Treatment trends in early-stage invasive lobular carcinoma: a report from the National Cancer Data Base

The impact of postmastectomy radiotherapy on local control in patients with invasive lobular breast cancer

PURPOSE

The aim of this population-based study was to examine the impact of postmastectomy radiotherapy on the risk of local recurrence in patients with invasive lobular breast cancer (ILC).

METHODS

The population-based Eindhoven Cancer Registry was used to select all patients with ILC, who underwent mastectomy in five general hospitals in the southern part of the Netherlands between 1995 and 2002. Of the 499 patients 383 patients fulfilled the eligibility criteria. Of these patients, 170 (44.4%) had received postmastectomy radiotherapy. The median follow-up was 7.2 years. Fourteen patients (3.7%) were lost to follow-up.

RESULTS

During follow-up 22 patients developed a local recurrence, of whom 4 had received postmastectomy radiotherapy. The 5-year actuarial risk of local recurrence was 2.1% for the patients with and 8.7% for the patients without postmastectomy radiotherapy. After adjustment for age at diagnosis, tumour stage and adjuvant systemic treatment, the patients who underwent postmastectomy radiotherapy were found to have a more than 3 times lower risk of local recurrence compared to the patients without (Hazard Ratio 0.30; 95% Confidence Interval: 0.10-0.89).

CONCLUSION

Local control is excellent for patients with ILC who undergo postmastectomy radiotherapy and significantly better than for patients not receiving radiotherapy.

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma

Background

Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome.

Methods

Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma.

Results

There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0·011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0·054).

Conclusion

These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.

Distinct clinical and prognostic features of infiltrating lobular carcinoma of the breast: combined results of 15 International Breast Cancer Study Group clinical trials

PURPOSE

To determine how patients with infiltrating lobular carcinoma (ILC) differ from patients with the more common infiltrating ductal carcinoma (IDC) with regard to patient and tumor factors, local treatment, and patterns of recurrence.

PATIENTS AND METHODS

Twelve thousand two hundred six breast cancer patients entered onto 15 International Breast Cancer Study Group trials between 1978 and 2002 were categorized as having ILC, IDC, or other/mixed types.

RESULTS

Seven hundred sixty-seven tumors (6.2%) were classified as ILC, 8,607 (70.5%) were classified as IDC, and 2,832 (23.2%) were classified as other. The analysis is limited to the 9,374 patients categorized as either pure IDC or ILC. The median follow-up time was 13 years. Compared with IDC, ILC was associated with older age; larger, better differentiated, and estrogen receptor (ER)-positive tumors; and less vessel invasion. Mastectomy was used more frequently for ILC (P < .01). There was a significant (P < .01) early advantage in disease-free survival and overall survival for the ILC cohort followed by a significant (P < .01) late advantage for the IDC cohort after 6 and 10 years, respectively. Similar patterns were observed in cohorts defined by ER status. ILC was associated with an increased incidence of bone events but a decrease in regional and lung events (all P < .01).

CONCLUSION

ILC is more than a histologic variant of breast cancer. The diagnosis of ILC carries distinct prognostic and biologic implications.

In situ and invasive lobular neoplasia of the breast

Lobular neoplasia of the breast represents a group of related malignancies with clinical implications ranging from risk lesions [atypical lobular hyperplasia and lobular carcinoma in situ (LCIS)] through to aggressive invasive lesions, notably invasive pleomorphic lobular carcinoma. The diversity in lobular carcinoma is evident at the morphological level, at the molecular marker level and in cytogenetic profiles. Research in these areas is already changing the face of the disease group, for example suggesting that some lobular and ductal carcinomas are closely related and even that one of the lobular group, the tubulo-lobular carcinomas, should, in fact, be regarded as a ductal cancer. More research is required to understand the long-term pathogenic implications of a diagnosis of in situ lobular neoplasia, particularly pleomorphic LCIS, and to understand the genetics behind the well-recognized high risk of bilateral disease. For invasive carcinoma, molecular studies will allow refinement of therapy and the possibility of novel targeted therapies, for example directed against fibroblast growth factor receptor 1.

Evidence based radiation oncology: Breast cancer

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.

[Indications of MRI in the initial local staging of early-stage breast cancer]

MR Imaging is the most sensitive technique for detecting breast cancer. In patients with breast cancer, the additional value of MRI is validated in patients candidates for a breast-conserving surgery and when: cancer is occult, size evaluation is difficult at standard imaging, parietal involvement is suspected, and before neoadjuvant chemotherapy. In fatty breasts, MRI is not routinely recommended, because of same performances as in standard imaging. In dense breasts, MRI becomes significantly more sensitive than mammography for detecting multifocality and multicentricity with a positive predictive value of 60% for detected additional foci. Thus, a decision of mastectomy should not be made solely on the basis of MRI and may require additional tissue sampling of areas of concern identified by breast MRI. The additional value of breast MRI is particularly useful in patients with dense breasts and high risk factors for local recurrence: young age (< 40 years), familial high risk, or because of a high-grade invasive cancer greater than 2 cm in size. Performing breast MRI in such patients underlies requirements: an expert breast imaging team, optimal MRI protocols, and radiologists working in concert with the multidisciplinary treatment team.

Margin status and the risk of local recurrence after breast-conserving treatment of lobular breast cancer

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.

Outcomes of breast-conservation therapy for invasive lobular carcinoma are equivalent to those for invasive ductal carcinoma

BACKGROUND

Breast-conservation therapy (BCT), including wide local excision and postoperative irradiation, is considered standard treatment for early-stage invasive ductal carcinoma (IDC). The use of BCT in patients with invasive lobular carcinoma (ILC) has been questioned because of concerns regarding ipsilateral breast recurrence and risk of bilateral breast cancer. We evaluated our institutional experience with BCT and compared treatment outcomes for ILC with those for IDC.

METHODS

A review of our BCT database revealed 84 patients with ILC and 1,126 with IDC with stage I or II disease treated with BCT and radiation between 1976 and 1999. We evaluated local-regional recurrence, disease-specific survival, and contralateral breast cancer rates in both groups.

RESULTS

The 5- and 10-year local-regional recurrence rates for the ILC group were 1% and 7%, respectively, and 4% and 9%, respectively, for the IDC group (P = .70). There were no significant differences in the 5- and 10-year disease-specific survival rates between the groups. Contralateral breast cancer occurred in 11.3% of patients with IDC and 11.9% of patients with ILC.

CONCLUSIONS

BCT achieves similar local-regional control and survival outcomes in selected patients with ILC or IDC. Breast-conservation therapy is an appropriate treatment strategy for patients with early-stage invasive lobular carcinoma.

Selecting patients for breast-conserving therapy

BACKGROUND

Concerns exist regarding the ability to select patients with lobular carcinoma for breast-conserving therapy (BCT) using mammography. The purpose of this study was to compare the conversion rate from BCT to mastectomy among patients with lobular (ILC) and ductal carcinoma (IDC), and to compare the number of resections needed to obtain negative margins.

METHODS

In all, 349 patients with pure or mixed ILC were identified from a database and 318 were successfully matched to 2 controls with IDC on the basis of year of diagnosis, menopausal status, and stage of disease. Conditional logistic regression was used to control for matching.

RESULTS

Patients with ILC were older, had larger tumors (2.6 vs. 2.1 cm; P<.001), and were more likely to have contraindications to BCT (25% vs. 20%). In patients thought to be candidates for BCT, no difference in success rate was noted on the basis of histologic type after controlling for age and stage. In those undergoing BCT, no difference in the number of procedures was seen on the bases of histology after adjustment for age and stage.

CONCLUSIONS

Patients with ILC are not more likely to fail BCT than those with IDC, nor do they require more operations to obtain negative margins. These results do not support the use of more extensive preoperative evaluation such as magnetic resonance imaging in patients with ILC.