Is axillary dissection necessary after positive sentinel node biopsy? Yes!

Axillary dissection has been considered a staging procedure in recent years. Sentinel node biopsy can accurately stage a patient as node-positive or node-negative, raising questions about the need for completion dissection when the sentinel node is positive. This article summarizes data indicating that approximately 50% of patients with sentinel node metastasis have additional positive nodes. For these women, completion axillary dissection provides prognostic information, maintains local control, and may have a survival benefit. Until definitive data from the American College of Surgeons Z11 study is available, completion dissection should remain standard practice.

Expression of epithelial mucins Muc1, Muc2, and Muc3 in ductal carcinoma in situ of the breast

Epithelial mucins are glycoproteins secreted by epithelial cells and their carcinomas. At least nine mucin genes have been identified, and their products (MUC1-MUC9) are expressed in various epithelia. MUC1 is a mucin expressed in breast epithelial cells, whereas MUC2 and MUC3 are primarily intestinal mucins. Although MUC1 and MUC2 expression has been documented in invasive ductal carcinoma of the breast, mucin expression in pure ductal carcinoma in situ (DCIS) has not been investigated. Sixty-one of 105 cases of DCIS without coexisting infiltrating carcinoma diagnosed during a 30-month period were selected as having sufficient tissue for study. Paraffin-embedded tissue sections were stained using immunohistochemical techniques with mouse monoclonal anti-MUC1, anti-MUC2, and rabbit-specific polyclonal anti-MUC3 antibodies. Immunoreactive epitopes of MUC1, MUC2, and MUC3 were expressed in DCIS in 61, 19, and 16 of 61 cases, respectively. MUC2 and MUC3 staining intensity in DCIS was markedly less than that observed for MUC1. Luminal and/or cytoplasmic patterns of staining were observed for MUC1. MUC2 and MUC3 showed only cytoplasmic staining. Cytoplasmic-only staining of MUC1 was associated with a higher grade of DCIS. Any MUC2 staining was also associated with a higher grade of DCIS. Coexpression of MUC2 and MUC3 was present in only 6 of 61 cases, and MUC3 staining was unrelated to the grade of DCIS. Cytoplasmic expression of MUC1 and MUC2 appears to be associated with a higher grade of DCIS. MUC3 expression appears to be independent of grade and expression of MUC1 and MUC2. The relationship of mucin expression and grade warrants further study.

Factors predicting the use of breast-conserving therapy in stage I and II breast carcinoma

PURPOSE

To define patterns of care for the local therapy of stage I and II breast cancer and to identify factors used to select patients for breast-conserving therapy (BCT).

PATIENTS AND METHODS

A convenience sample of 16,643 patients with stage I and II breast cancer treated in 1994 was obtained from hospital-based tumor registries. Histologic variables were determined from original pathology reports.

RESULTS

BCT was performed in 42.6% of patients. Multivariate analysis demonstrated that living in the Northeast United States (odds ratio [OR], 2.48; 95% confidence interval [CI], 2.16 to 2.84), having a clinical T1 tumor (OR, 2.51; 95% CI, 2.27 to 2.78), and having a tumor without an extensive intraductal component (OR, 2.07; 95% CI, 1.81 to 2.37) were the strongest predictors of breast-conserving surgery. Radiation therapy was given to 86% of patients who had breast-conserving surgery. Age less than 70 years was the most significant predictor of receiving radiation (OR, 2.11; 95% CI, 1.77 to 2.25). Tumor variables did not correlate with the use of radiation, but favorable tumor characteristics were associated with the use of breast-conserving surgery.

CONCLUSION

Despite strong evidence supporting the use of BCT, the majority of women continue to be treated with mastectomy. Predictors of the use of BCT do not correspond to those suggested in guidelines.

Prospective comparison of stereotactic core biopsy and surgical excision as diagnostic procedures for breast cancer patients

OBJECTIVE

To determine whether stereotactic core biopsy (SCNB) is the diagnostic method of choice for all mammographic abnormalities requiring tissue sampling.

SUMMARY BACKGROUND DATA

Stereotactic core needle biopsy decreases the cost of diagnosis, but its impact on the number of surgical procedures needed to complete local therapy has not been studied in a large, unselected patient population.

METHODS

A total of 1,852 mammographic abnormalities in 1,550 consecutive patients were prospectively categorized for level of cancer risk and underwent SCNB or diagnostic needle localization and surgical excision. Diagnosis, type of cancer surgery, and number of surgical procedures to complete local therapy were obtained from surgical and pathology databases.

RESULTS

The malignancy rate was 24%. Surgical biopsy patients were older, more likely to have cancer, and more likely to be treated with breast-conserving therapy than those in the SCNB group. For all types of lesions, regardless of degree of suspicion, patients diagnosed by SCNB were almost three times more likely to have one surgical procedure. However, for patients treated with lumpectomy alone, the number of surgical procedures and the rate of negative margins did not differ between groups.

CONCLUSIONS

Stereotactic core needle biopsy is the diagnostic procedure of choice for most mammographic abnormalities. However, for patients undergoing lumpectomy without axillary surgery, it is an extra invasive procedure that does not facilitate obtaining negative margins.

Factors influencing the use of breast reconstruction postmastectomy: a National Cancer Database study

BACKGROUND

Advances in surgical techniques and changes in our understanding of the biology of breast cancer have made immediate or early breast reconstruction a viable option for the majority of women with breast cancer. Little is known about national patterns of use of reconstruction. This study was undertaken to determine national patterns of care and factors that influence the use of breast reconstruction.

STUDY DESIGN

A large convenience sample reported to the National Cancer Data Base was studied. Patients coded as undergoing mastectomy between 1985 and 1990 (n = 155,463) and between 1994 and 1995 (n = 68,348) were evaluated. The use of reconstruction in the two time periods was compared, and patient and tumor factors influencing the use of the procedure were compared.

RESULTS

Between 1985 and 1990, 3.4% of mastectomy patients had early or immediate reconstruction, increasing to 8.3% in 1994-5. Patient age, income, geographic location, type of hospital where treatment occurred, and tumor stage all influenced the use of reconstruction in univariate analysis. In multivariate analysis, patients age 50 or under had a 4.3-fold greater likelihood of having reconstruction than their older counterparts. Patients with ductal carcinoma in situ were twice as likely as those with invasive cancer to have reconstruction. Family income of $40,000 or more (Odds Ratio 2.0), ethnicity other than African-American (Odds Ratio 1.6), surgery in a National Cancer Institute-designated cancer center (Odds Ratio 1.4), and surgery in a geographic region other than the Midwest or South (Odds Ratio 1.3) remained significant predictors of the use of reconstruction in multivariate analysis.

CONCLUSIONS

Breast reconstruction is an underused option in breast cancer management. Predictors of the use of reconstruction do not reflect contraindications to the procedure, and indicate the need for both physician and patient education.

The surgeon's role in breast cancer chemoprevention

An individual woman's level of risk for the development of invasive breast cancer can be accurately estimated using the Gail model. This model is not appropriate for use in women with prior breast cancer (invasive or in situ) or a family history suggestive of a genetic predisposition. Tamoxifen is an option for breast cancer risk reduction. The magnitude of benefit varies based on the factors that increase a woman's level of risk, but benefit has been seen in all risk subgroups that have been studied. The risks associated with tamoxifen for prevention vary with menopausal status. In premenopausal women, there are no life threatening toxicities, and quality-of-life issues predominate. In postmenopausal women, the increased risk of endometrial cancer and venous thrombosis mandate a careful assessment of the presence of other risk factors for these conditions prior to considering tamoxifen for prevention. At present, prevention options for the high-risk woman include surveillance, tamoxifen for five years, participation in the STAR trial (if postmenopausal), and bilateral prophylactic mastectomy.

Continued breast cancer risk reduction in postmenopausal women treated with raloxifene: 4-year results from the MORE trial. Multiple outcomes of raloxifene evaluation

Raloxifene, a selective estrogen receptor modulator approved for the prevention and treatment of postmenopausal osteoporosis, has shown a significant reduction in breast cancer incidence after 3 years in this placebo-controlled, randomized clinical trial in postmenopausal women with osteoporosis. This article includes results from an additional annual mammogram at 4 years and represents 3,004 additional patient-years of follow-up in this trial. Breast cancers were ascertained through annual screening mammograms and adjudicated by an independent oncology review board. A total of 7,705 women were enrolled in the 4-year trial; 2,576 received placebo, 2,557 raloxifene 60 mg/day, and 2,572 raloxifene 120 mg/day. Women were a mean of 66.5-years old at trial entry, 19 years postmenopause, and osteoporotic (low bone mineral density and/or prevalent vertebral fractures). As of 1 November 1999, 61 invasive breast cancers had been reported and were confirmed by the adjudication board, resulting in a 72% risk reduction with raloxifene (relative risk (RR) 0.28, 95% confidence interval (CI) 0.17, 0.46). These data indicate that 93 osteoporotic women would need to be treated with raloxifene for 4 years to prevent one case of invasive breast cancer. Raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer by 84% (RR 0.16, 95% CI 0.09, 0.30). Raloxifene was generally safe and well-tolerated, however, thromboembolic disease occurred more frequently with raloxifene compared with placebo (p=0.003). We conclude that raloxifene continues to reduce the risk of breast cancer in women with osteoporosis after 4 years of treatment, through prevention of new cancers or suppression of subclinical tumors, or both. Additional randomized clinical trials continue to evaluate this effect in postmenopausal women with osteoporosis, at risk for cardiovascular disease, and at high risk for breast cancer.

Symposium overview: estrogens and antiestrogens in managing the patient with breast cancer

The prevalence of breast cancer (a hormonally driven neoplasm) in the United States, the potential health benefits of estrogen replacement therapy for postmenopausal women, and the burgeoning research focusing on selective estrogen receptor modulators (SERMs) have resulted in additional complexity in managing breast cancer. In an attempt to clarify existing data, the Society of Surgical Oncology sponsored a symposium entitled "Estrogens and Antiestrogens in Managing the Patient with Breast Cancer" at its 52nd Annual Cancer Symposium. This conference was held in March 1999 and was chaired by Dr. S. Eva Singletary, Professor of Surgery and Chief of the Surgical Breast Section at The University of Texas M. D. Anderson Cancer Center in Houston, Texas. The following is a review of the material presented by the symposium participants.

Clinical highlights from the National Cancer Data Base, 2000

The National Cancer Data Base (NCDB) is the empirical data collection and analysis arm of the American College of Surgeons Commission on Cancer, and is supported in part by the American Cancer Society. The NCDB collects oncology patient demographic information, diagnostic and treatment information, and outcomes data from a broad spectrum of hospital-based cancer registries throughout the US, ranging from large research and teaching facilities to small community hospitals. Through this unique network, data are aggregated and reported back to participating hospitals to allow individual facilities to evaluate local patient care practices and outcomes. This article highlights the principal findings of articles published in 1999 and early 2000 that used NCDB data as the empirical basis of their analyses. Included among these are articles on breast cancer, gastric carcinoma, head and neck cancers, leukemia, liver carcinoma, lung cancer, parathyroid tumors, prostate carcinoma, small bowel adenocarcinoma, testicular malignancies, and vulvar melanoma. These articles are based on cases diagnosed between 1985 and 1996. The NCDB has accrued more than 6.4 million cancer cases for this time period. Sufficient numbers of rare cancers are reported to the NCDB to permit some types of clinical evaluation not possible using other data sources.

The evaluation of common breast problems

The most common breast problems for which women consult a physician are breast pain, nipple discharge and a palpable mass. Most women with these complaints have benign breast disease. Breast pain alone is rarely a presenting symptom of cancer, and imaging studies should be reserved for use in women who fall within usual screening guidelines. A nipple discharge can be characterized as physiologic or pathologic based on the findings of the history and physical examination. A pathologic discharge is an indication for terminal duct excision. A dominant breast mass requires histologic diagnosis. A breast cyst can be diagnosed and treated by aspiration. The management of a solid mass depends on the degree of clinical suspicion and the patient's age.

National Cancer Data Base survey of breast cancer management for patients from low income zip codes

BACKGROUND

The National Cancer Data Base (NCDB), a joint project of the American College of Surgeons Commission on Cancer and the American Cancer Society, is a cancer management and outcomes data base for health care organizations. It provides a comparative summary of patient care that is used by participating hospitals and communities for self-assessment. The most current (1995-1996) breast cancer data on patients from low income zip codes are described here.

METHODS

Since 1989, eight Calls for Data have been issued, yielding a total of 191,714 reports of non-Hispanic white patients with breast cancer for the years analyzed, 1995-1996. A total of 1961 hospital cancer registries have participated in at least one of the Calls for Data.

RESULTS

A diverse range of breast cancer cases was reported from a variety of geographic locations and medical care environments. There were general similarities in the treatment of patients from the different income groups; however, some differences were reported. Among patients from lower income zip codes, 60.7% were age 60 years or older, compared with 55.1% from other income zip code groups. The AJCC stage distribution was reported as less favorable for patients from low income zip codes than for other patients. The percentage of patients from low income zip codes diagnosed as Stage 0 or I was 51.2%, compared with 55.9% of patients from the other income zip codes. Of patients from lower income zip codes, 12.1% were reported to have Stage III or IV disease, compared with 10.0% of patients from other income zip codes. Patients from low income zip codes received less tissue-sparing surgery. Of patients from low income zip codes, 14.9% received partial mastectomy with or without radiation or systemic therapy, compared with 18.3% of patients from other income zip codes. The percentage of patients from low income zip codes who received a partial mastectomy with axillary lymph node dissection was 23.3% for patients from other income zip codes, the percentage was 30.5%. Conversely, 49.8% of patients from lower income zip codes received a modified radical mastectomy, compared with 40.5% of patients from other income zip codes.

CONCLUSIONS

Further improvements in the early diagnosis and surgical treatment of low income patients can probably be achieved. Programmatic activities that further explain or reduce the apparent nonpreferred treatment of some low income patients should be encouraged.

Phase I and pharmacologic study of the specific matrix metalloproteinase inhibitor BAY 12-9566 on a protracted oral daily dosing schedule in patients with solid malignancies

PURPOSE

To evaluate the feasibility of administering BAY 12-9566, a matrix metalloproteinase (MMP) inhibitor with relative specificity against MMP-2, MMP-3, and MMP-9, on a protracted oral daily dosing schedule in patients with advanced solid malignancies. The study also sought to determine the principal toxicities of BAY 12-9566, whether plasma BAY 12-9566 steady state concentrations (C(ss)) of biologic relevance could be sustained for prolonged periods, and whether BAY 12-9566 affected plasma concentrations of MMP-2, MMP-9, and tissue inhibitor of MMP-2 (TIMP-2).

PATIENTS AND METHODS

Patients with solid malignancies were treated with BAY 12-9566 at daily oral doses ranging from 100 to 1,600 mg. BAY 12-9566 dose schedules included 100 mg once daily, 400 mg once daily, 400 mg twice daily, 400 mg three times daily, 400 mg four times daily, and 800 mg twice daily. Plasma was collected to study the range of BAY 12-9566 C(ss) values achieved, and exploratory studies were performed to assess the effects of BAY 12-9566 on plasma concentrations of MMP-2, MMP-9, and TIMP-2.

RESULTS

Twenty-one patients were treated with 47 28-day courses of BAY 12-9566. The most common side effects were headache, nausea, vomiting, abnormalities in hepatic functions, and thrombocytopenia, which were rarely clinically significant. BAY 12-9566 was well tolerated on all dose schedules, and there was no consistent dose-limiting toxicity that precluded treatment in the range of dose schedules evaluated. Instead, dose escalation was terminated because BAY 12-9566 plasma C(ss) values increased less than proportionately and plateaued as the daily dose was increased within the dose range of 100 to 1,600 mg/d, suggesting saturable drug absorption. Mean plasma C(ss) values achieved with all dose schedules exceeded BAY 12-9566 concentrations required to inhibit MMPs in vitro and in vascular invasion and tumor proliferation in vivo models. There were no consistent effects of BAY 12-9566 on the plasma concentrations of MMP-2 and MMP-9 over the continuous dosing period at any dose schedule level. However, plasma levels of TIMP-2 seemed to increase in a dose-dependent manner (r(2) =.50, P =.046).

CONCLUSIONS

The recommended dose of BAY 12-9566 for subsequent disease directed studies is 800 mg twice daily, which resulted in biologically relevant plasma C(ss) values and an acceptable toxicity profile. Although exploratory studies of MMPs in plasma were not revealing, it is conceivable that some tumor types and disease settings are more likely to produce more readily quantifiable levels of activated MMPs than others. Therefore, attempts to identify and quantify surrogate markers of MMP inhibitory effects should continue to be performed in disease-directed studies in more homogenous patient populations.

Management of axillary lymph nodes in breast cancer: a national patterns of care study of 17,151 patients

OBJECTIVE

To determine the rates of axillary lymph node dissection (ALND) and axillary irradiation (AI) in patients with breast cancer and to identify the factors influencing them.

SUMMARY BACKGROUND DATA

Routine performance of ALND in the treatment of breast cancer has become controversial. AI has been proposed as an alternative to ALND, and it has been suggested that AI in addition to ALND may decrease local failure in high-risk patients.

METHODS

A joint study was conducted by the Commission on Cancer of the American College of Surgeons and the American College of Radiology. A total of 17,151 patients with stage I and II breast cancer treated at 819 institutions in 1994 were studied.

RESULTS

A total of 15,992 patients underwent ALND (93%). The mean ages of patients who did and did not undergo ALND were 60.4 and 73.0 years. Univariate analysis demonstrated significantly decreased rates of ALND for women age 70 or older (86% vs. 97%), patients with clinical T1 a tumors (81% vs. 93%), grade I histology (90% vs. 95%), and patients with favorable tumor types (88% vs. 94%). The ALND rate did not vary between palpable and nonpalpable tumors. Multivariate analysis of variables affecting the rate of ALND identified type of surgery, age, tumor size, histology, and payer status as significant. A total of 889 patients received AI. Patients not undergoing ALND were more likely to receive AI (10% vs. 5%). A total of 1.6% of patients with no lymph node metastasis underwent AI, 8.9% of those with one to three positive nodes underwent AI, 24.0% of those with four to nine positive lymph nodes underwent AI, and 29.9% of those with > or = 10 positive lymph nodes underwent AI. Multivariate analysis of variables affecting the proportion of patients who received AI and had undergone ALND identified nodal status and type of surgery as significant.

CONCLUSIONS

Axillary lymph node dissection continues to be routinely applied in the treatment of breast cancer, and AI remains underused in patients at high risk for local regional relapse.

Management of complex breast cysts

OBJECTIVE

This study was undertaken to evaluate the various strategies currently in use to manage complex cysts and specifically address the need for intervention.

MATERIALS AND METHODS

A review of 4562 breast sonograms obtained during an 18-month period revealed 308 complex cysts in 252 women. Data collected from review of patient records included the patient's age and risk factors for breast cancer, aspiration or biopsy results (or both), follow-up imaging studies, and management recommendations.

RESULTS

Management recommendations for complex cysts were 1-year follow-up in 13 patients, 6-month follow-up in 148, sonographically guided aspiration in 82, aspiration with possible core biopsy in 62, and excisional biopsy in three. No malignancies were diagnosed in the group treated with follow-up imaging, sonographically guided aspiration, or excisional biopsy. One malignancy, a papilloma with a 3-mm focus of ductal carcinoma in situ, was diagnosed in one of the patients who underwent core biopsy.

CONCLUSION

Of the lesions classified as complex cysts, the malignancy rate was 0.3% (1/308). This malignancy rate is lower than that for lesions classified as probably benign using mammographic criteria (i.e., for lesions classified as category 3 lesions using the Breast Imaging Reporting and Data System). Because the accepted standard practice for management of probably benign lesions is follow-up studies, the low yield of malignancy in this series suggests that complex cysts can be managed with follow-up imaging studies instead of intervention.

Learning sentinel node biopsy: results of a prospective randomized trial of two techniques

BACKGROUND

Evidence indicates that sentinel node (SN) biopsy can accurately predict axillary nodal status. Debate exists as to the optimal method of SN identification.

METHODS

Patients with clinical T1 or T2 tumors and negative axillae were randomized to SN localization with blue dye (B) alone (n = 50) or blue dye plus radioactivity (B+R) (n = 42). Patients undergoing needle localization (n = 47) were assigned to blue dye.

RESULTS

The SN was identified in 110 patients (79%) and contained metastases in 28. The SN predicted the axillary nodal status in 96% of cases. The SN identification rate did not differ between B (88%) or B+R (86%) but was significantly lower in patients requiring localization (64%). The time to SN identification also did not differ between B and B+R. The number of cases done by an individual surgeon was a significant predictor of SN identification. A stepwise logistic regression analysis of factors influencing the success of SN identification identified tumor location, needle localization, number of operations, and body mass index as significant predictors.

CONCLUSIONS

Our study does not identify any advantage for the use of the more expensive and complex method of SN identification using B+R compared with B alone, even for surgeons learning the techniques.

Breast cancer. Making the diagnosis

The approach to women with breast complaints must be individualized based on the presenting problem, patients' age, and the degree of clinical suspicion. Needle-biopsy, techniques are often cost-effective. In patients with suspicious breast abnormalities, a thorough imaging workup facilitates the selection of definitive local therapy.

Role conflict and rapid socio-economic change: breastfeeding among employed women in Thailand

Conflicts between women's productive and reproductive roles are intensified by rapid development and social change. Women have a right to offer optimum nutrition to their babies through breastfeeding; they also are entitled to seek gainful employment. For many, furthermore, employment is essential to the economic survival of their families. This article derives from a combined qualitative and quantitative study conducted in Chiang Mai, Thailand. Interviews were carried out with 313 women to investigate the experiences of those who resumed employment within six months after delivery. The findings demonstrate that urban women in the modern workplace face many obstacles in their efforts to maintain lactation while simultaneously undertaking paid work. Current public policies do not address these obstacles effectively, which is of particular concern in today's volatile economic climate.

Menstrual and reproductive factors for salivary gland cancer risk in women

Several observations suggest that salivary gland cancer may be, in part, a hormonally dependent disease. We examined associations between hormonally mediated life events and salivary gland cancer risk in a population-based case-control study. Of 76 women diagnosed between 1989 and 1993, 63 (83%) were interviewed. Of 111 population controls, 83 (75%) were interviewed. Early menarche (OR = 4.1, 95% CI = 1.4-12.1) and nulliparity (OR = 2.6, 95% CI = 1.0-6.7) were associated with increased risk whereas late age at first full-term pregnancy (OR = 0.19, 95% CI = 0.3-1.2) and longer duration of oral contraceptive use (OR = 0.31, 95% CI = 0.10-1.0) were associated with diminished risk. These findings are consistent with a hormonal component in salivary gland cancer risk.