Metastatic disease of the breast and local recurrence of breast cancer

Breast cancer is a major health problem worldwide with over 1 million new cases diagnosed each year. The aim of treatment is to achieve good loco-regional control, provide appropriate adjuvant therapy and treat potential micro-metastasis. Early detection with breast screening and better treatment options have improved outcome. However approximately 40% of patients will suffer a recurrence and still 35–40% will eventually present with metastatic disease. Metastatic disease is incurable with the median survival being 2–3 years. Several therapies have been shown to maintain a good quality of life whilst prolonging survival. In certain sub-groups of breast cancer, that is, human epidermal growth factor receptor 2 (HER2)-positive cancer the advent of trastuzumab has improved survival rates. A multidisciplinary team approach is essential to obtain the diagnosis and plan the appropriate treatment. The diagnosis of metastatic disease brings distress to patients and their relatives and support should be available from palliative care teams.     

The importance of distant metastases in hormone-sensitive breast cancer

Breast cancer is a leading cause of cancer death in women worldwide. Survival from breast cancer is improving, but distant metastases remain the most common type of breast cancer recurrence, resulting in more than 40,000 deaths per year in the USA alone. Distant metastases are associated with the poorest outcomes when compared with loco-regional or contralateral recurrences and are also associated with greater health care costs and diminished quality of life. The risk of distant metastases increases with larger primary tumor size, lymph node positive cancer, higher tumor grade, and prior loco-regional recurrence. Yet, even patients with minimal risk factors may develop distant metastases. Thus, reducing the development of such relapses is an important goal in adjuvant therapy. As the development of distant metastases has been consistently associated with eventual mortality from breast cancer, a reduction in distant metastases may serve as a better surrogate marker for overall survival and provide earlier results from clinical trials testing new types of adjuvant therapy.     

Value of hormone receptors in the management of breast cancer--I. Advanced breast cancer

A review of 152 women with locally advanced or metastatic breast cancer is presented. Only 32% of unselected women responded to appropriate endocrine therapy; 64% responded if ER was present and 71% if both ER and PR were present. Survival for the endocrine responders was prolonged and of good quality. Chemotherapy, used subsequently as initial treatment in ER negative women, significantly improved response rates but without a survival advantage. However, there was a strong clinical impression that good performance status was maintained until shortly before death. This data suggests therapy given according to hormone receptor status is of value and confirms the validity of our hormone receptor assays as applied to clinical practice.     

Treatment of locally advanced prostate cancer--the case for radical prostatectomy

The treatment of clinically locally advanced prostate carcinoma (stage cT3) remains controversial. One of the main reasons for this controversy results from the substantial staging error attached to the clinical diagnosis cT3 with overstaged T2 tumors and understaged node-positive cases. Treatment options in this situation include radical prostatectomy, external beam radiotherapy, immediate or delayed androgen deprivation treatment and the so-called 'watchful waiting'. Acceptable and often surprisingly good tumor-specific survival rates have been reported for radical prostatectomy in pT3 series--based on good clinical case selection--approaching those of pT2 series. In lymph node-positive pT3 cases, adjuvant hormone deprivation seems to prolong survival which it does not in lymph node-negative pT3 disease. A benefit of adjuvant external beam radiotherapy after radical prostatectomy for pT3 cases in prolonging overall survival has not been shown, despite the fact that it can prevent or delay biochemical and local recurrence. External beam radiotherapy as the only treatment for cT3 disease results in unfavorable tumor-specific survival rates, which can be significantly improved with adjuvant hormonal treatment with LHRH agonists. If, in case of advanced age and/or significant comorbidity, primary hormonal treatment is chosen, early hormonal deprivation therapy seems to offer marginal benefits in survival compared to delayed treatment.     

Breast cancer: locoregional recurrence and subsequent disease course]

The survival of 409 patients with breast cancer treated by surgery +/- adjuvant therapy is controlled in a retrospective study. 65 (15.9%) patients subsequently suffered from loco-regional recurrences. 41 (63.1%) of these patients showed either simultaneously with the loco-regional recurrence or at the latest within 2 1/2 years after the diagnosis of the loco-regional recurrence distant metastasis. The incidence of the distant metastasis is the more probable the shorter the interval between the primary treatment and the occurrence of the loco-regional recurrence. More prognostic factors for the survival after the diagnosis of the loco-regional recurrence are discussed.     

Should radical nephrectomy be performed in the face of surgically incurable disease?

The role of cytoreductive nephrectomy in the management of metastatic renal cancer remains controversial. Recent trials, like SWOG 8949 have suggested the usefulness of this approach at least in selected patients with good performance status and other favorable indicators. The timing of cytoreductive nephrectomy has also been controversial and remains so to this time.CommentaryAn estimated 30,000 new cases of renal cell carcinoma (RCC) are detected annually in the U.S. In approximately one-third of these cases, metastatic disease is diagnosed at presentation. Multi-modality treatment combines biologic response modifier (BRM) therapy with surgery in an attempt to improve survival with either form of treatment alone. The optimal timing of surgery relative to BRM therapy continues to be debated.Prior to the advent of multi-modality therapy, there were relatively few indications for nephrectomy in patients with metastatic RCC. The incidence of spontaneous regression of metastatic RCC following removal of the primary tumor is only 1–4% and, therefore, nephrectomy on this basis is not justified. There is a palliative role for nephrectomy in selected patients with metastatic RCC who are experiencing severe disability from associated local symptoms; however, some patients in this category can be managed with percutaneous renal angioinfarction. A small subset of patients with a solitary metastasis may benefit from nephrectomy and resection of the metastatic lesion based on reported 5-year survival rates of up to 30–35%.There has been controversy concerning the appropriate timing of adjuvant or cytoreductive nephrectomy in the multi-modality approach to treatment of metastatic RCC. Many protocols have involved preliminary removal of the primary tumor before the administration of BRM therapy. The rationale for this has been to enhance response rates to BRM therapy by reducing tumor volume and, in some cases, to provide immunoreactive cells for treatment. A drawback of this approach was that many patients underwent nephrectomy without subsequently receiving BRM therapy due to postoperative morbidity/mortality or rapid tumor progression. This prompted interest in an alternative approach of delayed adjuvant nephrectomy wherein BRM therapy was administered initially and nephrectomy was subsequently performed only in those patients who demonstrated a response to systemic therapy.The relative merits of initial versus delayed adjuvant nephrectomy in conjunction with BRM therapy for metastatic RCC have recently been clarified through two phase III prospective multicenter clinical trials conducted in Europe (EORTC) and the United States (SWOG). The results of both of these carefully done studies have indicated improved survival with initial nephrectomy followed by BRM therapy. The latter comprised interferon monotherapy in both studies, which opens the studies to criticism, however the essential observation of extended survival with preliminary nephrectomy appears to be valid. On this basis, there is now objective evidence to suggest that initial cytoreductive nephrectomy is the preferred approach in patients with metastatic RCC who are candidates for multi-modality therapy. The most appropriate candidates for such therapy remain patients with good performance status and low-volume (preferably pulmonary) metastatic disease. The ability to perform cytoreductive nephrectomy laparoscopically in some of these patients, with reduced morbidity, is a further development that has strengthened the argument in favor of initial nephrectomy.Andrew C. Novick, M.D.     

Loco-regional Recurrence from Colon Cancer: A Population-based Study

Background The survival after colon cancer surgery has not improved to the same extent as after rectal cancer treatment and studies on loco-regional recurrence after colon cancer surgery are scarce. The aim of this study was to assess the problem of loco-regional recurrence after potentially curative resections for colon cancer, regarding incidence, risk factors, management, and outcome. Methods All 1,856 patients submitted to potentially curative surgery for colon cancer in the Stockholm/Gotland region in Sweden between 1996 and 2000 were followed until January 2005 or until death. Follow-up data were prospectively collected. Risk factors for loco-regional recurrences were analyzed, treatment and outcome for patients with recurrence was studied. Results The cumulative 5-year incidence of loco-regional recurrence was 11.5%. Tumor locations in the right flexure and in the sigmoid colon, bowel perforation and emergent surgery were identified as independent risk factors for loco-regional recurrence. The risk also increased with increasing T- and N-stage. The median survival for all 192 patients with loco-regional recurrence was 9 months. Surgery was performed in 110 (57%) patients. In 23 (12%) patients a complete tumor clearance was achieved and the estimated 5-year survival in this group was 43%. Conclusion Loco-regional recurrence from colon cancer is a significant clinical problem. A multidisciplinary treatment approach, including preoperative staging, a complete resection of the recurrence and more effective adjuvant treatments may improve the outcome.     

Adjuvant therapy in renal cancer

Summary Surgery is the therapy of choice for patients with local renal cancer, but the results are unsatisfactory if the disease is locally advanced or systemic disease is present. As for the stage-related prognosis, patients with local disease (T1–2 N0 M0) show good prognosis, with a 5-year survival of 90–100% after nephrectomy. In these patients the indication for adjuvant treatment is limited; it is almost impossible to document the statistically significant efficacy for adjuvant treatment, even when this therapy results in a long-term complete remission rate of more than 50% of the patients with metastatic disease. If such a drug were available, survival would be improved by 5%, but more than 1200 patients would have to be included in this protocol to reveal any significance. Patients with locally advanced disease (T3–4) or with nodal or distant metastases (N1–3, M1) have a worse prognosis, even if the tumor can be completely removed surgically; the 5-year survival rates are 60%, 25% and 5%, respectively. For these patients it is reasonable to start prospective statistical studies concerning adjuvant treatment after surgery. The aims of the investigations should be survival, local or systemic progression of the disease, and quality of life. However, the number of prospective trials is still limited and the results are disappointing: hormone therapy, chemotherapy, immunotherapy and radiotherapy in metastatic renal cancer have reached response rates above 30%; a complete response has been seen in less than 10% of all cases and only for a short period of time. Therefore, we do not recommend any kind of adjuvant treatment after radical nephrectomy. Even adjuvant surgery (complete lymph-node dissection) cannot be recommended as a routine procedure, until the benefit for the patients has been proven by prospective trials.     

Surgical considerations for invasive breast cancer

The 1992 NIH Consensus Development Conference reported that "breast conservation treatment is an appropriate method of primary therapy for the majority of women with stage I and II breast cancer and is preferable because it provides survival equivalent to total mastectomy and axillary dissection while preserving the breast." This conclusion has been solidly confirmed by recent updates of all of the prospective clinical trials performed. The uneven utilization of this BCS indicates the personal discomfort of some surgeons in recommending it or in communicating their recommendations to patients. The appropriate candidate for mastectomy is the patient in whom it is evident that BCS will not control the tumor. This conclusion may be drawn after one or even two attempts at revision have shown more extensive microscopic disease. The experience with preoperative chemotherapy programs such as NSABP Protocol B-18 shows that even for larger tumors primary excision or excision after preoperative chemotherapy provides reasonable rates of local control with no evidence of diminished distant control or survival. Very large tumors, often accompanied by other grave signs, are best treated by primary chemotherapy, because they are essentially not stage I or stage II disease. Although recognizing that better long-term cure rates are a function of the treatment of micrometastases with adjuvant chemotherapy, surgeons should remember the need to balance cosmetic factors with techniques required for good local control. Cosmetic factors are always important, but the primary concern is adequate removal of the primary tumor with pathologically negative margins. The best way to prevent the need for a salvage mastectomy following local recurrence is to obtain adequate control at the initial procedure, but this does not mean that aggressive local surgery is needed, and it certainly does not mean that a primary mastectomy is needed except in unusual cases.     

Locally advanced breast cancer in the elderly

The data concerning the influence of old age and locally advanced stages on breast cancer treatment and outcome are lacking or sparse. The authors reviewed treatment modalities in women over 65 years old with locally advanced breast cancer. The purpose of the study is to determine if differences in treatment modalities, clinical stage and pathological type influence the outcome. For patients with locally advanced disease but without over evidence of metastatic disease, radical surgical procedures should be attempted. Most study results confirm that loco-regional therapy and adjuvant chemohormonotherapy is feasible and safe even for older patients.     

Radical cystectomy for invasive bladder cancer: long-term results of a standard procedure

Radical cystectomy with an appropriate lymphadenectomy remains the standard of therapy for high-grade invasive bladder cancer. This surgical approach provides the best survival rates with the lowest local recurrence rates and orthotopic diversion can be performed safely in most patients with an acceptable outcome and quality of life. Pathologic analysis of the bladder tumor and regional lymph nodes will help direct the need for adjuvant therapy in high-risk individuals. Equivalent long-term local control and survival are not seen with other forms of treatment including radiation therapy, chemotherapy, or a combination of the two. The rationale and clinical results of large, contemporary cystectomy series are presented, which provide a benchmark of outcomes with this form of surgical treatment.     

Real‐world effectiveness of fulvestrant monotherapy as first endocrine treatment in patients with metastatic breast cancer

Fulvestrant monotherapy is approved for postmenopausal women with hormone receptor‐positive, metastatic breast cancer (MBC) who progressed following antiendocrine therapy, or those with hormone receptor‐positive, human epidermal receptor 2‐negative advanced breast cancer (BC) not previously treated with endocrine therapy (ET). However, real‐world data are lacking. Retrospective reviews of 10 United States community oncology practices identified patients diagnosed with MBC between 1 January 2011 and 31 December 2015 who received fulvestrant as the first ET, either as initial therapy for metastatic disease or after progression following one line of chemotherapy. Endpoints were progression‐free survival (PFS) and overall survival (OS). Patients were classified as ET‐naïve or by relapse status following adjuvant ET (“early” recurrence during or ≤12 months of completing adjuvant ET, or “late” >12 months after completing adjuvant ET). Outcomes were evaluated using Kaplan‐Meier methods. Among 121 patients, median PFS (95% confidence interval) was 8.3 months (4.8‐12.3) for early relapse, 15.4 months (10.2‐21.2) for late relapse, and 18.7 months (10.1‐20.8) among ET‐naïve patients (P = .018). Median OS was 39.8 months (25.0‐55.1) for early relapse and 61.4 months (47.1‐61.4) for late relapse, but was not reached (NR; 55.6–NR) for ET‐naïve patients (P = .002). Fulvestrant monotherapy as the first ET after MBC diagnosis demonstrates PFS comparable to clinical study results; outcomes appeared better in patients without prior ET exposure and in patients with disease recurrence >12 months following adjuvant ET. These findings support fulvestrant monotherapy in patients with hormone receptor‐positive MBC.     

Adjuvant therapy for breast cancer

The use of adjuvant therapies after surgery for breast cancer has made a significant difference to breast cancer survival. The regular production of meta-analyses by the Early Breast Cancer Trials Collaborative Group has highlighted the effects of adjuvant therapies. The important histological factors that need to be considered when deciding the adjuvant therapy are tumour size, histological grade, nodal status and oestrogen receptor status. The original treatments were based on the idea that many breast cancers are hormone-sensitive and ovarian ablation was one of the first methods. The discovery of oestrogen receptors and the drug tamoxifen reduced breast cancer mortality and recurrence rates in patients with oestrogen receptor-positive tumours. Polychemotherapy regimens are very effective in pre- and post-menopausal women and are well tolerated. Anthracycline regimens are now used routinely in most pre-menopausal women (unless they have a very good prognosis). The results of ongoing trials which incorporate taxanes with chemotherapy are awaited. Another exciting potential treatment is the use of herceptin (an antibody against the HER-2 receptor) in the adjuvant setting. Postoperative radiotherapy can also be considered as an adjuvant treatment which decreases the risk of local recurrence in the breast after conservation treatment or in the chest wall after a mastectomy.     

The early discontinuation of adjuvant hormone therapy is associated with a poor prognosis in Japanese breast cancer patients

Purpose

It is important for patients to complete the planned hormone therapy to reduce both the recurrence and mortality rates of hormone receptor-positive breast cancer. We investigated the rates and factors related to the early discontinuation of adjuvant hormone therapy at our institution.

Methods

We identified 145 females prescribed adjuvant hormone therapy who were followed up for longer than 5 years. The rate of completing the planned hormone therapy and factors related to early discontinuation were examined. The relapse-free survival rate was examined between the completion group and the discontinuation group.

Results

The completion rate was 90.6 %. The primary reason for discontinuing hormone therapy within 5 years was side effects, such as arthritic pain. The primary factor related to early discontinuation was a significantly younger age. The relapse-free survival rate was significantly lower in the discontinuation group (p = 0.025).

Conclusions

More than 90 % of the patients completed the planned adjuvant hormone therapy, and early discontinuation was related to a shorter RFS. To improve the rate of the successful completion of adjuvant hormone therapy, it is important to provide supportive care to reduce the occurrence of side effects and to care for young females with a desire to become pregnant.     

Carcinoid tumor metastases: Prospective study of twenty-two patients

Twenty-two patients with advanced metastatic carcinoid disease, most of whom were moribund were subjected to oral administration of 200 mg of 5-fluorotryptophan three times daily. Seven patients died from complications of the tumor before completing the course of one year's treatment. Of the fifteen patients who survived long enough to complete the year of therapy, the average additional survival time was 2.3 years, varying from one to over nine years. The average survival time after the diagnosis of advanced metastatic carcinoid disease was made and prior to the initiation of treatment with 5-fluorotryptophan in these patients was 5.5 years, varying from one to eight years. Side effects of the analog were limited to gastric upset in one patient only. The control of serotonin production and its associated symptoms was considered excellent. Slowly progressive tumor growth led ultimately to death in thirteen of the fifteen patients which was considered due to mechanical factors and not to hormone abnormalities. Two patients continue to survive with good quality of life nine and six years, respectively, after analog therapy. Life in patients with advanced metastatic carcinoid disease has been extended with good to excellent quality by the simple oral administration of the tryptophan analog, 5-fluorotryptophan. Tumor growth does not seem to have been affected by the analog.     

Presentation, management and outcome of axillary recurrence from breast cancer

BACKGROUND: The impact of axillary node dissection on breast cancer survival is unclear. Limited axillary surgery has been proposed but may increase regional recurrence rates. Optimal management for axillary recurrence is poorly understood. METHODS: Axillary recurrences were initial treatment failure sites in 44 of 4,255 breast cancer patients (1%) seen at M.D. Anderson Cancer Center, 1982 to 1992. RESULTS: Twenty-one patients (48%) had early stage disease (0, I, II) at diagnosis. With 70.8 months median follow-up, complete control of axillary recurrence was achieved in 31 patients (71%). Distant metastases developed in 50% and were more likely with uncontrolled axillary recurrences. Failure to receive multimodality therapy and failure to undergo surgery for the recurrence correlated with resistant axillary disease. CONCLUSIONS: Axillary recurrence from breast cancer is uncommon but may follow any stage of disease. One half of affected patients develop distant metastases. Durable disease control is best achieved with multimodality therapy including a surgery component.     

Predictors of loco-regional recurrence and cancer-related death after breast cancer surgery

To determine which tumor-related factors might predispose the patient to loco-regional recurrence or death and the impact of these factors on the different types of events. We retrospectively analyzed the data of 1991 women between January 1998 and March 2010 for a first primary nonmetastatic breast cancer and treated with surgery and neo-adjuvant/adjuvant therapy. The overall survival distribution was estimated using the Kaplan-Meier method. The prognostic impact of several factors on cumulative overall and loco-regional recurrence free survival was evaluated by univariate (log-rank test) and multivariate analysis (Cox regression). At log-rank test, pT, nodal status, histotype, grading, lymphangioinvasive growth, tumor diameter, estrogen receptors (ER) status, progesterone receptors (PR) status, expression of Ki67, and expression of Her2/neu had a prognostic value on loco-regional recurrence or overall survival. In the multivariate analysis grading remained the only independent predictor of loco-regional recurrences. With regard to overall survival, the Cox model selected grading along with nodal status and PR status. Loco-regional recurrences after breast cancer surgery are not frequent events. They are markers of tumor aggressiveness and predictor of an increased likelihood of cancer-related death. However, loco-regional recurrence and systemic tumor progression are partially independent events, since some prognostic factors differ.     

2023年乳腺癌临床研究进展年终盘点

乳腺癌作为全球发病例数第一的恶性肿瘤,多年来一直是研究的热点。2023年,乳腺癌临床研究在局部治疗和系统治疗方面取得显著进展。在局部治疗方面,如何评估腋窝肿瘤负荷及选择合适的治疗手段是研究焦点。SOUND研究发现前哨淋巴结活检（SLNB）与无腋窝手术对于术前腋窝超声淋巴结阴性早期乳腺癌患者的5年无远处转移生存率相似,在术前超声对腋窝淋巴结筛查结果明确的情况下可避免SLNB。SENOMAC研究提供证据支持低负荷前哨淋巴结患者不进行腋窝淋巴结清扫（ALND）的可能性。OPBC05研究指出新辅助治疗后残留孤立肿瘤细胞（ITCs）的患者中ALND不改善长期生存,暗示豁免ALND的可行性。NSABP B-51研究显示,新辅助化疗（NAC）后腋窝淋巴结阴性（ypN0）患者的局部淋巴结放疗（RNI）并未显著改善主要研究终点。这些研究强调了个体化治疗方案的重要性,为乳腺癌的外科治疗和后续治疗提供重要指导。在系统治疗方面,早期激素受体阳性［HR（+）］乳腺癌治疗主要依赖手术、放疗及术后辅助内分泌治疗,但约30%的中高危患者仍面临复发和转移风险。MoHER2narchE和NATALEE研究证实了CDK4/6抑制剂（CDK4/6i）在早期HR（+）/人表皮生长因子受体2阴性［HER-2（-）］乳腺癌患者中的效果。此外,有关免疫治疗的研究,如KEYNOTE-756和CheckMate 7FL试验,探讨了PD-1单抗联合NAC在提高病理完全缓解（pCR）率和降低高危患者复发风险中的潜力。晚期HR（+）乳腺癌的标准治疗已从单一内分泌治疗发展为CDK4/6i联合内分泌治疗,但仍存在耐药问题,新型药物如ADC药物、PI3K/Akt/mTOR抑制剂正在被探索以提供更多治疗选项。TROPiCS-02和TROPION-Breast01研究验证了TROP2靶向ADC药物在治疗耐药HR（+）/HER-2（-）晚期乳腺癌患者中的有效性。同时,INAVO 120和Capitello-291研究突显了PI3K/Akt/mTOR信号通路抑制剂在提高治疗效果方面的潜力,尤其是对PIK3CA突变患者。在早期HER-2（+）乳腺癌治疗方面,PHERGain研究表明,基于¹⁸F-FDG PET/CT和根据pCR调整的降阶梯化疗在早期HER-2（+）乳腺癌新辅助治疗中有效。APTneo研究发现阿替利珠单抗联合化疗对新辅助治疗的pCR率提升有限,需进一步研究以优化疗效和安全性。在晚期HER-2（+）乳腺癌方面,PHILA和HER2CLIMB-02研究展示了TKI药物在一线和二线治疗中的有效性。DESTINY-Breast系列研究证明了德曲妥珠单抗（T-DXd）对HER-2（+）转移性乳腺癌各年龄段患者都有效且展现出良好的安全性。同时其对经治/稳定和未经治/活动性脑转移患者均有显著的疗效。早期三阴性乳腺癌（TNBC）的研究重点在于免疫治疗与化疗的联合应用,KEYNOTE-522研究显示化疗联合帕博利珠单抗的新辅助治疗及其作为后续辅助治疗显著提高了pCR率和无事件生存率,美国食品药品管理局和欧洲药物管理局已批准其用于高危早期TNBC的治疗。然而,IMpassion030研究表明,术后辅助免疫治疗可能并非所有早期TNBC患者的有效选项。对于晚期TNBC,KEYLYNK-009研究结果显示帕博利珠单抗联合PARP抑制剂奥拉帕利与帕博利珠单抗加化疗相比,并未显著改善预后,但在具有tBRCA突变的患者群体中,该联合疗法显著提高了中位无进展生存期（PFS）,表明其可作为这一患者群体的晚期一线维持治疗。BEGONIA研究的结果表明,Dato-DXd和度伐利尤单抗联合治疗显示出高反应率和较长的PFS,可能为晚期TNBC患者提供新的治疗选择。综上,2023年乳腺癌治疗领域的研究不仅在治疗方法上取得了突破,也在治疗理念上进行了革新,为乳腺癌患者带来了新的希望。     

Conservative treatment of breast cancer: Milan experience

Summary Background The conservative treatment of operable breast cancer has gradually become well-established during the last 20 years as it offers adequate loco-regional control of the disease and saves the brest. Moreover, larger, demolishing operations have not shown to decrease the risk of distant metastases. Methods Four prospective, randomized trials (Milan Trials I to IV) have been conducted at the Department of Surgical Oncology of the Istituto Nazionale Tumori Milan since 1973 comparing the radical Halsted approach in operable breast cancer to conservative treatments combining extensive breast resection and various radiotherapies. Results Data analysis lends force to the conservative treatment concept, showing that an extensive breast resection, defined as quadrantectomy, together with radiotherapy are a safe procedure that results in a long term survival comparable to that after Halsted's mastectomy. Furthermore, the studies reveal that too limited a resection (lumpectomy) and withdrawal of radiotherapy increase the risk of local recurrence. In women older than 55 years, however, quadrantectomy without radiotherapy yields good results. Young age and the presence of an extensive intraductal component are further, signficant and important risk factors of local recurrence. Conclusions If attention is paid to the defined risk factors and adjuvant therapeutic regimes the conservative surgical treatment of breast cancer yields excellent long term results.      

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.