margins were negative. The estimated 5-year survival after excision of recurrent tumor is 62%. FTCWR with immediate reconstruction with soft tissues should be considered in patients with local solitary recurrence after mastectomy for breast malignancy. This option offers good long-term results and minimal morbidity.     

Post‐mastectomy Radiotherapy for pT3N0 Breast Cancers: A Retrospective,Multi‐Institution Review

The role of post‐mastectomy radiotherapy for pT3N0 breast cancers remains undefined. The purpose of this study was to report institutional outcomes for women with pT3N0 breast cancers treated with and without post‐mastectomy radiotherapy. We collected data from two large tumor registries on pT3N0 breast cancers diagnosed between 1985 and 2014. Kaplan–Meier estimates were used to analyze freedom from local‐regional recurrence (FFLR), relapse free survival, and overall survival. This analysis identified 93 women with pT3N0 breast cancers. Of these, 53 received post‐mastectomy radiotherapy and 40 did not. Median follow‐up was 6.2 years and 5.3 years in the non‐post‐mastectomy radiotherapy and post‐mastectomy radiotherapy cohorts, respectively. Women not undergoing post‐mastectomy radiotherapy were more likely to be diagnosed in the 1980s and 1990s and were less likely to receive systemic therapies than women receiving post‐mastectomy radiotherapy (p < 0.05). There was a trend toward increased FFLR in the women receiving post‐mastectomy radiotherapy (p = 0.15). FFLR in the post‐mastectomy radiotherapy cohort was 98% at both 5 and 10 years. For women not receiving post‐mastectomy radiotherapy, FFLR was 88% at both 5 and 10 years. Women not receiving post‐mastectomy radiotherapy in our study had an isolated local‐regional failure rate of 12% at 10 years, despite receiving inferior systemic treatment by current standards. Local‐regional control after post‐mastectomy radiotherapy for pT3N0 breast cancers was excellent. Further research is needed to define post‐mastectomy radiotherapy indications for this patient population when receiving chemotherapy and endocrine therapy in line with current guidelines.     

Surgical treatment for invasive lobular carcinoma of the breast

The management and outcome of 131 women with infiltrating lobular carcinoma treated in the Belfast City Hospital between October 1987 and February 1999 were reviewed. Two patients had primary hormonal treatment and were excluded from the statistical analysis, and 129 patients were followed up. Fifty-four patients (41%) had initial breast conservation surgery, which was followed by re-excision of margins in eight patients (14.8%) and completion total mastectomy in 26 patients (48.1%). The breast conservation surgery group, 28 patients (21.7%), was compared with the total mastectomy group, 101 patients (78.2%), after a median follow-up period of 90 months (range 24-160 months). The overall survival was 68.7%. Survival analysis was performed using Kaplan-Meier and Cox regression which showed that lymph node involvement and tumour grade were the only variables affecting survival (P<0.0001, and 0.01, respectively). The type of surgery performed did not affect survival (P=0.42). The total number of patients who developed local recurrence was 17 patients (13.1%, 12 patients in the breast conservation surgery group and five patients in the total mastectomy group, P<0.0001). Kaplan-Meier analysis of local recurrence showed that the type of surgery (P<0.0001), patient age (P=0.02), tumour grade (P=0.002), adjuvant radiotherapy (P=0.013), chemotherapy (P=0.031) and hormonal treatment (P=0.003) significantly affected local recurrence. Cox regression analysis showed that the only factor significantly affecting local recurrence was the type of surgery performed (P=0.02). Patients who underwent mastectomy had less local recurrence than those who had breast conservation surgery. Local recurrence after breast conservation surgery is high, even with clear surgical margins and post-operative radiotherapy. The authors believe that total mastectomy for infiltrating lobular carcinoma is a safer option to control local disease, especially in younger patients and those with high-grade tumours. Overall survival is not affected by the type of surgical treatment. Local recurrence can be a late event and a long-term follow-up is recommended.     

Subcutaneous mastectomy for primary operable breast cancer

Subcutaneous mastectomy has been performed on 98 patients with primary breast cancer. Eighty-four have undergone breast reconstruction using a silicone prosthesis. The overall complication rate has been low. The rates of local recurrence and survival are similar to those in patients undergoing simple mastectomy.     

The "banked" TRAM: a method to insure mastectomy skin-flap survival

BACKGROUND: Necrosis of the skin flaps after mastectomy can be a devastating complication following immediate breast reconstruction with a TRAM flap. Skin-flap loss compromises the aesthetic result and may necessitate revisional surgery. The authors wish to present a simple and effective method to insure mastectomy skin-flap survival. METHODS: Seven patients over the last 5 years were treated with immediate breast reconstruction with a TRAM flap after skin-sparing mastectomy and had evidence of skin-flap compromise intraoperatively. These patients had their TRAM flaps "banked" under the flaps and returned to the operating room within 72 hours for definitive debridement of the skin flaps, deepithelialization, and insetting of the TRAM. RESULTS: In all cases, there was 100% survival of the skin flaps after delayed insetting. There was no skin-flap loss. No patients required additional surgery for revision. CONCLUSIONS: The banked TRAM is a simple and effective method to insure mastectomy skin flap survival if there is a question of flap viability.     

Breast conservation in patients with multiple ipsilateral synchronous cancers

BACKGROUND: Because breast cancer survival after breast conservation has proved comparable to mastectomy, contraindications to mastectomy are increasingly being challenged. We treated the majority of our patients with multiple synchronous ipsilateral cancers with breast conservation and we compared them with patients who underwent mastectomy for comparable disease during the same interval. STUDY DESIGN: Patients with multiple ipsilateral synchronous breast cancers between 1989 and 2002 were identified from prospective databases maintained by us. A comparison was made between 36 patients treated with lumpectomy and 19 patients treated with mastectomy. RESULTS: There were no significant (all p values >0.2) differences between mastectomy and breast conservation patients in age, racial distribution, size of cancers, pathology, tumor differentiation, nodal involvement, or hormone receptor positivity. The majority of patients treated with breast conservation underwent at least one reexcision to obtain clear pathologic margins, and they were more likely to receive postoperative radiotherapy than patients treated with mastectomy. There were no significant differences in the local (97% versus 100%, p = 0.54) or distant (97% versus 95%, p = 0.20) 5-year disease- free survival between the group treated with breast conservation and the group treated with mastectomy. One patient in each group developed distant metastases. One patient in the breast conservation group developed local recurrence at both primary sites simultaneously 39 months after lumpectomies. She is free of disease 78 months after mastectomy. The remaining 52 patients are alive and free of disease. CONCLUSIONS: Breast conservation is an effective treatment for patients with synchronous ipsilateral breast cancers.     

Prognosis after breast recurrence following conservative surgery and radiotherapy in patients with node-negative breast cancer

BACKGROUND: Breast conservation surgery with radiotherapy is a safe and effective alternative to mastectomy for early-stage breast cancer. This retrospective study examined the outcome of patients with isolated local recurrence following conservative surgery and radiotherapy in node-negative breast cancer. METHODS: Between November 1979 and December 1994, 503 women with node-negative breast cancer were treated by conservation surgery and radiotherapy without adjuvant systemic therapy. RESULTS: After a median follow-up of 73 months the 5-year rate of freedom from local recurrence was 94 per cent. Thirty-five patients developed an isolated local recurrence within the breast as a first event. Thirty-three patients were treated with salvage mastectomy and two patients were treated with systemic therapy alone. The 5-year rate of freedom from second relapse was 46 per cent and the overall 5-year survival rate was 59 per cent for patients who had salvage mastectomy. Patients who developed breast recurrence as a first event had a 3.25 greater risk of developing distant metastasis (P < 0.001) than those who did not have breast recurrence as a first event. CONCLUSION: Salvage mastectomy after local recurrence was an appropriate treatment if there was no evidence of distant metastasis. Breast recurrence after conservative surgery and radiotherapy in node-negative breast cancer predicted an increased risk of distant relapse.