Tumour bed clip localisation for targeted breast radiotherapy: Compliance is proportional to trial-related research activity: Tumour bed clip localisation in breast radiotherapy

Background

In breast cancer, with the increasing use of intensity-modulated radiotherapy (IMRT), the need for accurate tumour bed localisation is paramount. We determined current practice of clip usage in patients referred to a regional centre for radiotherapy following breast conserving surgery. We also investigated whether participation of surgical units in IMRT trials, where tumour bed clip use is emphasised, was associated with clip insertion.

Methods

A retrospective cohort study of consecutive CT planning images (n = 205), of breast cancer patients treated with radiotherapy following breast conserving surgery. Presence and number of clips; referring hospital and referring surgeon of the patient was recorded. This was correlated to previous participation of referring hospital to IMRT trials.

Results

Of 196 eligible patients, 126 (64%) had clips sited, of which 15 (12%) had two or fewer clips. Five referring hospitals were high recruiters (≥14 patients), and five hospitals were low/non-recruiters (≤1 patient) to IMRT trials. Of patients from low/non-recruiting centres, 29 of 43 (67%) had clips omitted, compared to 41 of 153 (27%) from high-recruiting centres (p < 0.001). Median number of clips used in centres recruiting high numbers of patients was four, compared to zero in low recruiting centres. Ten of 31 referring surgeons routinely omitted clips.

Conclusion

Despite inclusion in national guidelines, clip insertion has not become routine in the UK in patients undergoing breast conserving surgery. However, hospitals involved in breast radiotherapy randomised controlled trials are more compliant with clip usage recommendations. Auditing of clip insertion should be considered as a quality control marker in breast surgery.     

Breast conserving surgery after neoadjuvant therapy for large primary breast cancer

Aim

The aim of this study was to evaluate the safety of breast conserving surgery in patients with breast tumours satisfactorily downstaged after neoadjuvant therapy.

Methods

A retrospective cohort study was undertaken to analyze the loco-regional recurrence (LRR) after breast conserving surgery. We enrolled 88 patients with breast cancer subjected to neoadjuvant therapy (NAT group) who achieved an objective response due to neoadjuvant treatment and compared them with 191 patients with early breast cancer (EBC group) who were submitted to primary conserving surgery. Lumpectomy or quadrantectomy with axillary lymph node dissection was performed in all patients who received adjuvant radiotherapy. Systemic adjuvant therapy was offered to all patients. The mean periods of observation were 61.3 months in the NAT group and 67.5 months in the EBC group.

Results

The mean age was 53 years in the NAT group and 56 years in the EBC group (p = 0.04). There was no histological type and histological grade difference between groups. In the NAT group, the mean diameter of residual tumour was lower and the mean volume of breast tissue resection was higher than in the EBC group (p = 0.01 and p = 0.002, respectively). The ipsilateral recurrence rate was 7.9% in the NAT group and 7.8% in the EBC group (p = 0.9). The most important predictive factor of recurrence in the NAT group was the age of patient.

Conclusion

Breast conserving therapy is a safe procedure in satisfactorily downstaged breast cancer after neoadjuvant therapy.     

Outcomes of bilateral mammoplasty for early stage breast cancer

Aim

Long-term oncological follow-up of oncoplastic breast surgery.

Methods

Sixthy-one (63 cancers) patients affected by breast cancer suitable for breast conservation, were treated with bilateral breast reductions. Tumours located in the inferior pole of the breast were treated by a superior pedicle technique; lesions in the upper pole or in the infero-lateral or infero-medial quadrants of the breast were removed with an inferior pedicle reduction. Small and medium size breast irrespective of tumour location required a periareolar, or comma-shaped approach.

Results

Fifty-six patients were alive at a mean follow-up of 68 months. One patient recurred locally and she is currently alive free of disease.

Conclusion

Results from this study are in accordance with those reported by other similar papers. Oncoplastic breast surgery maximizes cosmetic results and with wider excisions provides effective local control.     

Completion axillary dissection can safely be omitted in screen detected breast cancer patients with micrometastases. A decade's experience from a single institution

Background

The need for completion axillary lymph node dissection (ALND) in breast cancer patients with micrometastases in the sentinel nodes (SNs) is controversial. The aim of this retrospective observational study is to determine if the method of detection of early breast cancer is predictive for additional positive nodes in patients with micrometastases in the SNs.

Methods

Between 2001 and 2011 a total of 1993 women with primary unilateral breast cancer had surgery at Skåne University Hospital, Lund. Of 1993 patients, 1458 had an SN biopsy and nearly all patients with micro- and macrometastases had ALND.

Results

Micrometastases defined as >0.2 mm/>200 cells and ≤2.0 mm were found in 62 of 757 screen-detected patients and in 81 of 701 patients with symptomatic breast cancer. Only 3 of the screen-detected patients with micrometastases, all with tumour size >15 mm (range 18–39 mm), had metastases in the completion ALND whereas this was found in 18 of the symptomatic patients with micrometastases (p = 0.01), (tumour size, range 10–30 mm). Logistic regression analysis adjusted for method of detection, tumour size and histological grade showed 5 times higher odds for further metastases in ALND in patients with symptomatic presentation vs. screen-detected breast cancer.

Conclusion

Despite the small number of patients with micrometastases in this large cohort of breast cancer patients, these results support the contention that completion ALND can safely be omitted in screen-detected breast cancer patients with micrometastases in the SNs.     

Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis

Objective

Recent studies indicate that removal of the primary tumour may have a beneficial effect on mortality risk of patients with primary distant metastatic breast cancer (stage IV), although most of them did not rule out confounding by the presence of co-morbidity. In this retrospective study the impact of surgical resection of the primary tumour on the survival of patients with primary distant metastatic disease is investigated, taking into account the presence of co-morbidity and other potential confounders.

Methods

Between 1993 and 2004, 15?769 patients with breast cancer were diagnosed in the south of the Netherlands. This study included the 728 patients with distant metastatic disease at initial presentation, which was 5% of all patients. Of them, 40% had surgery of the primary tumour. Follow-up was carried out until 1 July 2006.

Results

Median survival of the patients who had surgery of their primary tumour was significantly longer than for the patients who did not have surgery (31 vs. 14 months). The 5-year survival rates were 24.5% and 13.1%, respectively (p < 0.0001). In a multivariable Cox regression analysis, adjusting for age, period of diagnosis, T-classification, number of metastatic sites, co-morbidity, use of loco-regional radiotherapy and use of systemic therapy, surgery appeared to be an independent prognostic factor for overall survival (HR = 0.62; 95% CI 0.51–0.76).

Conclusion

Removal of the primary tumour in patients with primary distant metastatic disease was associated with a reduction of the mortality risk of around 40%. The association was independent of age, presence of co-morbidity and other potential confounders, but a randomized controlled trial will be needed to rule out residual confounding.     

Evaluation of quality of life after breast reconstruction using an autologous latissimus dorsi myocutaneous flap

Aims

To evaluate the patients’ satisfaction with breast reconstruction using the autologous latissimus dorsi technique and the impact of the procedure on the quality of life and body image of women who had mastectomy for breast cancer.

Methods

A retrospective transversal study was conducted at the Georges François Leclerc Cancer Care Center in Dijon, France. From 1990 to 2008, 193 women underwent reconstruction (RW), among these, 141 were matched for age at diagnosis and the date of the mastectomy with women who did not undergo reconstruction (NRW) identified using data from the Côte d’Or breast cancer registry. Questionnaires concerning quality of life, body image and satisfaction (MBROS-S, MBROS-BI, EORTC QLQ-C30, EORTC QLQ-BR23) were sent through the post following surgery.

Results

The overall response rate was 77% and the mean (MBROS-S) satisfaction score was 3.36. The quality of life (EORTC QLQ-C30, EORTC QLQ-BR23) in RW was no better than that in NRW, but body image was better (p = 0.0247) especially before 60 years (p = 0.0192), in obese patients (p = 0.03) and when the breasts of RW were heavy (p = 0.0197). Moreover, when the time from the mastectomy was less than 4 years, body image (p = 0.0008) and the sexual activity score (p = 0.0078) were higher in RW.

Conclusions

The level of satisfaction was higher in RW, and breast reconstruction made a strong contribution in terms of improvement in body image. A prospective study to evaluate quality of life in the long term is now necessary.     

Ultrasound and fine needle aspiration cytology of the axilla in the pre-operative identification of axillary nodal involvement in breast cancer

Aims

Pre-operative diagnosis of axillary nodal involvement in breast cancer allows one-stage axillary surgery. We evaluated the efficacy of axillary ultrasound (US) with US guided fine needle aspiration cytology (FNAC) in the diagnosis of axillary nodal involvement.

Methods

Over a 13-month period, we performed US of 369 axillae in patients with screen-detected (n = 278) and symptomatic (n = 91) invasive carcinoma of the breast, at the same time as US of the primary tumour. If abnormal lymph nodes were demonstrated, a single US guided FNAC of the most abnormal node was performed. US and FNAC results were compared with the final histology of the surgically excised lymph nodes.

Results

Among the 369 axillae studied, 102 had nodal macrometastases and 38 (37%) were identified by US guided FNAC. The rate was 33% in screen-detected and 44% in symptomatic patients. Sensitivity increased with increasing numbers of positive axillary nodes, and the more abnormal the appearances of the nodes on US.

Conclusion

US with FNAC of the most abnormal node allows pre-operative detection of a third of node positive axillae in screen-detected and over 40% of those with symptomatic breast cancer, allowing one-stage axillary surgery avoiding the sentinel node biopsy step in these patients.     

Tissue confirmation of disease recurrence in breast cancer patients: pooled analysis of multi-centre, multi-disciplinary prospective studies

Background

Treatment decisions in recurrent breast cancer are usually based on the estrogen (ER), progesterone (PgR) and HER2 receptor status of the primary tumour. Retrospective studies suggest that discordance between receptor expression of primary and recurrent breast cancer exists.

Methods

A pooled analysis of individual patient data from two large prospective studies comprising biopsy of recurrent lesions obtained from consenting patients was undertaken. Tissue was analyzed for ER, PgR by immunohistochemistry and HER2 by FISH. Receptor status of recurrent disease was compared with that of the primary tumour. Recruiting clinicians assessed whether or not receptor discordance affected subsequent systemic treatment.

Results

Two hundred and eighty-nine patients underwent biopsy. Recurrent biopsy specimens were obtained from locoregional recurrence in 48.1% and from distant metastases in 51.9%. Distant sites included skin/soft tissue (25.0%), bone/bone marrow (19.2%) and liver (15.8%). Benign disease or second primary cancer was observed in 7.6% of biopsies. Discordance in ER, PgR or HER2 between confirmed primary and recurrent breast cancer was 12.6%, 31.2% and 5.5%, respectively (all p < 0.001). Biopsy results altered management in 14.2% of patients undergoing biopsy (95% confidence intervals 10.4–18.8%, p ? 0.0001). The duration between primary and recurrent disease, the site of recurrence and the receptor profile of the primary tumour did not affect discordance rates.

Conclusions

There is substantial discordance in receptor status between primary and recurrent breast cancer. The number needed to biopsy in order to alter treatment was 7.1. Patients with recurrent breast cancer should have tissue confirmation of receptor status of recurrent disease.     

Interstitial laser thermotherapy (ILT) of breast cancer

Aim

To find out if ILT can be used as radical treatment of breast cancer.

Method

Twenty-four patients, aged 39–84 (mean 61), with invasive breast cancer were treated with ILT. All underwent mammography, ultrasound and core biopsy before treatment. The tumour was an invasive ductal carcinoma in 15 patients, a lobular carcinoma in eight and lobular–ductal cancer in one. Average tumour diameter was 14 mm on ultrasound (5–35). Patients were treated in the outpatient clinics under local anaesthesia. Probes were placed under ultrasound guidance, in 19 patients, and ILT was performed with a diode laser at a steady-state temperature of 48 °C for 30 min using temperature feedback control. Standard surgical excision was performed 12 (4–23) days after ILT and was preceded by Doppler ultrasound.

Results

Treatment-induced necrosis of invasive cancer was 33% (range 0–100) and was complete in three patients. At follow-up before surgery, the extent of laser damage could not be judged with ultrasound, although abolished tumour blood flow was demonstrated after treatment resulting in large necroses. Efficacy of treatment varied negatively with tumour size. The inefficacy of ILT was mainly due to the underestimation of tumour size by mammography and ultrasound and the shortcomings of these methods to demonstrate tumour borders, tumour irregularity and carcinoma in situ (CIS). ILT was well tolerated. Five patients had breast tenderness, and three patients had pain, during the first day after treatment. Small skin necroses were observed in two patients.

Conclusion

Small breast cancers can be treated radically with ILT. The method may become useful in the treatment of breast cancer but needs further refinement, even for small well-defined breast cancers, if it is going to be employed for radical treatment.     

Breast MRI in clinically and mammographically occult breast cancer presenting with an axillary metastasis: A systematic review

Background

Axillary metastatic lymphadenopathy with no primary tumour identified in the breast on physical examination, mammography or ultrasound is referred to as occult breast cancer. The goal of this systematic review is to give an overview of the value and additional considerations of using breast MRI in occult breast cancer.

Methods

The databases of Pubmed, Embase, CINAHL and the Cochrane library were searched for studies addressing the use of breast MRI in occult breast cancer. Cross-referencing was used to find additional articles.

Results

8 retrospective studies were included. Breast MRI can detect an otherwise occult breast cancer in more than two thirds of patients with a high sensitivity but lower specificity. In 80% of patients MRI detected lesions could be localized again by using ultrasound. Furthermore the size and localization of the lesions found on MRI most often correlated closely with findings at pathology. Breast MRI also provided the possibility of breast conserving surgery in one thirds of patients.

Conclusion

Breast MRI can result in additional detection of otherwise occult lesions in occult breast cancer. Because of low specificity of malignant lesion detection by breast MRI, lesions should be histologically confirmed. This can be achieved either by MRI or ultrasound guided biopsy, as long as all MRI detected lesions are histologically checked. Routine application of breast MRI in occult breast cancer may also alter locoregional treatment by offering the possibility of breast conserving surgery in one thirds of patients.     

Identification of residual breast tumour localization after neo-adjuvant chemotherapy using a radioactive 125 Iodine seed

Introduction

The use of neo-adjuvant chemotherapy has increased in the treatment of loco-regionally advanced primarily operable breast cancer. As a result of improved neo-adjuvant chemotherapy regimes the number of clinical as well as radiological responses have increased. In case of a complete response it is difficult to identify residual disease and to perform an adequate radical breast-conserving surgery. Therefore localization of the original tumour bed is mandatory. In this study we propose a novel technique with a seed containing radioactive 125 Iodine (¹²⁵I). The ¹²⁵I has a half-time of 60 days and is therefore still recognisable with a gamma probe after admittance of several courses of neo-adjuvant chemotherapy.

Material and Methods

In the period from July 2003 and November 2008, 47 consecutive patients had successful ¹²⁵I seed localization of a breast tumour before starting neo-adjuvant chemotherapy.

Results

The overall clinical response rate to neo-adjuvant chemotherapy was 100%. Complete clinical response occurred in 34 patients, partial clinical response occurred in 13 patients. Complete radiological response occurred in 18 patients, partial radiological response occurred in 29 patients. The initial surgical treatment consisted of breast-conserving surgery for all 47 patients, after a mean of 170 days (range: 70–220) after ¹²⁵I seed localization. In 19 patients pathology revealed no residual tumour, 23 patients showed a partial response. Only 3 lumpectomies were irradical.

Conclusion

This study has shown that ¹²⁵I seed localization is a novel and highly successful technique in localizing the tumour bed in patients who receive neo-adjuvant chemotherapy for breast cancer leading to a high percentage of radical margins in case of breast-conserving surgery.     

Real-time intraoperative detection of breast cancer using near-infrared fluorescence imaging and Methylene Blue

Background

Despite recent developments in preoperative breast cancer imaging, intraoperative localization of tumor tissue can be challenging, resulting in tumor-positive resection margins during breast conserving surgery. Based on certain physicochemical similarities between Technetium(^99mTc)-sestamibi (MIBI), an SPECT radiodiagnostic with a sensitivity of 83–90% to detect breast cancer preoperatively, and the near-infrared (NIR) fluorophore Methylene Blue (MB), we hypothesized that MB might detect breast cancer intraoperatively using NIR fluorescence imaging.

Methods

Twenty-four patients with breast cancer, planned for surgical resection, were included. Patients were divided in 2 administration groups, which differed with respect to the timing of MB administration. N = 12 patients per group were administered 1.0 mg/kg MB intravenously either immediately or 3 h before surgery. The mini-FLARE imaging system was used to identify the NIR fluorescent signal during surgery and on post-resected specimens transferred to the pathology department. Results were confirmed by NIR fluorescence microscopy.

Results

20/24 (83%) of breast tumors (carcinoma in N = 21 and ductal carcinoma in situ in N = 3) were identified in the resected specimen using NIR fluorescence imaging. Patients with non-detectable tumors were significantly older. No significant relation to receptor status or tumor grade was seen. Overall tumor-to-background ratio (TBR) was 2.4 ± 0.8. There was no significant difference between TBR and background signal between administration groups. In 2/4 patients with positive resection margins, breast cancer tissue identified in the wound bed during surgery would have changed surgical management. Histology confirmed the concordance of fluorescence signal and tumor tissue.

Conclusions

This feasibility study demonstrated an overall breast cancer identification rate using MB of 83%, with real-time intraoperative guidance having the potential to alter patient management.     

Extensive soft tissue resection with autologous tissue closure for locally recurrent breast cancer: Lasting local control and acceptable morbidity

Introduction

Locoregional breast cancer recurrence can be detected at an advanced stage of the disease. To achieve local control for these larger local breast cancer recurrences, wide soft tissue resections with autologous tissue coverage of the defect is an option. The aim of this study was to assess the local control and morbidity of surgical salvage of patients with advanced local breast cancer recurrence using autologous tissue closure of the defect.

Material and methods

Eighty-eight patients were treated with wide soft tissue resections with autologous tissue coverage from 1993 to 2006. Two different operating techniques were used for closure of the defect; transposition of the greater omentum covered with split skin graft and the latissimus dorsi musculo-cutaneous flap. Demographic, treatment and mortality information were retrieved from original patients' files.

Results

Postoperatively 10 patients (11%) developed complications which required an additional operation. In patients treated with curative intent (n = 67) median disease-free interval after extensive surgery was 24 months and median survival was 45 months. In 42 patients (47% of all included patients) the first recurrence after extensive surgery was a locoregional relapse. The two surgical techniques did not differ in overall survival (p = 0.739) and local control.

Conclusion

Large soft tissue resection for extensive local relapse of breast cancer may result in lasting local control in half of the patients with acceptable morbidity.     

The role of FDG PET/CT in patients with locoregional breast cancer recurrence: A comparison to conventional imaging techniques

Purpose

The aim of this study was to evaluate the impact of ¹⁸F-fluorodeoxyglucose positron-emission tomography/computed tomography (FDG PET/CT) on clinical management in patients with locoregional breast cancer recurrence amenable for locoregional treatment and to compare the PET/CT results with the conventional imaging data.

Patients and methods

From January 2006 to August 2008, all patients with locoregional breast cancer recurrence underwent whole-body PET/CT. PET/CT findings were compared with results of the conventional imaging techniques and final pathology. The impact of PET/CT results on clinical management was evaluated based on clinical decisions obtained from patient files.

Results

56 patients were included. In 32 patients (57%) PET/CT revealed additional tumour localisations. Distant metastases were detected in 11 patients on conventional imaging and in 23 patients on PET/CT images (p < 0.01). In 25 patients (45%), PET/CT detected additional lesions not visible on conventional imaging. PET/CT had an impact on clinical management in 27 patients (48%) by detecting more extensive locoregional disease or distant metastases. In 20 patients (36%) extensive surgery was prevented and treatment was changed to palliative treatment. The sensitivity, specificity, accuracy, positive and negative predictive values of FDG PET/CT were respectively 97%, 92%, 95%, 94% and 96%.

Conclusions

PET/CT, in addition to conventional imaging techniques, plays an important role in staging patients with locoregional breast cancer recurrence since its result changed the clinical management in almost half of the patients. PET/CT could potentially replace conventional staging imaging in patients with a locoregional breast cancer recurrence.     

Prognosis following local recurrence after breast conserving treatment in young women with early breast cancer

Background

Few studies have focussed on the prognosis of young women with local recurrence (LR) after breast-conserving therapy and the factors that can be used to predict their prognosis.

Methods

We studied the outcome and related prognostic factors in 124 patients with an isolated local recurrence in the breast following breast-conserving surgery and radiotherapy for early stage breast cancer diagnosed at the age of 40 years or younger.

Results

The median follow-up of the patients after diagnosis of LR was 7.0 years. At 10 years from the date of salvage treatment, the overall survival rate was 73% (95% CI, 63–83), the distant recurrence-free survival rate was 61% (95% CI, 53–73), and the local control rate (i.e. survival without subsequent LR or local progression) was 95% (95% CI, 91–99). In the multivariate analysis, the risk of distant metastases also tended to be higher for patients with LR occurring within 5 years after BCT, as compared to patients with LR more than 5 years after BCT (Hazard ratio [HR], 1.89; p = 0.09). A worse distant recurrence-free survival was also observed for patients with a LR measuring more than 2 cm in diameter, compared to those with a LR of 2 cm or smaller (HR, 2.88; p = 0.007), and for patients with a LR causing symptoms or suspicious findings at clinical breast examination, compared to those with a LR detected by breast imaging only (HR 3.70; p = 0.03).

Conclusions

These results suggest that early detection of LR after BCT in young women can improve treatment outcome.     

Prospective randomized comparison of conventional instruments and the Harmonic Focus device in breast-conserving therapy for primary breast cancer

Background

In recent years, surgeons have utilized Harmonic instruments to perform breast cancer resection. Retrospective and prospective studies have demonstrated that the use of this surgical device for mastectomy and axillary dissection can reduce perioperative blood loss, seroma formation, and duration and total amount of drainage. No study has analyzed the feasibility of Harmonic instruments in breast-conserving surgery. We conducted a prospective, randomized clinical trial comparing Harmonic instrument and conventional surgery in the performance of breast-conserving surgery and axillary procedures to determine differences in surgical procedures, postoperative outcome, and complications.

Methods

One hundred and six patients with operable breast cancer who underwent breast-conserving surgery at a single institution between December 2009 and January 2011 were included in the analysis. Surgery was performed in 52 patients with the Harmonic Focus^® device and in 54 with scissors and electrocautery. This study focused on operative time, drainage volume, and postoperative outcome measures like blood loss, surgery related complications and patient-reported postoperative pain.

Results

We found a multivariable independent influence in axillary seroma formation and volume of breast drainage with HS. Evident difference in volume and duration of axillary and breast drainage, subjective and objective postoperative pain, reduction in serum hemoglobin, size and weight of resected breast tissue and length of hospital stay in favor of the Harmonic instrument could also be shown.

Discussion

The Harmonic instrument provides key benefits in surgical technique, postoperative outcome, and complication rates in breast cancer surgery.     

Liver metastases from breast cancer: Surgical resection or not? A case-matched control study in highly selected patients

Aim

To determine whether, in a highly selected patient population, medical treatment combined with surgical resection of liver metastases from breast cancer is associated with improved survival compared with medical treatment alone.

Patients and methods

Between 1988 and 2007, 100 liver resections for metastatic breast cancer were performed at Institut Curie, 51 of which met the criteria for inclusion in this case-control study. With the exception of bone metastases, patients with other distant metastasis sites were excluded. Surgery was only performed in patients with stable disease or disease responding to medical treatment evaluated by imaging evaluation. Surgical cases were individually matched with 51 patients receiving medical treatment only. All patients had 4 or fewer resectable liver metastases. The study group was matched with the control group for age, year of breast cancer diagnosis, time to metastasis, TNM stage, hormone receptor status and breast cancer tumour pathology.

Results

Univariate analysis confirmed a survival advantage for patients lacking bone metastases and axillary lymphadenopathy at the time of breast cancer diagnosis and for surgically treated patients. Multivariate analysis indicated that surgery and the absence of bone metastases were associated with a better prognosis. A multivariate Cox model adapted for paired data showed a RR = 3.04 (CI: 1.87–4.92) (p < 0.0001) in favour of surgical treatment.

Conclusion

Surgical resection of liver metastases from primary breast cancer appears to provide a survival benefit for highly selected patients.     

Effectiveness of routine follow-up in the detection of contralateral breast cancer in young women with early breast cancer

Background

The purpose of the study was to determine the effectiveness of routine follow-up to detect contralateral breast cancer (CBC) in young women.

Methods

We used the data of the population-based Eindhoven Cancer Registry, which covers the southern part of the Netherlands. Between 1988 and 2005, 1451 women aged ≤40 years were treated for early-stage breast cancer with breast-conserving treatment or mastectomy.

Results

Of the 94 patients who developed CBC 17 had an in situ carcinoma. Fifty-seven CBCs (61%) were diagnosed more than 5 years after the primary tumour. Forty-two CBCs (45%) were detected during routine follow-up visits, while 52 (55%) presented between two visits. Of the CBC diagnosed between two visits, only 27 (60%) were visible on mammography. Of the invasive CBCs more than 25% was larger than 2 cm in diameter and in 34% positive axillary lymph nodes were found.

Conclusions

These figures indicate that routine follow-up does not guarantee early detection of CBC in young women with breast cancer.     

A population based study of variations in operation rates for breast cancer,of comorbidity and prognosis at diagnosis: Failure to operate for early breast cancer in older women

Background

Older women are less likely to have surgery for operable breast cancer. This population-based study examines operation rates by age and identifies groups which present with early or late disease.

Methods

37 000 cancer registrations for 2007 were combined with Hospital Episode Statistics comorbidity data for England. Operation rates were examined by age, ethnicity, deprivation, comorbidity, screen-detection, tumour size, grade and nodal status. Early and late presentation were correlated with Nottingham Prognostic Index (NPI) groups and tumour size.

Results

The proportion of women not having surgery increased from 7–10% at ages 35–69 to 82% from age 90. From age 70, the proportion not having surgery rose by an average of 3.1% per year of age. Women with a Charlson Comorbidity Index score of ≥1 (which increased with age), with tumours >50 mm or who were node positive, were less likely to have surgery. Although women aged 70–79 were more likely to have larger tumours, their tumours were also more likely to have an excellent or good NPI (p < 0.001). Good prognosis tumours were more likely to be screen-detected, and less likely in women aged 0–39, the deprived and certain ethnic groups (p < 0.02).

Conclusions

From age 70 there is an increasing failure to operate for breast cancer. Younger women and certain ethnic groups presented with more advanced tumours. Older women had larger tumours which were otherwise of good prognosis, and this would not account for the failure to operate which may in part be related to comorbidity in this age group.     

Association of breast tumour bed seroma with post-operative complications and late normal tissue toxicity: Results from the Cambridge Breast IMRT trial

Aims

There are two main surgical techniques for managing the tumour bed after breast cancer excision. Firstly, closing the defect by suturing the cavity walls together and secondly leaving the tumour bed open thus allowing seroma fluid to collect. There is debate regarding which technique is preferable, as it has been reported that a post-operative seroma increase post-operative infection rates and late normal tissue side effects.

Methods

Data from 648 patients who participated in the Cambridge Breast IMRT trial were used. Seromas were identified on axial CT images at the time of radiotherapy planning and graded as not visible/subtle or easily visible. An association was sought between the presence of seroma and the development of post-operative infection, post-operative haematoma and 2 and 5 years normal tissue toxicity (assessed using serial photographs, clinical assessment and self assessment questionnaire).

Results

The presence of easily visible seroma was associated with increased risk of post-operative infection (OR = 1.80; p = 0.004) and post-operative haematoma (OR = 2.1; p = 0.02). Breast seroma was an independent risk factor for whole breast induration and tumour bed induration at 2 and 5 years. The presence of breast seroma was also associated with inferior overall cosmesis at 5 years. There was no significant association between the presence of seroma and the development of either breast shrinkage or breast pain.

Conclusion

The presence of seroma at the time of radiotherapy planning is associated with increased rates of post-operative infection and haematoma. It is also an independent risk factor for late normal tissue toxicity. This study suggests that full thickness surgical closure may be desirable for patients undergoing breast conservation and radiotherapy.