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Poortmans P. Evidence based radiation oncology: Breast cancer. Radiother Oncol 2007; 84:84-101. [PMID: 17599597 DOI: 10.1016/j.radonc.2007.06.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 05/30/2007] [Accepted: 06/02/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE Radiotherapy is, similar to surgery, a local treatment. In the case of breast cancer, it is generally given after conservative or after more extensive, tumour and patient adapted, surgery. The target volumes can be the breast and/or the thoracic wall and/or the regional lymph node areas. The integration and the extent of radiotherapy as part of the comprehensive treatment of the breast cancer patient, including the amount of surgery and the sequencing with the systemic treatments, has to be well discussed with all medical specialists involved in treating breast cancer on a multidisciplinary basis. Guidelines for the appropriate prescription and execution of radiotherapy are of utmost importance. However, individualisation based on the individual patients' and tumours' characteristics should always be envisaged. MATERIALS AND METHODS Based on a review of the literature the level of evidence that is available for the indications for radiotherapy is summarised, as well as the main clinical questions that are unanswered today. An overview of the recent and ongoing clinical trails in breast cancer will highlight some of the current ongoing debates. CONCLUSIONS In the case of breast cancer, radiotherapy, given after as well conservative as extensive risk-adapted surgery, significantly reduces the risk of local and regional recurrences. Especially for patients with an intermediate to high absolute risk for local recurrences, a positive influence on overall survival has been shown, notably when appropriate radiotherapy techniques are used. Most important is that the best results that we can offer to our breast cancer patients for all clinical endpoints (local and regional control; quality of life; cosmetic results; survival) can be obtained by a multidisciplinary and patient-oriented approach, involving all those involved in the treatment of breast cancer patients.
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Affiliation(s)
- Philip Poortmans
- Dr. Bernard Verbeeten Instituut, Radiotherapy, Tilburg, Netherlands.
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Katz A, Saad ED, Porter P, Pusztai L. Primary systemic chemotherapy of invasive lobular carcinoma of the breast. Lancet Oncol 2007; 8:55-62. [PMID: 17196511 DOI: 10.1016/s1470-2045(06)71011-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Invasive lobular carcinoma is the second most frequent histological type of breast cancer and its incidence is increasing. It has unique clinical, biological, and molecular features. Invasive lobular carcinoma is almost invariably positive for the oestrogen receptor and, when compared with invasive ductal carcinoma, it is typically of a lower grade. Even though invasive lobular carcinoma represents a distinct clinical entity, the same criteria used for invasive ductal carcinoma are currently applied to establish the need for primary or adjuvant systemic chemotherapy. We reviewed randomised trials of neoadjuvant and adjuvant chemotherapy and noted that insufficient evidence is available to support or withhold use of chemotherapy in patients with invasive lobular carcinoma. Thus, the benefit from systemic chemotherapy for individuals with this form of breast disease is unclear. Invasive lobular carcinoma deserves to be investigated separately in prospective clinical trials to define the best treatment and prevention strategies.
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Affiliation(s)
- Artur Katz
- Centro Paulista de Oncologia and Hospital Albert Einstein, Sao Paulo, Brazil.
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Raje D, Bollard R, Wilson A. Invasive lobular cancer of the breast--is breast conservation surgery a good option? Breast J 2007; 12:574-5. [PMID: 17238992 DOI: 10.1111/j.1524-4741.2006.00351.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Invasive ductal carcinoma and ductal carcinoma in situ account for about 85% of breast cancers. Unusual breast neoplasms may be broadly divided into invasive lobular carcinoma, well-differentiated subtypes of invasive ductal carcinoma, cancers of stromal origin, and metastatic neoplasms. Clues are often present in imaging characteristics, patient demographics, and/or clinical features that may suggest that the finding is not the usual type of breast cancer. Some rare malignancies also provide specific clues to their diagnosis. This review provides an overview of unusual and a few rare malignant breast neoplasms, highlighting particular or specific clinical or imaging findings that will enable residents to expand their differential diagnosis of breast lesions beyond invasive ductal carcinoma.
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Affiliation(s)
- Jennifer A Harvey
- Department of Radiology, University of Virginia, Box 800170, Charlottesville, VA 22908, USA.
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Smitt MC, Horst K. Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer. Ann Surg Oncol 2007; 14:1040-4. [PMID: 17203329 DOI: 10.1245/s10434-006-9308-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 11/10/2006] [Accepted: 11/11/2006] [Indexed: 11/18/2022]
Abstract
PURPOSE To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins. MATERIALS AND METHODS Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45), grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative). RESULTS Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus 61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional biopsy (79 and 78%, respectively). CONCLUSIONS Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation. Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of negative margins at initial excision.
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MESH Headings
- Adult
- Biopsy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Invasiveness/pathology
- Neoplasm Staging
- Neoplasm, Residual
- Preoperative Care
- Probability
- Reoperation
- Retrospective Studies
- Risk Assessment
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Affiliation(s)
- Melanie C Smitt
- Department of Radiation Oncology, Stanford University, 875 Blake Wilbur Dr, Stanford, CA 94305, USA.
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van den Broek N, van der Sangen MJC, van de Poll-Franse LV, van Beek MWPM, Nieuwenhuijzen GAP, Voogd AC. Margin status and the risk of local recurrence after breast-conserving treatment of lobular breast cancer. Breast Cancer Res Treat 2006; 105:63-8. [PMID: 17115109 DOI: 10.1007/s10549-006-9431-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 10/11/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Invasive lobular breast carcinoma is known for its multicentricity and is associated with a higher incidence of incomplete excision after breast-conserving therapy. The aim of the study was to examine the influence of positive surgical margins on the local recurrence rate in patients diagnosed with invasive lobular cancer and treated with breast-conserving therapy. METHODS All 416 women diagnosed with invasive lobular breast cancer and undergoing breast-conserving treatment between 1995 and 2002 were selected from the population-based Eindhoven Cancer Registry. Their medical charts were reviewed and detailed information was collected. RESULTS The risk of margin involvement was 29% after the first operation and 17% when taking into account the final margin status of the patients undergoing re-excision. During follow-up, 18 patients developed a local recurrence. The 5 year actuarial risk of developing a local recurrence was 3.5% (95% confidence interval 2.5-4.5) and the 8 year risk was 6.4% (95% confidence interval 4.7-8.0). There was no influence of positive surgical margins on the risk of local recurrence, neither in the univariate analysis nor after adjustment for age, tumour size, nodal status and adjuvant systemic treatment. CONCLUSION Patients with invasive lobular cancer, treated with breast-conservation, have a low risk of local recurrence, despite their high risk of having a microscopically incomplete excision of the tumour.
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Affiliation(s)
- N van den Broek
- Faculty of Medicine, Maastricht University, Maastricht, The Netherlands
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57
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Whitman GJ, Huynh PT, Patel P, Wilson J, Cantu A, Krishnamurthy S. Sonography of Invasive Lobular Carcinoma. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.cult.2007.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Aziz D, Rawlinson E, Narod SA, Sun P, Lickley HLA, McCready DR, Holloway CMB. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J 2006; 12:331-7. [PMID: 16848842 DOI: 10.1111/j.1075-122x.2006.00271.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
One of the most important factors associated with local recurrence after lumpectomy in breast cancer patients is the status of the surgical margin. Standard surgical practice is to obtain clear margins even if this requires a second surgical procedure. It is assumed that reexcision to achieve clear margins when positive margins are present at initial excision is as effective as complete tumor removal at a single procedure; however, the efficacy of reexcision in this context has not been well studied. A retrospective search of the Henrietta Banting Breast Centre database from 1987 to 1997 identified 1430 patients who underwent lumpectomy for invasive breast cancer: 1225 patients (group A) had negative margins at the initial surgery and 152 patients (group B) underwent one or more reexcisions to achieve negative margins. Fifty-three patients had positive margins at final surgery, but no reexcision was done (group C). Logistic regression was used to identify factors that were predictive of a positive margin; predictors of local recurrence in women whose tumors were completely resected were determined using Cox's proportional hazards model. Patients in groups A, B, and C differed with respect to mean age at diagnosis (58 years, 51 versus, and 56 years, respectively, p < 0.0001), mean tumor size (19 mm, 16 mm, and 26 mm, respectively, p < 0.0001), node positivity (30%, 22%, and 41%, respectively, p = 0.004), and the presence of a ductal carcinoma in situ (DCIS) component (60%, 64%, and 79%, respectively, p = 0.007). The mean follow-up period was similar for the three groups (8 years, 8 years, and 9 years, respectively, p = 0.17). Young age was the only variable predictive of positive margins. Among patients undergoing complete tumor excision, there was a suggestion of a higher 10 year local recurrence rate in reexcision group B, but the difference did not reach statistical significance (11.6% versus 16.6%, p = 0.11). Cox's multivariate regression analyses identified older age, smaller tumor size, receiving radiation therapy, and tamoxifen use as significantly decreasing the rate of local recurrence in patients with negative margins at initial surgery or after reexcision. Our data confirm the results of previous studies indicating that young age is an independent predictor of positive margins after lumpectomy for invasive breast cancer. The only independent predictor of local recurrence in our study cohort was large tumor size. There was a trend toward a higher local recurrence rate if more than one procedure was required to secure clear margins, although this effect was not independent of other factors. Reexcision to clear involved margins is an important surgical intervention for both younger and older women.
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Affiliation(s)
- Dalal Aziz
- Department of Surgery and Biostatistics, Centre for Research in Women's Health, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Dillon MF, Hill ADK, Fleming FJ, O'Doherty A, Quinn CM, McDermott EW, O'Higgins N. Identifying patients at risk of compromised margins following breast conservation for lobular carcinoma. Am J Surg 2006; 191:201-5. [PMID: 16442946 DOI: 10.1016/j.amjsurg.2005.03.041] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2004] [Revised: 03/25/2005] [Accepted: 03/25/2005] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association of invasive lobular carcinoma with high rates of compromised margins in breast conservation makes choice of operation for these patients difficult. We sought to identify patients at risk of compromised margins following breast conservation surgery. METHODS We reviewed all patients with invasive lobular and invasive ductal carcinoma over a 5-year period (1999-2004). The imaging, pathology and surgical details of patients with invasive lobular carcinoma undergoing breast conservation were analyzed. RESULTS A total of 991 patients with invasive ductal carcinoma and 150 patients with invasive lobular carcinoma were identified. Lobular carcinomas had a compromised margin rate of 49% (n = 38/77) in breast conservation compared to 24% (n = 143/588) of ductal carcinomas (P < .0001). Mammographic size (P = .017), pathological size (P = .01), age (P = .03), multifocality (P < .0001), and lymphovascular invasion (P = .015) were significantly associated with compromised margins. CONCLUSION Invasive lobular carcinoma has a 49% rate of compromised margins following breast conservation. Mammographic size greater than 1.5 cm and young age were preoperative factors predictive of compromised margins.
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Affiliation(s)
- Mary F Dillon
- Department of Surgery, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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61
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Cahill RA, Walsh D, Landers RJ, Watson RG. Preoperative Profiling of Symptomatic Breast Cancer by Diagnostic Core Biopsy. Ann Surg Oncol 2006; 13:45-51. [PMID: 16378157 DOI: 10.1245/aso.2006.03.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2004] [Accepted: 08/07/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Precise preoperative profiling of breast tumors could facilitate fuller consideration of (neo)adjuvant therapies. METHODS Diagnostic core biopsy (DCB) accuracy in profiling the primary tumor was prospectively studied in 95 patients with operable breast cancer. The histological type and grade (hematoxylin and eosin staining) and membrane receptor status (semiquantitative immunohistochemistry for estrogen [ER] and progesterone [PR] receptors, as well as Her-2 antigen expression) were assigned by the DCB before surgery. These measures were then compared with those of the definitive surgical specimen available after operation. RESULTS DCB correctly ascribed tumor type and grade and ER, PR, and Her-2 receptor status in most cases (correlating exactly in 97.5%, 77%, 68%, 71%, and 60%, respectively) with at least moderate concordance (weighted kappa, >.41). When miscategorized, DCB consistently tended to upscore the receptor stain intensity compared with the surgical specimen (22%, 19%, and 27% had higher ER, PR, and Her-2 categorical scores, respectively). ER H-scores correlated best in specimens that stained strongly (224.4 +/- 3 vs. 215.5 +/- 5) and were significantly higher on DCB in those that stained either moderately (195.6 +/- 8.2 vs. 156.8 +/- 5.1; P < .0001) or weakly (157.1 +/- 24.8 vs. 81.4 +/- 4; P = .02). DCB accurately identified all tumors with clinically important ER and Her-2 expression. Furthermore, it promoted three patients into the therapeutically significant range of ER (n = 1) or Her-2 (n = 2) expression. ER negativity on DCB (n = 25) indicated a high-grade tumor (88%), although 11 (44%) patients also overexpressed Her-2. Significant Her-2 expression (n = 16) on DCB predicted the tumor as being poorly differentiated (80%) and both ER and PR negative (67%). CONCLUSIONS DCB accurately profiles clinically relevant measures of primary tumor cell differentiation. It also reliably categorizes patients with regard to (neo)adjuvant therapy before radical surgery is attempted.
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Affiliation(s)
- Ronan A Cahill
- Department of Surgery, Breast Care Unit, Waterford Regional Hospital, Waterford, Ireland.
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Reimer SB, Séguin B, DeCock HE, Walsh PJ, Kass PH. Evaluation of the effect of routine histologic processing on the size of skin samples obtained from dogs. Am J Vet Res 2005; 66:500-5. [PMID: 15822596 DOI: 10.2460/ajvr.2005.66.500] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effects that routine histologic processing has on the dimensions of samples of normal skin of dogs and assess whether the inclusion of a muscle or fascial layer in such samples alters those effects. SAMPLE POPULATION Skin samples obtained from 6 medium-sized adult dogs with grossly normal skin. PROCEDURE From each dog, skin samples (with or without underlying fascia or muscle) were obtained from 3 sites bilaterally (6 samples/dog) and processed routinely for histologic evaluation; their dimensions were measured at intervals during the experiment. RESULTS As a result of processing, skin samples decreased in size (combined percentage change in length and width) and increased in thickness, compared with their original dimensions. Samples without fascia or muscle decreased in size by 21.1% to 32.0% and increased in thickness by 45.1 % to 75.8%. The site of sample origin influenced processing-associated changes in sample size but did not affect the change in thickness. Decreases in dimensions did not vary with inclusion of fascia but did vary with inclusion of muscle. The change in thickness did not vary with inclusion of a layer of fascia or muscle. CONCLUSIONS AND CLINICAL RELEVANCE Processing of skin samples obtained from dogs for histologic evaluation can cause changes in sample dimensions; samples may decrease in length and width by as much as 32% and increase in thickness by 75.8%, compared with their original dimensions. The presence of muscle in canine skin samples can restrict the amount of shrinkage in length or width associated with processing.
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Affiliation(s)
- S Brent Reimer
- Veterinary Medical Teaching Hospital, School of Veterinary Medicine, University of California, Davis, CA 95616, USA
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63
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Paumier A, Sagan C, Campion L, Fiche M, Andrieux N, Dravet F, Pioud R, Classe JM. Évaluation de la validité du traitement conservateur dans le carcinome lobulaire infiltrant du sein. IMAGERIE DE LA FEMME 2005. [DOI: 10.1016/s1776-9817(05)80635-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Molland JG, Donnellan M, Janu NC, Carmalt HL, Kennedy CW, Gillett DJ. Infiltrating lobular carcinoma—a comparison of diagnosis, management and outcome with infiltrating duct carcinoma. Breast 2004; 13:389-96. [PMID: 15454194 DOI: 10.1016/j.breast.2004.03.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Revised: 03/10/2004] [Accepted: 03/24/2004] [Indexed: 10/26/2022] Open
Abstract
The treatment and outcomes for 182 patients with lobular carcinoma were compared with 1612 patients with infiltrating ductal carcinoma managed concurrently at The Strathfield Breast Centre. The lobular carcinomas were larger (P < 0.0001) but of lower grade (P < 0.0001). Diagnosis with mammography and FNA was less sensitive in ILC (mammography P = 0.0002, FNA P < 0.0001). Although similar numbers of patients underwent initial attempted conservation, patients with ILC were more likely to have positive margins at attempted breast conservation surgery and the final mastectomy rate was higher (58.2% ILC versus 47% IDC, P = 0.0041). Of the patients who had successful conservation, the local recurrence rates for ILC (3.9%) were equivalent to the patients with IDC (5.3%). There was no significant difference in overall survival (90% ILC, 87% IDC, median follow-up 3.6 years ILC, 4.3 years IDC) or disease free survival (87.9% ILC, 81.6% IDC). Although mastectomy is more likely to be necessary to obtain clear margins, breast conservation therapy is reasonable in patients with infiltrating lobular carcinoma where clear margins can be obtained.
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Affiliation(s)
- J G Molland
- Breast Endocrine Unit, Department of Surgery, Ground Floor West, Repatriation General Hospital Concord, Hosipital Road, Concord NSW 2139, Australia.
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Moorthy K, Asopa V, Wiggins E, Callam M. Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees? Am J Surg 2004; 188:45-8. [PMID: 15219484 DOI: 10.1016/j.amjsurg.2003.11.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Revised: 11/08/2003] [Indexed: 11/23/2022]
Abstract
BACKGROUND It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery. METHODS Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration. RESULTS The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33). CONCLUSIONS In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.
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Affiliation(s)
- Krishna Moorthy
- Breast Care Unit, Department of Surgery, Bedford Hospital, Bedford, MK42 9DJ, United Kingdom.
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Mullenix PS, Cuadrado DG, Steele SR, Martin MJ, See CS, Beitler AL, Carter PL. Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy. Am J Surg 2004; 187:643-6. [PMID: 15135683 DOI: 10.1016/j.amjsurg.2004.01.003] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 01/18/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Breast conservation therapy (BCT) is an oncologically equivalent and cosmetically preferable alternative to mastectomy for most early-stage breast cancers. The number of operations required to complete the surgical phase of therapy with BCT has not been widely reported. METHODS From our institutional tumor registry, we reviewed the records of all patients receiving primary surgical therapy for breast cancer from January 1, 1998, to June 30, 2002. There were 204 patients with 210 breast cancers in the cohort. These cancers were initially managed with either BCT (n = 150) or mastectomy (modified radical mastectomy or total mastectomy with sentinel lymph node biopsy) (n = 60). We compared the percentages of patients in each group who required additional surgeries to obtain clear margins, manage axillary disease, or otherwise complete the surgical phase of therapy. Patients with secondary surgery related to long-term local recurrence were excluded. RESULTS Fifty-one percent of patients initially managed with BCT required additional surgery compared with 12% in the mastectomy group (P <0.05). Factors independently associated with multiple surgeries among all patients included management with BCT (odds ratio [OR] 5.4, P = 0.01) and positive margins at initial excision (OR 4.7, P <0.01). Significant independent predictors of positive margins included BCT (OR 11.9, P <0.01); disease stage (OR 6.7, P <0.01); submission of supplemental margins in addition to the main specimen (OR 2.8, P = 0.03); and positive nodes (OR 1.1, P = 0.04). Breast conservation was ultimately successful in 95% of patients who underwent BCT. CONCLUSIONS Patients undergoing BCT may require multiple surgeries to reconcile successful breast conservation with sound oncologic resection.
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MESH Headings
- Aged
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal/pathology
- Carcinoma, Ductal/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Immunohistochemistry
- Logistic Models
- Male
- Mastectomy, Modified Radical/adverse effects
- Mastectomy, Modified Radical/methods
- Mastectomy, Modified Radical/statistics & numerical data
- Mastectomy, Segmental/adverse effects
- Mastectomy, Segmental/methods
- Mastectomy, Segmental/statistics & numerical data
- Mastectomy, Simple/adverse effects
- Mastectomy, Simple/methods
- Mastectomy, Simple/statistics & numerical data
- Middle Aged
- Neoplasm Staging
- Patient Selection
- Predictive Value of Tests
- Registries
- Reoperation/adverse effects
- Reoperation/methods
- Reoperation/statistics & numerical data
- Retrospective Studies
- Sentinel Lymph Node Biopsy/adverse effects
- Sentinel Lymph Node Biopsy/methods
- Sentinel Lymph Node Biopsy/statistics & numerical data
- Treatment Outcome
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Affiliation(s)
- Philip S Mullenix
- Department of General Surgery, Madigan Army Medical Center, 9040A Reid St., Tacoma, WA 98431-1100, USA
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Fleming FJ, Hill ADK, Mc Dermott EW, O'Doherty A, O'Higgins NJ, Quinn CM. Intraoperative margin assessment and re-excision rate in breast conserving surgery. Eur J Surg Oncol 2004; 30:233-7. [PMID: 15028301 DOI: 10.1016/j.ejso.2003.11.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2003] [Indexed: 10/26/2022] Open
Abstract
AIM The aim of this study was to assess the efficacy of intraoperative margin assessment in obtaining clear margins in conserving surgery for breast cancer. METHODS Two hundred and twenty patients undergoing wide local excision (WLE) for core biopsy proven primary invasive breast cancer, during a 30 months period, were included in the study. Following surgical excision the breast specimen was orientated with sutures, inked using India ink and coloured pigments and incised to identify the tumour, maintaining orientation. The distance to the individual radial margins were estimated macroscopically by the pathologist and conveyed intraoperatively to the surgeon. A macroscopic tumour-margin distance of less than 10 mm was considered compromised and the margin(s) in question was then excised if feasible. RESULTS Eighty-one patients (37%) were judged to have compromised margins following intraoperative macroscopic evaluation and had at least one margin re-excised. Sixteen of the 81 patients (20%) in this subgroup had compromised margins on microscopy and required a second operation. One hundred and thirty-nine patients (63%) were deemed to have clear margins intraoperatively, subsequently confirmed on microscopic examination in 135 patients (97%). Intraoperative macroscopic assessment of margin status was associated with 9.1% of patients requiring a second operation. In the absence of intraoperative assessment of margin status a further 47 patients (21.4%) would have required a second operation. CONCLUSION Intraoperative macroscopic margin assessment is an effective technique in reducing the number of second operative procedures in patients undergoing conserving surgery for primary invasive breast cancer.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Humans
- Intraoperative Period
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm, Residual
- Reoperation
- Treatment Outcome
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Affiliation(s)
- F J Fleming
- Department of Surgery, St Vincent's University Hospital, University College Dublin, Elm Park, Dublin 4, Ireland
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Takehara M, Tamura M, Kameda H, Ogita M. Examination of breast conserving therapy in lobular carcinoma. Breast Cancer 2004; 11:69-72. [PMID: 14718796 DOI: 10.1007/bf02968006] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Experience with conserving surgery for lobular carcinoma has grown as more breast conserving surgeries have been performed. We examined the results of breast conserving therapy in lobular carcinoma. PATIENTS AND METHODS We examined the postoperative positive margin rate, presence or absence of additional surgery, presence or absence of local or systemic recurrence and role of breast helical CT in 25 cases of breast conserving surgery performed at this department from 1991 through June 2003. RESULTS Among the 303 cases of all breast conserving surgeries, there were 63 case with positive margins (20.8%), but there were 15 of 25 positive margin cases (60.0%) among the lobular carcinoma cases. In 8 of the 15 positive margin cases the technique was changed to mastectomy. One case of recurrence in the breast has been observed thus far. Although the positive margin rate and positive margin rate in infiltrating carcinoma cases tended to decline after the introduction of breast helical CT, the rates remained high. CONCLUSIONS Since the positive margin rate was significantly high at the time of breast conserving surgery for lobular carcinoma, careful selection of technique based on imaging studies such as breast helical CT and MRI along with careful follow-up is considered necessary.
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Affiliation(s)
- Megumi Takehara
- Department of Breast Surgery, National Sapporo Hospital, 4-2 Kikusui, Shiroishi-ku, Sapporo, Hokkaido 003-0804, Japan.
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Miller AR, Brandao G, Prihoda TJ, Hill C, Cruz AB, Yeh IT. Positive margins following surgical resection of breast carcinoma: Analysis of pathologic correlates. J Surg Oncol 2004; 86:134-40. [PMID: 15170651 DOI: 10.1002/jso.20059] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES Histologic margin positivity represents a significant source of adverse clinical outcome affecting breast conservation therapy for in situ or invasive malignancy. Elucidation of factors associated with positive margin status might clarify and improve local therapy strategies. In order to define our experience with margin positivity and to identify relevant pathologic criteria, we retrospectively analyzed the cases of 143 patients who underwent resections for carcinoma with intent of breast conservation between 1995 and 1999. METHODS Histologic features and indices of biologic aggressiveness were compared among tumors resected with positive versus negative margins in order to determine whether such markers could be used to anticipate outcome. RESULTS Twenty-eight pathologic specimens were identified to possess histologically positive margins. Twenty-six patients underwent additional operative procedures. Of the 26 re-excision specimens, 17 (65%) contained residual malignancy. Statistical analysis demonstrated that margin positivity correlated with in situ histology and with Her 2/neu positivity. CONCLUSIONS These data suggest certain pathologic factors that may portend difficulty in achieving negative resection margins in patients in whom breast conservation therapy is considered.
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MESH Headings
- Aged
- Breast Neoplasms/chemistry
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/chemistry
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/chemistry
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Lymph Nodes/pathology
- Lymphatic Metastasis
- Mastectomy, Segmental
- Middle Aged
- Neoplasm, Residual
- Receptor, ErbB-2/analysis
- Retrospective Studies
- Treatment Outcome
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Affiliation(s)
- Alexander R Miller
- Division of Surgical Oncology, Cancer Therapy and Research Center, San Antonio, Texas 78229-3900, USA.
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Henley JD, Goulet RJ, Cramer HM. Invasive lobular carcinoma and breast conserving therapy: implications for the pathologist. Breast J 2003; 9:439. [PMID: 12968973 DOI: 10.1046/j.1524-4741.2003.09521.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mersin H, Yildirim E, Gülben K, Berberoğlu U. Is invasive lobular carcinoma different from invasive ductal carcinoma? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2003; 29:390-5. [PMID: 12711296 DOI: 10.1053/ejso.2002.1423] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS The purpose of this study is to determine whether the histopathologic features and outcome in invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC) are different, and whether the histologic type is a prognostic factor for outcome. METHODS A retrospective cohort study was conducted in consecutive 510 stage I/II breast carcinoma patients who underwent modified radical mastectomy. The features of 65 patients with ILC were compared with those of 445 patients with IDC. In patients with median follow-up period of 44 months, univariate and multivariate prognostic factor analyses for cancer-specific death and relapse were carried out. RESULTS The median ages in patients with ILC and those with IDC were 52 and 41 (P=0.04). Tumor size, estrogen receptor positive expression and nodal positivity were not significantly different between the histologic types. Patients with ILC had more frequently (81.5%) low grade tumors and less lymphatic vascular invasion (9.3%) in primary tumor than those with IDC (P<0.05). Whereas the rates of 5-year overall survival were 94% in ILC and 90% in IDC, the rates of 5-year event-free survival were 71 and 67%, respectively (P=NS). Multivariate analyses in all patients demonstrated that tumor size, pathologic lymph node status and age at diagnosis were the most important prognostic factors for overall and event-free survival. Histologic type was not statistically significant for both outcomes. CONCLUSIONS Although patients with ILC had older age, low grade tumor and less lymphatic vascular invasion, they had no survival advantage comparing with their counterparts. Histologic type was not an independent prognostic factor for outcome.
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Affiliation(s)
- H Mersin
- Department of Surgery, Ankara Oncology Hospital, Ankara, Turkey.
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Munot K, Dall B, Achuthan R, Parkin G, Lane S, Horgan K. Role of magnetic resonance imaging in the diagnosis and single-stage surgical resection of invasive lobular carcinoma of the breast. Br J Surg 2002; 89:1296-301. [PMID: 12296901 DOI: 10.1046/j.1365-2168.2002.02208.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
Background
Conventional imaging with mammography and ultrasonography has a low sensitivity for diagnosis and a tendency to underestimate the extent of invasive lobular carcinoma (ILC) of the breast. The aim was to determine whether magnetic resonance imaging (MRI) had any advantages for the characterization of ILC.
Methods
Twenty patients with histologically proven ILC underwent preoperative imaging with MRI. MRI was performed to aid detection of malignancy in six patients with a clinically suspicious presentation but normal or indeterminate imaging on mammography and ultrasonography. In 14 patients MRI was performed to determine tumour extent.
Results
MRI accurately identified malignancy in five of six patients with normal or indeterminate conventional imaging. In seven of 14 patients in whom MRI was performed to determine tumour extent, it provided significant additional information. These included four patients in whom conventional imaging grossly underestimated tumour size, two patients in whom MRI identified an unsuspected contralateral breast tumour and one patient in whom MRI predicted tumour invasion of the pectoral muscle. The correlation between tumour size on histological examination was better with MRI (r = 0·967) than with mammography (r = 0·663) and ultrasonography (r = 0·673).
Conclusion
MRI can provide considerable additional information in the detection and characterization of ILC.
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Affiliation(s)
- K Munot
- Department of Surgery, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
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Affiliation(s)
- H K Gill
- Department of Radiology, University of Maryland School of Medicine, 419 W Redwood St, Ste 110, Baltimore, MD 21201, USA
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Moore MM, Whitney LA, Cerilli L, Imbrie JZ, Bunch M, Simpson VB, Hanks JB. Intraoperative ultrasound is associated with clear lumpectomy margins for palpable infiltrating ductal breast cancer. Ann Surg 2001; 233:761-8. [PMID: 11371734 PMCID: PMC1421318 DOI: 10.1097/00000658-200106000-00005] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the efficacy of intraoperative ultrasound in obtaining adequate surgical margins in women undergoing lumpectomy for palpable breast cancer. SUMMARY BACKGROUND DATA Adequacy of surgical margins is a subject of debate in the literature for women undergoing breast-conserving therapy. The emerging technology of intraoperative ultrasound-guided surgery lends itself well to a prospective study evaluating surgical accuracy and margin status after lumpectomy. METHODS Two groups of women undergoing lumpectomy for palpable breast cancer were studied, one group using intraoperative ultrasound (n = 27) and the other without (n = 24). Pathologic specimens were evaluated for size, margins, and accuracy, and patients were questioned about satisfaction with cosmetic results. RESULTS Surgical accuracy was improved with intraoperative ultrasound-guided surgery. Margin status was improved, patient satisfaction was equivalent, and cost was not affected using ultrasound technology. Intraoperative ultrasound appears especially efficacious for women whose preoperative mammogram shows dense parenchyma surrounding the lesion. CONCLUSIONS The use of ultrasound-guided surgery optimizes the surgeon's ability to obtain satisfactory margins for breast-conserving techniques in patients with breast cancer. Patient satisfaction is excellent and a cost savings is most likely realized.
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Affiliation(s)
- M M Moore
- Martha Jefferson Physician Hospital Organization, Charlottesville, Virginia 22903, USA.
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