Results of salvage surgery for mammary recurrence following breast-conserving therapy.

A retrospective analysis was performed of 118 surgically treated mammary recurrences, occurring following primary conservative excision and radiation therapy for clinical Stages I and II breast cancer. Actuarial cancer-specific survival following salvage surgery was 72% at 5 years and 58% at 10 years. With a median followup of 7 years, further local-regional recurrences were observed in 20 of the 118 patients, many of whom could be treated by further surgery. Actuarial survival after recurrence was significantly influenced by initial clinical stage, as well as by the disease-free interval following primary therapy, but was similar for both premenopausal and postmenopausal patients and for patients treated by radical or breast-conserving salvage operations. For recurrences after the fifth year, actuarial survival following salvage surgery was 83% and 68% at 5 and 10 years, respectively. Survival for Stage I patients was favorable regardless of disease-free interval. It is concluded that recurrences in the breast following primary treatment with limited surgery and irradiation have a considerably more favorable prognosis than that of local failures after primary radical surgery. Suggestions for the management of these recurrences are presented.     

Limited Surgery and Tamoxifen in the Treatment of Elderly Breast Cancer Patients

Abstract A conservative approach to treating breast cancer patients was adopted for those more than 70 years of age with T1-3 and small localized T4b N0-1 lesions. It consists of tumor excision or simple mastectomy with adjuvant tamoxifen. From the prospective breast cancer database, patients 70 years or older at the time of diagnosis were identified for the period January 1990 to December 1996. Demographic, clinical, pathological, and oncologic data were retrieved. A total of 236 patients were identified. Ninety-seven patients (41%) were treated according to the conservative protocol. Of these, 74 had a tumor excision and 23 had a simple mastectomy. Their mean age was 79 years. TNM staging was stage I in 18 patients, stage II in 66 patients, and stage III in 13 patients. There was no 30-day mortality. Eleven patients were not compliant with tamoxifen use. Two patients were lost to follow-up. The mean follow-up is 51 months (range 4 to 109 months). The cumulative incidence of local and regional recurrence at 8 years is 5% and 7%, respectively. Locoregional recurrences were controlled with excision, mastectomy, or axillary dissection. The cumulative disease-specific, overall, and disease-free survival at 5 years is 86%, 64% and 46%, respectively. Tumor excision or simple mastectomy with tamoxifen offers sufficient tumor control for elderly patients. Axillary dissection and breast or chest wall radiotherapy can safely be omitted, thereby greatly reducing health care resource utilization.     

Management of local recurrence in well-differentiated thyroid carcinoma.

Local recurrence of well-differentiated thyroid carcinoma has a reported mortality approaching 50%. The University of Kentucky experience was reviewed to determine whether aggressive surveillance and treatment with reoperation and/or I-131 ablation increased survival following recurrence. Records of 66 consecutive patients with well-differentiated thyroid carcinoma treated at the University of Kentucky Medical Center (1980-1989) were reviewed. Forty-nine cases of papillary carcinoma and 17 cases of follicular carcinoma were studied; median follow-up was 68 months. At presentation, patients with follicular carcinoma were older (48 versus 35 years; P less than 0.05) and more frequently had metastatic disease (17% versus 2%, P less than 0.05). Fifty-eight (88%) patients were alive and disease-free at last follow-up. Fifteen patients (24%) had developed recurrent disease; median time to recurrence was 24 months. Multivariate regression examined the variables of age, sex, histology, tumor size, cervical adenopathy, capsular and vascular invasion, multicentricity, and surgical procedure. While distant metastases affected actuarial survival, no factor independently predicted local recurrence. In six patients with local recurrence, nonpalpable disease was detected by I-131 scan. All were treated with ablation and remain disease-free (mean follow-up 42 months). Eight patients with local recurrence presented with palpable lesions; seven underwent surgery. While two patients developed repeated local recurrences, the other five remain disease-free (mean follow-up 52 months). Early detection and aggressive treatment of local recurrence improve survival in patients with well-differentiated thyroid carcinoma. To facilitate use of I-131, we advise total thyroidectomy for patients with well-differentiated thyroid carcinoma.     

Results of local excision of benign and malignant rectal lesions

Local excision of selected rectal cancers is an acceptable alternative to radical surgery. The results of local excision of various rectal lesions using either the transanal or trans-sacral approach were reviewed over a 10-year period at this institution. A total of 56 procedures were performed on 47 patients (50 transanal/six trans-sacral). The trans-sacral approach was used six times on five patients for lesions averaging a distance of 8 cm from the anal verge. The transanal approach was used 50 times on two patients for lesions occurring at an average distance of 5 cm from the anal verge. Twenty-six malignant lesions were excised (25 transanal/one trans-sacral) with pathologies ranging from poorly to well-differentiated adenocarcinoma. Staging included 12 T1 lesions (46%), 10 T2 lesions (38%), and four T3 lesions (16%). Eighteen malignancies were completely excised and recurrence occurred in four of 18 (22%) with an average follow-up of 2.3 years (range 0-10 years). Local recurrence occurred in two patients (T1 and T2 lesions) and recurrence was in the form of distant metastasis in two patients (two T3 lesions). Three of the recurrences occurred in patients with T3 lesions (three of four; 75%), two occurred in a patient with a T2 lesion (two of 10; 20%), and one occurred in a patient with a T1 lesion (one of 12; 8%). There were no cancer-related deaths during the study period. Twenty-six premalignant lesions (adenomatous polyps) and four benign lesions were excised (25 transanal/five trans-sacral). Local recurrence occurred 10 times with an average follow-up of 1.8 years. In conclusion local excision of certain rectal cancers is an acceptable alternative in the treatment of these malignancies.     

Prognostic factors in node negative premenopausal women treated with breast conserving therapy without adjuvant systemic therapy

PURPOSE: To study the prognostic factors in node negative premenopausal women treated with breast conserving therapy (BCT) without any adjuvant systemic therapy. METHODS: Of the 1022 women treated with BCT at Tata Memorial Hospital, there was a cohort of 175 women who were premenopausal, node negative and had not received any adjuvant systemic therapy. BCT consisted of wide excision, complete axillary clearance, whole breast radiotherapy (45 Gy in 25 fractions) with 6 MV photons plus tumour bed boost either with brachytherapy or electrons. RESULTS: The median age at presentation was 38 years (range 22-51 years) and the median pathological tumour size was 3 cm (1-5 cm). The 5-year actuarial local control rate was 89.5% and the overall survival (OS) was 88%. On univariate analysis, lymphovascular invasion (LVI) was the only prognostic factor affecting all failures and disease-free survival. The 5-year local control rate in absence of LVI was 93.5% in contrast to 76.5% (p=0.0098) when LVI was present. Similarly, the OS in absence of LVI was 91% in contrast to 74% in presence of LVI (p=0.02). On multivariate analysis, LVI was the independent prognostic factor affecting the disease-free survival (p=0.001; 95% CI: 1.46-4.96). CONCLUSION: LVI emerged as the most important prognostic factor for node negative premenopausal women not receiving adjuvant systemic therapy. There is a need to take into consideration the presence of LVI while deciding adjuvant systemic therapy in T1N0 patients.     

HER-2阳性乳腺癌保乳术后局部复发的多因素研究

目的研究人类表皮生长因子受体2(HER-2)阳性乳腺癌保乳治疗后影响局部复发的风险因素。方法收集我院2002年6月～2012年6月间收治的82例HER-2阳性乳腺癌保乳治疗后的随访资料,分析年龄、HER-2状态、雌激素受体(ER)/孕激素受体(PR)状态、淋巴结转移状态、肿瘤大小、抗HER-2治疗对局部复发的影响。结果 82例中位随访52(8～118)个月,同侧乳房局部复发9例(10.97%),远位转移11例(13.4%),5年无病生存率82.9%,5年无远处转移生存率93.9%,5年总体生存率98.7%。单因素分析显示,淋巴结状态是影响局部复发的风险因素;复发高峰时间为术后第2年至第3年,以及第5年至第6年;多因素分析显示淋巴结状态及HER-2状态是局部复发的独立影响因素。82例病人中,接受曲妥珠单抗治疗35例,112个月出现1例局部复发,复发率2.86%(1/35);未接受者47例,11～108个月出现局部复发8例,复发率17.02%(8/47)。差异有显著性统计学意义(P<0.001)。结论保乳治疗后出现两个局部复发高峰时间段,淋巴结状态和HER-2表达状态是局部复发的独立影响因素,抗HER-2治疗可降低局部复发和远处转移。对于具有高危因素的患者更需积极治疗。     

Characteristics and outcome of 1755 operable breast cancers in women over 70 years of age

From 1981 to 1995, 1755 patients aged 70 years or over who had nonmetastatic unilateral breast carcinoma received curative local or regional treatment in our institute. Median follow-up was 8 years. The median age of these patients was 75 years (range: 70-94), and 86% were under 81 years of age. Tumors were classed as T3-4 in 24% of them; 18% had N1b/N2 tumors, and in 12% grade 3 disease was present. Only 19% were both ER and PR negative. The S phase fraction was <5% in 79% of patients. In 1046 patients (60%) modified radical mastectomy was performed, while 20% underwent lumpectomy and in 20% radiotherapy was the only treatment administered. Adjuvant endocrine therapy was given in 463 (26%) cases, and only 3% of patients received chemotherapy. The median overall survival time was 121 months. The overall cancer-related death rate was 49%. The 10-year disease-free survival (DFS) rate was 64%, and the 10-year local relapse rate was 14%. Prognostic factors determined on univariate analysis were tumor size, clinical nodal status (ER and PR), and grade. No significant difference in outcome was observed between mastectomy and conservative treatment. Parameters for which correlations with DFS were found on multivariate analysis were clinical nodal status (P < 0.0001), tumor size (P < 0.0001), ER (P < 0.0001), and PR (P = 0.04). Breast cancer in elderly women is frequently hormone-dependent (81%) with a low proliferation index. Prognostic factors are the same as in younger postmenopausal patients. More than 50% of these patients died from a cause other than their breast cancer.     

Atypical lipomatous tumors/well-differentiated liposarcomas: clinical outcome of 67 patients

Atypical lipomatous tumors/well-differentiated liposarcomas are low-grade malignant mesenchymal neoplasms with high propensity to local recurrence and potential to dedifferentiate to higher grades over time. However, the published risks of local recurrence and dedifferentiation vary, and no unified treatment and follow-up plan has been accepted. We performed a study to evaluate the long-term clinical behavior and proper treatment and follow-up strategy for these tumors. We retrospectively reviewed the files of 101 patients treated between 1990 and 2008 with the diagnosis of atypical lipomatous tumors/well-differentiated liposarcomas. For 67 of these patients, complete data and 2-year minimum follow-up were available and were included in the study; 47 patients (group A) had primary surgical treatment at our institution and 20 patients (group B) were referred after ≥1 local recurrences. Mean follow-up was 81 months (range, 24-229 months). The local recurrence rate of primary atypical lipomatous tumors/well-differentiated liposarcomas was 10.6% (5/47 group A patients). The local re-recurrence rate of the recurrent atypical lipomatous tumors/well-differentiated liposarcomas was 52% (13/67 group A and B patients). Recurrences developed as late as 140 months after diagnosis and treatment. The rate of dedifferentiation at recurrences was 4% (1/25 group A and B patients with recurrent tumors). No patients developed metastases. Atypical lipomatous tumors/well-differentiated liposarcomas are associated with an increased rate of local re-recurrence and low risk of dedifferentiation at recurrences. Long-term follow-up is recommended for early diagnosis and treatment of local recurrences.     

Phyllodes tumors of the breast: a review of 32 cases

Most general surgeons involved in breast cancer care have limited experience with phyllodes tumors. We analyzed a comprehensive database incorporating 8567 breast cancer cases treated surgically in the Tulsa, Oklahoma, region between 1969 and 1993. This yielded 32 cases of phyllodes tumors (0.37%) in 31 patients. The median age was 57 years (range, 18-91). There were 9 low-grade (28%), 2 intermediate-grade (6%), and 21 high-grade (66%) lesions. Size distribution consisted of 23 (72%) lesions 5 cm or less and 9 (28%) greater than 5 cm (mean, 3; range, 1.2-17.5 cm). Of 137 resected nodes in 13 patients, none were positive for metastatic disease. Surgical management consisted of wide excision or mastectomy. No patients received adjuvant chemoradiation therapy. The disease-free, locoregional disease-free, and overall mean survival rates were 80, 81, and 97 months, respectively. Ten-year disease-free survival (DFS), locoregional disease-free survival (LRDFS), and overall survival (OS) rates were 66, 72, and 55 per cent, respectively. Although there was a tendency toward a higher rate of locoregional recurrences and metastases with high-grade lesions, this was not statistically significant and did not affect DFS, LRDFS, or OS rates. Similarly, size of lesion did not affect DFS, LRDFS, or OS rates. Three patients (9.6%) had metastatic disease at presentation, and a further two (6.4%) developed metastases during follow-up. Overall, nine (28.1%) recurrences developed in eight patients, seven locoregional and two distant. Four patients (12.9%) died with evidence of disease. These findings indicate prolonged survival in this patient population with cystosarcoma phyllodes. Wide local excision of primary and recurrent lesions remains the mainstay of therapy. Neither regional lymph node dissection nor adjuvant chemoradiation adds significant benefit.     

Long-term outcome of bladder papillary urothelial neoplasms of low malignant potential

OBJECTIVE: To evaluate the long-term outcome of bladder papillary urothelial neoplasms of low malignant potential (PUNLMP). PATIENTS AND METHODS: Of 475 consecutive patients with newly diagnosed bladder tumours between 1976 and 1993, 330 (69%) had superficial (Ta and T1) tumours and 53 (11%) were diagnosed as having PUNLMP. Fifty patients (mean age at presentation 57.2 years, range 26-83; male-to-female ratio 6 : 1) who were followed for> 5 years or until they died, were included in the present study. All histological slides were reviewed, and fulfilled the diagnostic criteria of the 1998 World Health Organization/International Society of Urological Pathology classification system. RESULTS: The mean (median, range) follow-up was 11.7 (10.8, 1.3-24.4) years. During the follow-up, 30 patients (60%) had local recurrences. The 2, 5 and 10-year recurrence-free rates were 66%, 51% and 36%, respectively. No patients developed high-grade or muscle-invasive (>/= T2) carcinomas, or upper urinary tract tumours, or died from the disease. At the last follow-up, 34 patients (68%) had been disease-free for> 5 years. CONCLUSIONS: Despite a high recurrence rate, PUNLMP carries a very low malignant potential. We agree with the use of the term 'papillary urothelial neoplasms of low malignant potential' instead of 'superficial bladder carcinoma (cancer)' for these tumours.     

Patterns of recurrence in anal canal carcinoma

HYPOTHESIS: The initial modality of treatment of anal canal carcinoma (ACC) influences the pattern of recurrence of disease. DESIGN: A retrospective analysis comparing patterns of recurrence in patients with ACC undergoing either surgery or chemoradiotherapy as their initial therapeutic intervention. Anal margin cancers and adenocarcinomas were excluded. SETTING: A university-affiliated urban medical center. PATIENTS: Eighty-one patients were given a diagnosis of ACC between February 1, 1952, and December 31, 1998. Fifty-one (63%) of the patients initially underwent surgery: abdominoperineal resection in 38 patients (75%) and local excision in 13 patients (25%). Chemoradiotherapy was the initial therapeutic intervention in 30 patients (37%). MAIN OUTCOME MEASURES: The patterns of recurrence (local vs distant disease) and survival were compared between the group that underwent palliative surgery (hereafter referred to as the surgical group) and the group that received chemoradiotherapy (hereafter referred to as the chemoradiotherapy group). RESULTS: The mean follow-up was 40 months. Local recurrence occurred in 7 patients (14%) in the surgical group vs 7 patients (23%) in the chemoradiotherapy group (P =.46). Using Kaplan-Meier actuarial analysis, local recurrence rates for the surgical and chemoradiotherapy groups at 1 year were 0% and 6%, respectively (P =.32), and at 5 years were 17% and 36%, respectively (P =.02). The average (+/-SD) time to local recurrence in the surgical group was 23 +/- 0.7 months and for the chemoradiotherapy group 16 +/- 2.9 months (P =.27). Five (71%) of the 7 patients with local recurrences in the chemoradiotherapy group underwent salvage abdominoperineal resection with 100% disease-free survival at a mean follow-up of 35 months. When patients presenting with metastatic disease were excluded, distant recurrences developed in 7 patients (16%) in the surgical group and 2 (7%) in the chemoradiotherapy group (P =.31). Actuarial 5-year distant recurrence rates for the surgical and chemoradiotherapy groups were 26% and 19%, respectively (P =.65). Five-year survival was 42% in the surgical group and 74% in the chemoradiotherapy group (P =.01). CONCLUSION: There was a higher rate of local recurrence in patients with ACC treated with chemoradiotherapy vs surgical resection as the initial therapeutic intervention. However, when this occurred, abdominoperineal resection was effective salvage therapy and was associated with a 100% disease-free survival at 3 years. Therefore, chemoradiotherapy is justified as the initial treatment for ACC and has an overall 5-year survival that is significantly higher than that attained with initial surgical treatment.     

Tubular Carcinoma of the Breast: A Histologic Subtype Indicative of Breast-Conserving Therapy

We reviewed the clinical and pathologic features of pure tubular carcinoma of the breast with particular emphasis on the reported risk factors associated with local recurrences and survival following breast-conserving therapy. Of 1653 cases of invasive breast cancer, 12 (0.7%) were identified as pure tubular carcinoma. Clinical/pathologic features of pure tubular carcinoma were compared with those of T1 invasive carcinoma of all other histologic types (T1 IC). Of the 12 patients with pure tubular carcinoma (median tumor diameter 1.4 cm; range 0.5–3.0 cm), a multicentric association was identified in one patient while a multifocal association was seen in two. One patient had nodal metastatic disease out of the ten who underwent axillary dissection. No lymphatic vessel invasion was identified in any tumors (P < 0.1 vs T1 IC). In addition, extensive intraductal spread was not present in any tumors (P < 0.05 vs T1 IC). This study shows that patients with pure tubular carcinoma are appropriate candidates for breast-conserving therapy based on the clinical/pathologic features. When a multifocal association is suspected preoperatively, either a wide local excision or a quadrantectomy which includes other lesions is thus recommended. Received: January 21, 2000 / Accepted: July 25, 2000     

DCIS Treated with Excision Alone Using the National Comprehensive Cancer Network (NCCN) Guidelines

Background

In 2008, the NCCN published guidelines allowing low-risk DCIS patients to be treated by excision alone. The goal of this study was to determine local and distant recurrence and breast-cancer specific survival in patients with DCIS that meet NCCN criteria and are treated with excision alone.

Methods

A prospective, single institution database was analyzed for patients with the following: pure ductal carcinoma in situ (no microinvasion), tumor extent 20 mm or less, age ≥50 years, margin width ≥2 mm, and nuclear grade 1 or 2 (non-high grade). Patients were treated with excision alone. Kaplan-Meier analysis was used to determine recurrence and survival rates.

Results

A total of 205 patients were treated with excision alone. The median age was 59 years. The median time of follow-up was 51 months. The median extent of disease was 8 mm. There were a total of nine local recurrences. The 6-year probability of local recurrence was 6.6  %. The 12-year probability of local recurrence was 7.8  %. The 12-year breast cancer-specific survival probability was 100  %.

Conclusions

The 12-year local recurrence rate for DCIS patients in NSABP Protocol B-17 treated with excision alone was 32 %, and for excision plus radiation therapy, it was 16 %. In this study, retrospectively applying the NCCN Guidelines to our patients, the 12-year local recurrence rate for excision alone was 7.8 %. Patients with a low risk of local recurrence, if treated by excision alone, can be safely selected using the NCCN Guidelines.     

Surgical treatment of breast cancer in the elderly

AIM: The aim of this study is to evaluate the prognosis and survival of patients aged over 70 years and affected by breast cancer. METHODS: From January 1994 through December 2000, 56 patients with breast cancer aged 70 years or older were submitted to surgical treatment. Associated diseases were present in 24 patients, while no patient showed distant metastases at the time of hospital admission. All patients underwent breast preserving surgery regardless the tumour size and in 31 subjects out of 56, the surgical procedure was performed under local anesthesia. An axillary lymphectomy was associated in 46 patients. According to the TNM staging system, tumours were classified as follows: 10 T1Nx, 18 T1N0, 9 T1N1, 7 T2N0, 10 T2N1 and 2 T3N1. RESULTS: There was no postoperative mortality and in 6 cases an axillary seroma was observed. Radiotherapy and tamoxifen treatment followed surgery in all cases. The median follow-up was 44 months. Nineteen patients (34%) died during the follow-up: 6 patients of cancer progression with a specific cancer-death of 10.7% while 13 patients (23.2%) died because of concurrent diseases. A local relapse (1.8%) was observed in a single patient 2 years after the primary surgical treatment and, at 3 years, 37 patients (66%) are alive and disease-free. Long-term survival was significantly related to the stage of disease at the time of surgery, while our data do not allow any conclusions concerning the impact of axillary dissection on long-term outcome. CONCLUSIONS: In conclusion, results for breast cancer therapy are comparable in old and young patients and therefore strategies and treatment protocols should be similar, breast preserving surgery followed by radiotherapy and ormonal treatment being 'the gold standard'.     

Tubular carcinoma of the breast. Predicting axillary nodal metastases and recurrence.

BACKGROUND: Tubular carcinoma of the breast, a well-differentiated variant of infiltrating ductal carcinoma, has been regarded as a very favorable histologic subtype. The infrequency of nodal metastases and low recurrence rates have led to questions about the value of axillary dissection. OBJECTIVE: The authors evaluated the frequency of axillary nodal metastases, the prognostic value of histologic features of the primary tumor, and treatment outcome in patients with tubular carcinoma of the breast. METHODS: This retrospective analysis evaluated 50 patients who received diagnoses of tubular carcinoma from The University of Texas M. D. Anderson Cancer Center between 1944 and 1992. Medical records were reviewed for information about the patient, the tumor, treatment, and outcome. Hematoxylin-eosin stained sections were reviewed to confirm the diagnosis and assess histologic features. RESULTS: The median tumor diameter was 1.0 cm. Nine (20%) of 44 axilla had histologically confirmed lymph node involvement. Lymph node involvement was neither infrequent nor predicted by features of the primary tumor. Recurrences developed in 4 patients, and 1 patient died of tubular carcinoma. The 5-year disease-free survival rate was 88%. The local therapy used, mastectomy or breast preservation, did not affect disease-free survival. Contralateral cancer was noted in 26% of the patients. CONCLUSIONS: Axillary metastases occur in 20% of patients and are not predicted by features of the primary tumor. Breast preservation is a safe treatment option for tubular carcinoma of the breast.     

Predictors of Recurrence After Local Excision and Postoperative Chemoradiation Therapy of Adenocarcinoma of the Rectum

Background: Local excision of rectal cancer preserves anal continence, bladder function, and normal sexual function. However, local recurrence after excision remains a significant problem. To further define the indications for local excision, we analyzed possible factors predictive of recurrence after local excision of rectal cancer.Methods: The charts of all patients undergoing local excision of adenocarcinoma of the rectum between 1985 and 1995 at a single institution were reviewed. Patients with metastatic disease at the time of excision and patients treated preoperatively with chemoradiation therapy were excluded. All available slides were reviewed by a single pathologist, who assessed the depth of invasion; the presence or absence of vascular invasion, lymphatic invasion, perineural invasion, and lymphocytic infiltrate; the mucinous status; and the degree of differentiation. Using the log-rank test and Cox proportional hazards model, univariate and multivariate analyses were performed to identify predictors of recurrence.Results: Ninety patients underwent local excision, 46 transanally and 44 using a Kraske approach. The breakdown of patients by tumor stage was as follows: Tis, 13%; T1, 41%; T2, 30%; T3, 15%; and Tx, 1%. Sixty-eight percent of patients with T1 tumors were treated with postoperative radiotherapy; all patients with T2 or T3 tumors were treated postoperatively with or without 5-fluorouracil. The median duration of follow-up was 51 months. The median tumor diameter was 2.5 cm (range, 0.4 to 7 cm), and the median distance of the tumor from the anal verge was 4.5 cm (range, 1 to 10 cm). The 4-year actuarial local disease-free survival rate broken down by tumor stage was as follows: Tis, 100%; T1, 95%; T2, 80%; and T3, 73%. The median time to local recurrence was 23 months (range, 7 to 61 months). Multivariate analysis showed that only tumor stage and margin status were predictors of local recurrence.Conclusions: Local excision and postoperative radiotherapy result in adequate local control of early stage (Tis and T1) adenocarcinoma of the rectum. Higher rates of recurrence were seen in patients with T2 and T3 tumors, especially in those with positive margins.Presented at the 51st Annual Meeting of The Society of Surgical Oncology, San Diego, California, March 26–29, 1998.     

Mammographically detected ductal carcinoma in situ treated with conservative surgery with or without radiation therapy: patterns of failure and 10-year results

OBJECTIVE: The authors reviewed their institution's experience treating mammographically detected ductal carcinoma in situ (DCIS) of the breast with breast-conserving therapy (BCT) to determine 10-year rates of local control and survival, patterns of failure, and factors associated with outcome. SUMMARY BACKGROUND DATA: From January 1980 to December 1993, 177 breasts in 172 patients were treated with BCT for mammographically detected DCIS of the breast at William Beaumont Hospital, Royal Oak, Michigan. METHODS: All patients underwent an excisional biopsy, and 65% were reexcised. Thirty-one breasts (18%) were treated with excision alone, whereas 146 breasts (82%) received postoperative radiation therapy (RT). All patients undergoing RT received whole-breast irradiation to a median dose of 50.0 Gy. One hundred thirty-six (93%) received a boost to the tumor bed for a median total dose of 60.4 Gy. Median follow-up was 5.9 years for the lumpectomy alone group and 7.2 years for the lumpectomy + RT group. RESULTS: In the entire population, 15 patients had an ipsilateral breast recurrence. The 5- and 10-year actuarial rates of ipsilateral breast recurrence were 7.8% and 7.8% for lumpectomy alone and 8.0% and 9.2% for lumpectomy + RT, respectively. Eleven of the 15 recurrences developed within or immediately adjacent to the lumpectomy cavity and were designated as true recurrences or marginal misses (TMM). Four recurred elsewhere in the breast. Eleven of the 15 recurrences were invasive, whereas 4 were pure DCIS. Only one patient died of disease, yielding 5- and 10-year actuarial cause-specific survival rates of 100% and 99.2%, respectively. Eleven patients were diagnosed with subsequent contralateral breast cancer, yielding 5- and 10-year actuarial rates of 5.1% and 8.3%, respectively. Clinical, pathologic, and treatment-related factors were analyzed for an association with ipsilateral breast failure or TR/MM. No factors were significantly associated with ipsilateral breast failure. In the entire population, the omission of RT and younger age at diagnosis were significantly associated with TR/MM. Patients younger than 45 years at diagnosis had a significantly higher rate of TR/MM in both the lumpectomy + RT and lumpectomy alone groups. None of the 37 patients who received a postexcisional mammogram had an ipsilateral breast failure versus 15 in the patients who did not receive a postexcisional mammogram. CONCLUSIONS: Patients diagnosed with mammographically detected DCIS of the breast appear to have excellent 100-year rates of local control and overall survival when treated with BCT. These results suggest that the use of RT reduces the risk of local recurrence and that patients diagnosed at a younger age have a higher rate of local recurrence with or without the use of postoperative RT.     

Factors Associated With Local-Regional Recurrence After a Negative Sentinel Node Dissection: Results of the ACOSOG Z0010 Trial

OBJECTIVE:: To determine factors important in local-regional recurrence (LRR) in patients with negative sentinel lymph nodes (SLNs) by hematoxylin and eosin (H&E) staining. BACKGROUND:: Z0010 was a prospective multicenter trial initiated in 1999 by the American College of Surgeons Oncology Group to evaluate occult disease in SLNs and bone marrow of early-stage breast cancer patients. Participants included women with biopsy-proven T1-2 breast cancer with clinically negative nodes, planned for lumpectomy and whole breast irradiation. METHODS:: Women with clinical T1-2,N0,M0 disease underwent lumpectomy and SLN dissection. There was no axillary-specific treatment for H&E-negative SLNs, and clinicians were blinded to immunohistochemistry results. Systemic therapy was based on primary tumor factors. Univariable and multivariable analyses were performed to determine clinicopathologic factors associated with LRR. RESULTS:: Of 5119 patients, 3904 (76.3%) had H&E-negative SLNs. Median age was 57 years (range 23-95). At median follow-up of 8.4 years, there were 127 local, 20 regional, and 134 distant recurrences. Factors associated with local-regional recurrence were hormone receptor-negative disease (P = 0.0004) and younger age (P = 0.047). In competing risk-regression models, hormone receptor-positive disease and use of chemotherapy were associated with reduction in local-regional recurrence. When local recurrence was included in the model as a time-dependent variable, older age, T2 disease, high tumor grade, and local recurrence were associated with reduced overall survival. CONCLUSIONS:: Local-regional recurrences are rare in early-stage breast cancer patients with H&E-negative SLNs. Younger age and hormone receptor-negative disease are associated with higher event rates, and local recurrence is associated with reduced overall survival.     

Survival after local treatment for early breast cancer

A 10-year survival rate of 82% was found in 517 women with early localized breast cancer (pathological stage T1-2N0M0) who had been treated with local therapy alone (total mastectomy and axillary clearance). Factors influencing survival were tumour size (T1 versus T2) and age; patients older than 50 years fared better than younger patients at 5 years but this advantage had disappeared at 10 years. Receptor status influenced disease-free survival, but not survival. Recurrence developed in 93 patients--systemic in 46 and local in 47. Support for the contention that all breast cancer is systemic was thus not found at 10 years, and the value of local therapy alone in node-negative women was endorsed.     

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.