Local and distant failures after limited surgery with positive margins and radiotherapy for node-negative breast cancer

PURPOSE

To determine the outcome of patients with positive margins after lumpectomy for breast cancer and to address the issue of the relationship between local recurrences and distant metastasis in the absence of chemotherapy.

METHODS AND MATERIALS

Among 3697 patients with primary breast cancer, we retrospectively analyzed 152 patients who had undergone conservative surgery with axillary dissection, had infiltrating carcinomas with positive margins, were node-negative, and received radiotherapy without chemotherapy. One-third received hormonal therapy. Endpoints were local failure and distant metastasis. Median follow-up was 72 months.

RESULTS

Five- and 10-year recurrence-free survival were 0.80 and 0.71 respectively for local recurrences, and 0.85 and 0.73 respectively for metastasis. Infiltrating carcinoma on the margins was associated with early local relapse as opposed to intraductal carcinoma. Local and distant recurrences had similar patterns of yearly-event probabilities. Hazard of relapsing from metastasis was 2.5 times higher after a local recurrence. In the multivariate analysis, negative estrogen receptors (ER-)(p = 0.0012), histologic multifocality (p = 0.0028), and no hormonal therapy (p = 0.017) predicted local relapses, while ER- (p = 0.004) and pathologic grade (p = 0.009) predicted metastasis. Hormonal therapy did not prevent early local recurrences.

CONCLUSION

In this population, reexcision is advisable for local purposes and because the data support the hypothesis that local and distant recurrences are tightly connected.

[Local recurrences after conservative treatment of breast cancer: risk factors and influence on survival]

AIMS OF THE STUDY

To determine the risk factors for local and distant failure in node-negative breast cancer treated with breast-conservative surgery and radiotherapy and to determine the relationship between these two events.

MATERIAL AND METHODS

We retrospectively selected 908 patients who received conservative surgery and radiotherapy but no chemotherapy between 1980 and 1995, for a node-negative breast cancer. Patients were divided in two groups according to the status of the margins of resection. All pathology specimens were reviewed.

RESULTS

In case of negative margins, the risk factors for local recurrences picked up by the Cox model were histologic multifocality (P = 0.0076), peritumoral vessel invasion (P = 0.021) and age < or = 40 years (P = 0.024), and in case of involved margins, negative oestrogen receptors (P = 0.0012), histologic multifocality (P = 0.0028), and absence of hormonal therapy (P = 0.017). The 10-year local recurrence rate was 18% in case of negative margins and 29% in case of involved margins, although in the latter case patients received high-dose adjuvant radiotherapy. Accordingly, the 10-year distant failure rates were 16% and 27%, respectively. Many arguments suggest that local and distant failures are closely related.

CONCLUSION

Patients with histologic multifocality or positive margins are at high risk of local failure and then of distant failure, and require a more aggressive initial treatment.

[Prognostic value of early normalization of CA 125 during chemotherapy in stages III and IV ovarian tumors]

The value of early CA 125 assays and analysis of its diminution kinetics during chemotherapy have been the subject of numerous studies. In contrast, routine utilization of CA 125 assays in clinical practice remains controversial or at best difficult to apply because the definitions and prognostic values associated with CA 125 assays vary greatly from one study to the next. This study was designed to determine whether serial CA 125 assays during induction chemotherapy for ovarian carcinoma, using simple evaluation criteria directly applicable in routine clinical practice such as early normalization (level < 35 UI/ml) are predictive of response to treatment or improved survival. This retrospective longitudinal analysis concerned a historical population of 140 patients with ovarian carcinoma stages III and IV treated at the Antoine-Lacassagne Cancer Center between 1978 and 1993. All the patients were treated by chemotherapy based on platinum salts every 21 days. Serum CA 125 assays were performed both before and after surgery and during each chemotherapy cycle. Eighty-four patients had a pre-operative CA 125 assay. No difference is observed in survival as a function of their preoperative CA 125 concentration (p = 0.4). Sixty-seven patients had a CA 125 assay the 6th week after initiation of chemotherapy, 62 the 9th week and 47 the 18th week. Normalization of CA 125 the 6th week (p = 0.0001), the 9th week (p = 0.0008) and the 18th week (p = 0.03) after the initiation of the chemotherapy cycle are correlated with survival. The median survival in our study is 42 months if the CA 125 is below 35 UI/ml the 6th week versus 13 months if the level of CA 125 remains more than 35 UI/ml. In all, 66 of the 105 FIGO stage III patients underwent second-look surgery. Normalization of CA 125 levels is correlated with the absence of any gross residual tumor at the second-look procedure, the 6th week of chemotherapy (p = 0.0019), the 9th week of chemotherapy (p = 0.0003) and the 18th week of chemotherapy (p = 0.0015). This correlation is not confirmed when the presence of histologic residual tumor in biopsy specimens obtained during second-look surgery is taken into consideration. Overall, 88% of patients whose CA 125 levels failed to normalize during evaluation at the second cycle of chemotherapy have residual tumor at second-look surgery. Outside of clinical trials, repeated early CA 125 assays to determine the chemosensitivity and the prognosis of patients with ovarian carcinoma are of little interest compared to a single CA 125 assay at the 6th week after initiation of chemotherapy. This approach seems to be a good compromise between the information sought and its practical use. However the interest of early modification of chemotherapy regimen after 2 cycles, if the level of CA 125 remains more than 35 UI/ml, will have to be showed.

[A comparative study of 4 sequential first-line chemotherapy protocols in locally advanced breast cancer]

Between 1977 and 1994, our center administered successively 4 different chemotherapy regimens to 242 evaluable patients with locally advanced breast cancer. Patients with inflammatory signs were excluded. Sixty-eight patients were treated by AVCF (A (adriamycine) + V (vincristine) + C (cytoxan) + F (5FU)), 47 by AECF (A + E (vindesine) + C + F), 81 by CAFP (C + A + F + P (prednisone)) and 46 by AN (A + N (vinorelbine)). The mean number of cycle was 3. One hundred and twenty-five patients (52.5%) responded to chemotherapy and we recorded 35 complete response (14.7%). The response rates at the different combinations were respectively: AVCF: 29.4%, AECF: 53.2%, CAFP: 64.9%, AN: 65.2%, and were independent of tumor size, grade and receptor status. The response rate at the AVCF regimen was significantly worse than the others (p = 0.0005). Breast conserving surgery was performed in 31 patients (14%) and 17 patients (8%) had a complete response. Among the 35 patients with complete response, 21 were treated by radiotherapy alone. Local recurrence occurred in 19 patients (7.9%) and 96 (40%) had advanced disease. The mean follow-up of AVCF regimen was 150 months, 115 months for AECF, 111 for CAFP and 42 months for AN. The disease-free survival and the overall survival were significantly better with AECF, CAFP and AN regimens (DFS p < 0.04, OS p < 0.02). Survival was better in those patients with an objective response (p = 0.002) or with non-affected axillary node at the time of surgery. Our study showed already that AVCF combination was significantly lower than AECF, CAFP, AN in terms of response rate, disease-free survival and overall survival. Waiting the results of randomized studies about the impact of neoadjuvant chemotherapy on survival, we look for chemotherapy regimen improving the rate of conservative surgery.

[Treatment of ifosfamide induced encephalopathy with methylene-blue]

The authors report a case of encephalopathy after treatment with ifosfamide treated by a methylene blue infusion. This side-effect is rare but influenced by high doses and short infusions of this drug. Recently, a treatment of ifosfamide encephalopathy with methylene blue has been reported. This case report confirms the interest of such a treatment.