Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer

The significance of the pathology margins of the tumor excision on the outcome of patients treated with definitive irradiation for early stage breast cancer

To evaluate the significance of the pathology margins of the tumor excision on the outcome of treatment, an analysis was performed of 697 consecutive women with clinical Stage I or II invasive carcinoma of the breast treated with breast-conserving surgery and definitive irradiation. Complete gross excision of the primary tumor was performed in all cases, and an axillary staging procedure was performed to determine pathologic axillary lymph node status. The 697 patients were divided into four groups based on the final pathology margin from the primary tumor excision or from the re-excision if performed. These four groups were: (a) 257 patients with a negative margin (greater than 2 mm), (b) 57 patients with a positive margin, (c) 37 patients with a close margin (less than or equal to 2 mm), and (d) 346 patients with an unknown margin. The patients with positive final pathology margins were focally positive on microscopic examination. Patients with grossly positive margins or with diffusely positive microscopic margins were treated with conversion to mastectomy. There was a significant difference in the total radiation dose for the four groups (median dose of 6000 vs 6500 vs 6400 vs 6240 cGy, respectively; p less than .0001). There was no significant difference among the four groups for 5-year actuarial overall survival (p = .19), no evidence of disease (NED) survival (p = .95), or relapse-free survival (p = .80). There was no significant difference among the four groups for five year actuarial local or regional control (all p greater than or equal to .29). Subset analyses did not identify any poor outcome subgroups. These results have demonstrated that selected patients with focally positive or close microscopic pathology margins can be adequately treated with definitive breast irradiation. Patient selection and the technical delivery of radiation treatment including a boost may have been important contributing factors to the good outcome in these patients.

DNA ploidy of primary breast cancer and local recurrence after breast-conserving therapy

The value of DNA-flow cytometry and clinico-pathological prognostic factors for the prediction of local recurrences after breast-conserving therapy (BCT) were evaluated in a retrospective study. Thirty-one patients with a local recurrence were compared with 31 matched patients without a local recurrence. Morphology and DNA-indices of the local recurrences and their corresponding primary tumours were compared. Ductal carcinoma in situ was present significantly more often in the group with a primary recurring tumour, than in the matched group (P less than 0.001), and the same holds for lobular carcinoma (n = 5). Half of the tumours that recurred had macroscopically positive surgical margins compared to about one-fourth of the matched group. Fifty-six per cent of the DNA-aneuploid stemlines in cases with local recurrence were present in the corresponding primary tumour as well (confidence limits 45%-75%), an indication that the majority of local recurrences are true recurrences and not independently developed tumours. The lack of similarity of DNA stemlines between some primary DNA-aneuploid tumours and their local recurrences indicates that these tumours had developed independently. The percentage of DNA-aneuploid cases in the group with local recurrence (89%) did not differ significantly from that in the matched group (70%). However, the findings suggest a selective recurrence of DNA-diploid stemlines. This might indicate increased resistance of DNA-diploid tumour cells to radiotherapy as compared with the resistance level in DNA-aneuploid cells.

Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection

Tylectomy with axillary lymph node dissection and radiotherapy (TAD) has become an accepted treatment for early breast cancer and has been shown to result in equal 5- and 8-year survival when compared with modified radical mastectomy (MRM). In order to determine the safety of TAD with respect to wound complications and to identify potential risk factors, we reviewed the charts of 560 patients undergoing MRM (n = 387) and TAD (n = 173) at Virginia Mason Medical Center from 1983 through 1989. The incidence of infection, seroma, hematoma, and epidermolysis were compared, and obesity, age 60 years or older, smoking, antibiotics, and wound drainage were examined as possible risk factors. There were more wound complications in the MRM group versus the TAD group (49% versus 35%; p less than 0.01), specifically more seromas (29% versus 18%; p less than 0.01) and epidermolysis (18% versus 0%). In the MRM group, age 60 years or older was associated with seroma (p less than 0.01) and smoking was associated with epidermolysis (p less than 0.01). In the TAD group, obesity was associated with infection. In both groups, volume of drainage from closed suction wound drains greater than 30 mL in the 24 hours prior to removal of the last drain was associated with seroma (p less than 0.05).

Recent advances in the treatment of breast cancer

Multidisciplinary efforts have defined a number of prognostic factors and newer strategies to improve the outcome of patients with breast cancer. Conservative surgery has led to improved functional and cosmetic results. The development of a number of effective adjuvant regimens has led to improved survival. In patients with stage I disease, several biological characteristics of tumor have been identified that are associated with increased risk of relapse. A multimodality approach to patients with locally advanced disease and inflammatory cancer has resulted in improved survival. A number of hormonal and cytotoxic drug contaminations can palliate metastatic disease, with a small fraction of patients remaining in extended remission. Dose-intensive programs may lead to further improvements in survival of selected patients with this disease.

Breast deformity, its correction, and assessment of breast conserving surgery

A combination of quadrantectomy, axillary dissection, and radiotherapy (QUART) is the regimen most favored by Japanese surgeons among a variety of breast conserving therapies currently available against breast cancer. Unfortunately, extensive resections such as quadrantectomy often give poor local cosmetic results in patients with small breasts. With the aim of improving the cosmetic aspect after an extensive resection, immediate transposition of the latissimus dorsi muscle (LDM) was carried out in breast conserving surgery. To date, twenty-one patients have been entered in this study. Post-quadrantectomy breast deformity was not corrected in six patients including one with bilateral breast cancers, but was corrected by transposition of a part of LDM in 14 other patients. In the last patient, who also had bilateral breast cancers, the right breast was treated by QUART and the left breast by subcutaneous mastectomy followed by transposition of LDM. The cosmetic outcome for these patients was assessed both subjectively and objectively; the objective assessment used a Moire topography camera. The postoperative appearance and topography revealed a satisfactory symmetry of breasts in the transposed patients, especially those with small breasts, when compared with non-transposed patients. It may be concluded that the transposition of LDM is useful in preventing breast deformity following an extensive resection in breast conserving surgery.

Effects of primary chemotherapy in conservative treatment of breast cancer patients with operable tumors larger than 3 cm. Results of a randomized trial in a single centre

272 women with operable breast adenocarcinomas larger than 3 cm were included in a randomized trial. The patients in group A (n = 138) with histological nodal involvement (N+) or a lack of estrogen and progesterone receptors (EPR-) were treated by initial mastectomy and axillary node dissection + adjuvant chemotherapy. Those in group B (n = 134) were treated by initial chemotherapy (the same as in group A) followed by loco-regional treatment, adjusted according to their response to chemotherapy. Prognostic factors were identical in the two groups. In group A, 32 patients received no adjuvant treatment (N- and EPR+), while 104 were given adjuvant chemotherapy (N+ and/or EPR-). Two patients were lost to follow-up. In group B, all patients received initial chemotherapy; 44 were in complete clinical remission and were treated with radiotherapy only; 40 with residual tumor (less than 20 mm) were treated with tumorectomy + axillary node dissection + radiotherapy; 49 with residual tumors (greater than 20 mm) had mastectomies. Conservative treatment was administered to 84 patients in group B (62.6%). EPR-tumors responded better to chemotherapy than did EPR+ ones (p = .003). After a median follow-up of 34 months, isolated local recurrences were more frequent in the group with initial chemotherapy, which, however, experienced a better overall survival (p = 0.04).

Factors affecting recurrence in lumpectomy without irradiation for breast cancer

Between 1980 and 1988, 122 women with operable invasive breast cancers underwent wide excision and axillary dissection without subsequent irradiation. During the follow-up period of 1 to 8 years (median, 4 years), recurrences were observed in 23 patients (19%), 22 occurring in the breast and one in the axilla. This is a significant rate of recurrence and supports the need for breast irradiation after conservative surgery. The incidence of recurrence in the breast did not appear to be related to the presence or absence of axillary nodal metastasis. No recurrences were noted in 20 patients whose primary tumors were smaller than 1 cm. The incidence of recurrence was directly correlated to the increasing size of the tumor, but it also appeared to decrease with advancing age. In 31 patients over 70 years of age, only one (3%) recurrence was observed. If these early findings are confirmed, it is likely that patients with tumors smaller than 1 cm or patients over 70 years of age may be spared breast irradiation after wide excision.

Have changing treatment patterns affected outcome for operable breast cancer? Ten-year follow-up in 1288 patients, 1965 to 1978

From 1965 to 1978, 1288 patients with primary operable breast cancer were treated by the senior author, using extended radical (ERM), radical (RM), and modified radical (MRM) mastectomy operations exclusively. Results were analyzed for trends in overall and disease-free survival, and patterns of local and distant relapse, the years 1965 to 1970 versus 1971 to 1974 versus 1975 to 1978. Significant changes (p less than 0.00001) from 1965 to 1978 included progressively earlier stage of disease, less frequent use of RM and ERM, a decline in the use of postoperative radiotherapy, and the introduction in 1975 of multidrug adjuvant chemotherapy. Ten-year disease-free survival rates improved significantly for all patients (by 11%, p = 0.00004) and for node-negative (by 12%, p = 0.0024), node-positive (by 8%, p = 0.012), clinical stage II (by 15%, p = 0.0022), and pathologic stage II (by 12%, p = 0.016) disease. Ten-year local recurrence for all patients was 3% (local only) and 2% (local with distant metastasis), and survival from date of recurrence for all patients failing treatment increased two times (p less than 0.0001) for patients treated most recently. As the primary surgical treatment of breast cancer continues to become more moderate, the promise of systemic adjuvant therapies can be realized only with continued emphasis on earlier diagnosis and maximal local control of disease.

The axilla: not a no-go zone

Many surgeons, particularly in the UK, give inadequate primary treatment to patients with operable breast cancer. For spurious reasons they regard axillary clearance as unnecessarily extensive surgery and rely instead upon total mastectomy or tumour excision and node sampling, with or without postoperative radiotherapy. But it is now clear that relapse-free and overall survival can be improved by appropriate adjuvant therapy. Thus inadequate exploration of the axilla is doubly unjustified. Not only is there the obvious risk of failure to remove nodes that contain metastases--so that some patients are deprived of cure by primary treatment--but the extent of tumour spread will be inadequately assessed in many more patients, with the risk that they may not receive appropriate adjuvant treatment.

Treatment of early breast cancer with conservation of the breast. A review

This paper reviews the current status of conservative treatment for early breast cancer. While the first patients were treated with such techniques more than 60 years ago, it is during the last decade that randomized trials have confirmed that such treatment is comparable to mastectomy in preventing breast cancer death. Radiotherapy to the breast after local tumour excision is important to prevent local breast relapse, but it is not clear whether it has any influence on the risk of distant metastases. Several questions remain to be answered. While most investigators agree that the breast should receive a radiation dose of about 50 Gy in 5 weeks, there is no general agreement about the need for a tumour bed booster dose. Considering patients with tumour infiltration at the surgical resection line for whom it is not possible for cosmetic reasons to perform re-resection, it is not clear whether an acceptable local control rate can be achieved through application of a high booster dose in the tumour bed. More trials are needed to show whether certain patients with small invasive carcinomas should be treated with wide local excision without radiotherapy. The need for radiotherapy after local excision for small intraductal (ductal carcinoma in situ) cancers is being addressed in ongoing trials.

Iridium implant treatment without external radiotherapy for operable breast cancer: a pilot study

A pilot study has been conducted to examine a new approach to the treatment of operable breast carcinoma. 27 patients with tumours measuring up to 4 cm in diameter have been treated by tumourectomy, axillary clearance and high dose iridium-192 implant (55 Gy) without any external beam radiotherapy. This enabled the entire local primary treatment of the breast carcinoma to be given in five days. The technique was compatible with adjuvant chemotherapy for those with involved axillary nodes. Local complications have been few and locoregional control has to date been satisfactory. With a relatively short median follow-up of 27 months, cosmesis was objectively rated as good or excellent in over 80% of cases and subjectively rated good/excellent in 96%. High dose brachytherapy now requires testing in a prospective clinical trial to determine whether it is as effective as standard breast conservation techniques for management of early breast cancer.

DNA ploidy and cell-cycle analysis: tools for assessment of cancer prognosis

DNA ploidy and cell cycle analysis as measured by flow cytometry (FC) and image analysis (IA) have moved out of the realm of the research laboratory to become valid clinical tests used in the assessment of prognosis of the cancer patient. Although much information on the relationship of DNA ploidy/%S-phase analysis to patient prognosis is available in the literature, the data are not presented in such a way as to be helpful in clinical decision making. Because predictive values and confidence intervals, which measure the likelihood that a given clinical test will rule in or rule out a clinical outcome, were not calculated in previous reviews, conclusions about the clinical utility of these analyses were not possible. Using the available raw data on DNA ploidy and %S-phase analysis from previously published papers, predictive values and confidence limits were calculated for specific clinical presentations. In several such clinical situations (tumor type, stage, etc.), predictive value of greater than 90% was derived. We conclude that in these situations DNA ploidy and %S-phase analysis can be used to predict clinical outcome, to design treatment, and to guide patient management. The evaluation of the clinical utility of these tests must ultimately rest on prospective trials which show that randomized arms respond to treatment regimens dependent upon the DNA ploidy and %S-phase status.

Results of treating ductal carcinoma in situ of the breast with conservative surgery and radiation therapy

To determine the frequency, pattern, and time course of tumor recurrence in the breast, the outcome of 38 women with ductal carcinoma in situ (DCIS) treated with conservative surgery and radiation therapy between 1976 and 1985 was studied. Surgery typically consisted of local excision without evaluation of the microscopic margins of resection. The median radiation dose to the tumor site was 6400 cGy. With a median follow-up time of 81 months, eight patients (21%) have experienced a recurrence in the breast. The time course to recurrence was protracted in some cases, with failures occurring at 17, 27, 43, 63, 71, 83, 92, and 104 months. The 5-year and 8-year actuarial rates of tumor recurrence in the breast were 8% and 27%, respectively. Seven patients had a recurrence at or near the primary tumor site, four with invasive carcinoma, and one had an invasive recurrence at a site elsewhere in the breast. No clinical or pathologic factor was significantly associated with an increased risk of recurrence, but the number of patients in the study population was small. The authors reached the following conclusions for patients with DCIS treated with conservative surgery and radiation therapy without careful mammographic and pathologic evaluation: (1) recurrence in the breast may be seen in at least one fifth of the patients; (2) recurrence typically occurs at or near the primary site; and (3) recurrence can occur long after treatment. Careful mammographic and pathologic assessment may be useful in reducing the local recurrence rate and should be considered essential if patients are considered for conservative surgery and radiation therapy.

Epidermal growth factor receptor (EGFr); results of a 6 year follow-up study in operable breast cancer with emphasis on the node negative subgroup

More accurate criteria are required for the selection of patients with node-negative breast cancer for systemic adjuvant therapy. Expression of epidermal growth factor receptor (EGFr) has been shown previously to be inversely related to oestrogen receptor (ER) in patients with operable breast cancer and to be associated with a poorer prognosis. Analysis of EGFr and ER was performed on tumour samples from 231 patients with operable breast cancer followed for up to 6 years after surgery. The median duration of follow-up in patients still alive at the time of analysis was 45 months. Thirty-five percent of patients (82) had tumours with greater than 10 fmol mg-1 I125-EGF binding (EGFr+) and 47% (109) and cystolic ER concentrations greater than 5 fmol mg-1 (ER+), with a marked inverse relationship between EGFr and ER (P less than 0.00001). In a univariate analysis EGFr was second only to axillary node status as a prognostic marker for all patients both in terms of relapse-free and overall survival (P less than 0.001, log rank). For patients with histologically negative axillary nodes EGFr was superior to ER in predicting relapse and survival (P less than 0.01 and P less than 0.005 respectively compared to P less than 0.1 and P less than 0.1, log rank). In a multivariate (Cox model) analysis only EGFr, out of EGFr, ER, size and grade, was predictive for either relapse-free or overall survival for patients with node-negative disease (P = 0.05 and P = 0.026 respectively). EGFr has been shown to be a marker of poor prognosis for patients with node-negative breast cancer. Since patients with EGFr+ tumours are unlikely to respond to hormone therapy it may be possible to select them for trials of systemic adjuvant chemotherapy.

Adjuvant therapy of breast cancer. International Breast Cancer Study Group

Adjuvant systemic therapy has been shown to reduce relapses in treated women and to prolong their survival. This is true for all studied subpopulations. Multidrug chemotherapy for the duration of 6 months for the premenopausal patients, and tamoxifen or short-term chemotherapy with long-term tamoxifen for the postmenopausal patients represent the treatments of choice to reduce the risk of relapse. Some of the high priority questions relate to i) the definition of a population for which the risk of relapse is low enough to avoid the use of systemic adjuvant therapy, and ii) the definition of an optimal way of using available adjuvant therapies. These might find answers from ongoing research. The modest but real improvement of the prognosis in operable breast cancer was exclusively obtained only by means of clinical trials, and it is mandatory that participation in programs of clinical research becomes medically and socially the treatment of choice.

Patterns of surgical treatment of breast cancer in Victoria

We analysed data on admissions to Victorian public hospitals for surgical treatment of breast cancer over the period July 1985 to December 1988. Of the 2993 women admitted, 28.7% received breast-preserving surgery. The probability of a woman being treated conservatively was dependent on age, with women aged less than 50 or more than 70 years more likely to receive breast-preserving surgery than women aged 50-69. There was an age-specific change, of marginal statistical significance, in the proportion of women receiving breast-preserving surgery over the period. The public hospitals admissions database is a potentially useful means of monitoring patterns of surgical treatment.

Selection of breast-preservation therapy for primary invasive breast carcinoma

Breast-preservation treatment for primary breast cancer should not be used for all women. Women frequently excluded from consideration for such treatment or who choose not to have it may be elderly and not concerned about cosmetic appearance or live at a distance so that 6 weeks of daily trips to radiotherapy would be inconvenient or even impossible. Also, if radiotherapeutic expertise or facilities are not available, a breast-preservation program is difficult. In Massachusetts, a full course of just over 6000 cGy (4500 cGy to the whole breast and a 1600-cGy local boost) costs roughly $6000. Thus, breast preservation is more expensive than mastectomy even with reconstruction, as patients still frequently require a hospital admission with general anesthesia for an axillary dissection. Although insurance policies cover such expenses, patients who do not have insurance or have inadequate coverage may find the extra expense of the breast-preservation technique burdensome or impossible. Women with a small breast and a proportionately large cancer may have an unsatisfactory cosmetic outcome after appropriate lumpectomy. The cosmetic result in such patients frequently cannot be predicted beforehand; this fact adds emphasis to the need for a two-step process of lumpectomy and then re-evaluation of the cosmetic outcome as well as pathologic features for decisions regarding breast preservation. Finally, women may have strikingly different attitudes toward breast preservation than expected by the surgeon. For some women, the urge to preserve the breast is so strong that they will accept virtually any risk to achieve this option, whereas for other women, the constant anxiety about a recurrence or undergoing radiation therapy is traumatic enough that they readily accept mastectomy. In our referral surgical oncology practice, roughly 60% of patients are currently treated with breast-preservation techniques; the remainder undergo mastectomy, with immediate reconstruction in approximately three fourths of the cases. The proportion of patients who elect to have breast preservation depends greatly on local medical customs and attitudes; the radiotherapeutic skills available; women's attitudes, which frequently are dependent on the local press and publicity; and the surgeon's interest and enthusiasm for such a program. There is no appropriate proportion of patients who should be treated by breast-preservation techniques, but clearly, the proportion of patients so treated increases with experience, acceptability, publicity, and availability. Thus, the selection of breast-preserving therapy for individual patients is a result of an extraordinary array of factors that need to be considered in each patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of local and regional recurrence after mastectomy or breast-conserving treatment

Locoregional failures after primary treatment for breast cancer include a diverse group of lesions that represent different categories of failures with various prognoses. Although patients with chest wall recurrences and regional nodal failures after traditional radical surgery have a poor prognosis, many patients can still achieve a significant degree of palliation and even long-term survival or cure with carefully orchestrated multimodal treatment. In patients who have breast failures after breast-conservation surgery and radiation, long-term salvage and cure can be achieved for the majority with prompt detection and appropriate treatment, which, like treatment for primary breast cancer, includes a consideration not only of local control but also of the risk of subsequent systemic failure and its need for treatment.

Results of conservative surgery and radiation therapy for breast cancer

For stage I or II breast cancer, conservative surgery and radiation therapy are as effective as modified radical or radical mastectomy. In most cases, cosmetic considerations and the availability of therapy are the primary concerns. The extent of a surgical resection less than a mastectomy has not been a subject of a randomized trial and is controversial. It appears that removal of a quadrant of the breast for small lesions is safe but excessive. Using histologic findings in the biopsy as a guide, it may be possible to limit the breast resection to gross tumor removal for most patients while using wider resections for patients with an extensive intraductal component or for invasive lobular carcinoma. It also appears that excluding patients from breast conservation on the basis of positive margins on the first attempt at tumor excision may be unnecessarily restrictive. Although patients with an extensive intraductal component or invasive lobular carcinoma should have negative margins, it appears that a patient with predominantly invasive ductal carcinoma can be treated without re-excision if all gross tumor has been resected and there is no reason to suspect extensive microscopic disease. Patients with indeterminate margins should have a re-excision. Axillary dissection provides prognostic information and prevents progression of the disease within the axilla. Axillary dissections limited to level I will accurately identify a substantial number of patients who have pathologically positive but clinically negative nodes. When combined with radiation therapy to the axilla, a level I dissection results in a limited number of patients with progressive axillary disease. Patients with pathologically positive axillas and patients at particularly high risk for systemic disease because of the extent of axillary node involvement can be identified by dissections of levels I and II. Radiation therapy can be avoided safely in patients who have pathologically negative axillas by level I and II dissection. There appears to be no advantage to routine dissection of level III lymph nodes. Lymphedema of the arm and breast increases with more extensive dissections and with radiation therapy.

Role of mastectomy in breast cancer

The surgical management of breast cancer continues to evolve in an attempt to define the ideal line between therapeutic efficacy and morbidity. It is clear that breast cancer is a biologically heterogeneous group of diseases, and no single hypothesis explains its behavior. The surgical options proposed to the individual patient must draw from the experience of retrospective clinical studies and prospective randomized trials in an attempt to optimize the treatment plan. Most patients without distant disease are eligible to consider mastectomy, which can accomplish excellent local control and significantly improve survival for earlier stages of disease. However, breast conservation remains an appropriate alternative for a carefully defined subset of patients. Today, with early-stage disease, no patient need leave the operating room without a breast. Recent advances in reconstructive surgery make mastectomy with immediate reconstruction or limited resection plus axillary dissection with postoperative radiation therapy the two principal treatment choices available. Future studies will focus on the integration of other treatment modalities. Clinical research into the use of preoperative chemotherapy to downstage the disease to permit less extensive surgery is of interest. Recent application of molecular biologic techniques such as oncogene analysis, cytogenetic studies, proliferative indices, and the highly sensitive detection of distant micrometastases using monoclonal antibodies may assist in the design of innovative approaches to surgery, radiation therapy, and systemic drug treatment. These advances show great promise for improving the quality of life and the cure rate for patients with breast cancer. Today, surgical treatment options have evolved that fulfill some of the objectives outlined by Dr. James Ewing of Memorial Hospital some 50 years ago. His concerns about breast cancer remain as relevant today as they were half a century ago: "I have drawn the impression that in dealing with mammary cancer, surgery meets with more peculiar difficulties and uncertainties than with almost any other form of the disease. The anatomical types are so numerous, the variations in clinical course so wide, the paths of dissemination so free and diverse, the difficulties of determining the actual conditions so complex, and the sacrifice of tissues so great, as to render impossible in the majority of cases a reasonably accurate adjustment of a means to an end."

Conservative surgery and radiotherapy for early breast cancer

In 1984, as part of a prior American Cancer Society National Conference on Breast Cancer, the authors reported on the status of conservative surgery (CS) and radiotherapy (RT) as primary local treatment for women with early stage breast cancer. Since that time, additional data have become available regarding the use of this approach and its comparability to mastectomy. In general, these data support the use of CS and RT and, as a result, this approach is now more widely employed in the United States and abroad than it was in 1984. The current focus of inquiry has shifted from whether or not CS and RT is an acceptable option for patients with early stage breast cancer to the following questions. For which patients are CS and RT suitable? What are the best techniques of surgery and RT? Are there any patients who can be treated safely with CS without RT? How should RT and systemic therapy be integrated when both are to be used? In this report, recent results on the use of CS and RT from both retrospective and prospective trials are summarized, and these current areas of inquiry are addressed.

Racial differences in the early detection of breast cancer in metropolitan Detroit, 1978 to 1987

This population-based study presents trends in stage at diagnosis of invasive female breast cancer during the decade from 1978 to 1987 in the Detroit metropolitan area. Its purpose is to determine whether there has been an increase in early breast cancers: those that are smaller than 2 cm at diagnosis and have no axillary lymph node involvement. Trend analyses of tumor size, node status, year of diagnosis, age, and race were performed for 17,216 incident cases drawn from the Metropolitan Detroit Cancer Surveillance System (MDCSS). Although trends toward earlier diagnosis of breast cancer are observed, less improvement is seen for black women than white women in the presentation of breast cancer at smaller, node-free stages. Implications for breast cancer screening are discussed.

Surgical management of stage I and stage II breast cancer

Patients with Stage I or II breast cancer are candidates for either modified radical mastectomy or breast preservation, with limited resection of the primary, axillary dissection, and breast irradiation. Overall survival rates with these two approaches are comparable in retrospective reviews and in ongoing clinical trials. Longer follow-up has confirmed earlier findings. Patients should be given these options by surgeons, radiation therapists, and other physicians involved in their care. Not all breast cancer patients will choose breast preservation, and not all are candidates for it due to tumor-related and other factors. Patient selection criteria are discussed, and optimal surgical techniques are reviewed.

The role of surgery in the management of supratentorial intermediate and high-grade astrocytomas in adults

In this analysis, the authors review studies over the last 50 years addressing the association between long-term survival and type of surgical management in adults with supratentorial intermediate or high-grade astrocytomas. Earlier reports are included because they are repeatedly referenced in current works and clearly are an important basis upon which present attitudes are predicated. Because recent work has definitively demonstrated the significance of prognostic variables on outcome, the handling of such factors in studies that investigated survival data according to degree of surgery is emphasized. Study design, experimental methods used, and methods of data analysis are also examined. This analysis shows that there is little justification for dogmatic statements concerning the relationship between increasing patient survival times and aggressive surgical management in adults with supratentorial intermediate or high-grade astrocytomas, if patients receive postoperative radiotherapy.

Impact of radiation therapy and/or chemotherapy on the risk for a second malignancy after breast cancer

The risk of any second malignancy was determined for all patients treated for a primary cancer of the breast without evidence of distant metastasis at Duke University Medical Center between 1970 and 1981. The incidence, 10-year actuarial risk (AR), and relative risk (RR) of a second malignancy developing were calculated for the 407 patients who were treated with surgery alone, 226 who were treated with surgery followed by adjuvant chemotherapy (CT), 140 who were treated with surgery plus adjuvant radiation therapy (RT), and 308 who received all three modalities (CRT). The AR of a subsequent cancer (8.4% for CRT, 8.7% for CT, 8.7% for RT, and 11.7% for surgery only patients) did not differ significantly between treatment groups. The overall second cancer RR was 1.0% after CRT (95% confidence interval [CI], 0.4 to 2.0), 1.3% after RT (95% CI, 0.6 to 2.5), 1.6% after CT (95% CI, 0.9 to 2.6), and 1.7% after surgery alone (95% CI, 1.2 to 2.4). Contralateral breast cancers (RR of 4.2%; 95% CI, 2.7 to 6.3) account for the statistically significant excess of second malignancies among the surgery alone patients. The AR for contralateral breast cancer in the surgery group was higher than in either group receiving CT (P less than 0.01), but was not significantly different from the RT group. The RR for solid tumors other than breast cancer was not significantly different from unity in any of the treatment groups. The RR for acute leukemia was 16.7% in the CRT group (95% CI, 0.2 to 92.7), 11.1% in the CT group (95% CI, 0.1 to 61.8), 10.0% in the surgery alone group (95% CI, 1.1 to 36.1), and 0.0% in the RT group (95% CI, 0.0 to 61.1). This study indicated that inclusion of RT and/or CT in the initial treatment of breast cancer did not impact negatively on patients' overall risk for a subsequent malignancy during the first decade after therapy, and that adjuvant CT with or without RT may decrease their risk of a contralateral breast cancer.

Survival following locoregional recurrence after breast conservation therapy for cancer

We postulated that locoregional recurrence after limited surgery and radiotherapy for breast cancer might be associated with an additional survival hazard, similar to that of a second primary tumor with the same extent of local and regional disease. Using this hypothesis we examined the likely resultant effect on survival. Our calculations indicated that no statistically significant survival deficit due to such recurrence would be detectable until a randomized controlled trial comparing breast conservation with mastectomy had monitored more than 10,000 patients for more than 10 years. A simple mathematical model predicted 5-year survival rates in a cohort of patients treated with breast conservation of 75%, compared to 83% in those without locoregional recurrence. From the date of locoregional recurrence, a 61% 5-year survival rate was predicted, compared to 83% if no hazard was associated with locoregional recurrence. These predictions were compared with the actuarial survival rates of 499 patients with unilateral breast cancer, 49 of whom had developed locoregional recurrence. From the date of initial treatment, the 5-year survival rate of those whose disease recurred was 79%, compared to 88% for those without locoregional recurrence (p = 0.19). The actuarial 5-year survival rate from the date of locoregional recurrence was 63%. The similarity between the patient data and the predictions of the mathematical model indicates that locoregional failure after breast conservation therapy may result in reduced survival. The lack of a significant survival deficit in our cohort or in controlled trials comparing breast conservation therapy with mastectomy is compatible to the small size of the overall effect.

Techniques of lumpectomy and axillary dissection

Preservation of the breast with a good or excellent cosmetic appearance is achievable in most patients. Careful attention to the details of surgical technique allows these procedures to be carried out easily and comfortably for the patient and the surgeon alike.

Intraoperative Ir-192 implantation for early breast cancer. Techniques and results

Patients with early breast cancer (T1-2 N0-1) can be treated by lumpectomy and irradiation with a local control and survival equal to more radical surgery. Between 1982 and 1988, 323 patients with early breast cancer were treated, when possible, with Ir-192 implants at the time of lumpectomy to a local dose of 2000 cGy in 40-50 hours. Ten to 14 days later, the whole breast was treated to 4500 cGy at 180 per fraction in 5 weeks. The 6-year actuarial survival for stages I and II disease was 98% and 91%, respectively, and the recurrence-free survival was 96% and 98%, respectively. When these 323 patients were evaluated by T status, a local control of 97% was the same for T1 and T2 lesions. The cosmetic results were good to excellent in 95% of the patients. This approach has improved our ability to accurately place the boost dose in the breast.

The detection of local recurrence after definitive irradiation for early stage carcinoma of the breast. An analysis of the results of breast biopsies performed in previously irradiated breasts

One hundred forty-five breast biopsies were performed in 139 treated breasts to evaluate for potential recurrent carcinoma of the breast in women previously treated with definitive breast irradiation for early stage carcinoma of the breast. One hundred thirty-four patients had undergone one breast biopsy, four patients had undergone two breast biopsies, and one patient had undergone three breast biopsies. The median interval from completion of definitive irradiation to breast biopsy was 28 months (range, 2 to 117 months). Of the 145 breast biopsies, 52% (76 of 145) were positive, and 48% (69 of 145) were negative. The positive biopsy rate was related to the type of biopsy, the location of the biopsy, and the findings on physical examination and mammography. In patients with a negative physical examination but mammographic findings of a mass, microcalcifications, or both, the positive biopsy rate was 66% (25 of 38). For patients with a mass on physical examination but a negative mammogram, the positive biopsy rate was 28% (nine of 32). For patients with a mass on physical examination and a positive mammogram, the positive biopsy rate was 72% (13 of 18). For patients undergoing an incisional or Tru-Cut (Travenol Laboratories, Deerfield, IL) needle biopsy, the positive biopsy rates were 94% (15 of 16) and 75% (three of four), respectively, whereas the positive biopsy rate for an aspiration cytology was 25% (five of 20). Of the 76 positive biopsies, 64% (49 of 76) were from an in field or marginal location. The rate of detection of a subsequent local recurrence after an initial negative biopsy was 5% (three of 66). Of the evaluable patients, the complication rate was 9% (seven of 81). This study has documented the results of breast biopsies after definitive irradiation for early stage carcinoma of the breast.

Primary therapy for limited breast cancer. Radiation therapy techniques

Available data show that breast conserving surgery followed by radiation therapy results in freedom of breast cancer recurrence rates that range from 86% at 10 years to 80% at 20 years for Stage I and II carcinoma. Breast cancer recurrence may be reduced further by the administration of systemic chemotherapy. Mastectomy and breast conserving therapy give equal tumor control and survival, but the latter results in superior quality of life. To achieve the best tumor control with optimal cosmesis, certain generally accepted principles of surgical and radiotherapeutic management need to be followed. The surgeon must use a neat technique that avoids excessive removal of breast and axillary tissue, improper placement of the surgical scar in the breast, and the formation of seromas or hematomas, which result in breast or arm edema. The radiation oncologist must use supervoltage energy, fields that avoid excessive irradiation of the lungs and other sensitive structures, proper field matching, whole breast doses ranging from 4500 to 5000 cGy with fractions of 180 to 200 cGy per day, and brachytherapy or electron beam boost to achieve a total dose of approximately 6000 cGy in the tumor area. These principles should result in good to excellent cosmesis in more than 80% of treated breasts. Breast conserving management offers women an incentive to achieve early detection. Early detection is the most promising approach to reduce mortality from breast cancer.

Breast compliance: a new method for evaluation of cosmetic outcome after conservative treatment of early breast cancer

As a measure of cosmetic outcome, the compliance of normal and irradiated breasts has been quantified using a new method of Breast Compliance Evaluation (BCE). A total of 151 women were studied, of whom 100 were normal controls and 51 had previous breast irradiation as part of breast-conserving treatment. Compliance was taken as the difference between the anterior breast surface length from infra-mammary fold to the nipple when the patient was in erect and supine positions. Irradiated cases were rated as having satisfactory outcome (good or excellent cosmetic result) or unsatisfactory (fair or poor cosmetic result). Mean compliance of normal cases was 1.8 cm. In the irradiated women with satisfactory cosmetic results, mean compliance was 1.45 compared with only 0.77 cm in those with unsatisfactory outcome. The difference between the compliance of both breasts was 0.1 cm for the controls, 0.3 cm in the satisfactory group and 2 cm in the unsatisfactory group. A difference in compliance greater than 1 cm was usually associated with an unsatisfactory cosmetic outcome. Factors determining cosmetic outcome included volume of excised lump and breast size. The cosmetic result was not affected by tumour site, clinical or pathological tumour size, or the total number of axillary nodes excised. This simple, painless, and easily reproducible measurement may be a useful objective indicator of cosmetic result after conservative treatment of early breast cancer.

Radiobiological advantages of an immediate interstitial boost dose in conservative treatment of breast cancer

Minimum surgery with irradiation is emerging as one of the main modalities of therapy for operable early breast cancer. Between June 1982 and June 1986, 110 breasts with Tis, T1 to T3 lesions have been treated at our institution with lumpectomy and interstitial irradiation to the tumor bed with Iridium-192 perioperatively followed by external beam irradiation. There have been two local recurrences at or near the vicinity of the primary, at a median follow-up of 60 months. To analyze the parameters that might have contributed to the local control, we have examined the treatment volumes, prescribed dose to the tumor bed, dose at the core of the tumor bed, and dose to the surrounding normal tissue. Immediate interstitial implant has the radiobiological advantage of delivering continuous low dose irradiation, immediately upon removal of gross tumor to residual foci. Implantation of the afterloading catheters intraoperatively facilitates accurate dose delivery and avoidance of geographical misses. By precise treatment of any residual foci, immediately upon removal of the gross mass, perioperative interstitial irradiation improves local control and by facilitating less radical surgical excision, leads to better cosmetic results.

Simple mastectomy with postoperative irradiation versus extended radical mastectomy in breast cancer. A twenty-five-year follow-up of a randomized trial

From November 1951 to December 1957, all patients with untreated breast cancer admitted to the Radium Centre in Copenhagen were randomized before their operability was evaluated into two groups, if the patients were operable, viz. simple mastectomy with postoperative x-ray treatment or extended radical mastectomy. Twenty-five-year results are presented, showing no difference in survival or recurrence-free survival of the operable patients. Histological grading was performed in nearly all cases. Patients with grade 1 tumours had a better survival than grades 2 and 3, but there was no difference in survival between the two treatment groups, when histological grading was taken into account. Histological node positive patients had more grades 2 and 3, tumours, whereas node negative patients had more grade 1 than grades 2 and 3 tumours. Premenopausal women had a significantly better survival than postmenopausal in all stages.

Quadrantectomy versus lumpectomy for small size breast cancer

Between 1985 and 1987 quadrantectomy plus external radiotherapy and lumpectomy plus external and interstitial radiotherapy were compared in a randomized trial of patients with small carcinomas of the breast. Quadrantectomy involves excision of 2-3 cm of normal tissue around the tumour plus the removal of a sufficiently large portion of overlying skin and underlying fascia whilst lumpectomy removes only the tumour mass with a narrow margin of normal tissue. Patients in both groups also received total axillary dissection. 705 cases were evaluable, 360 quadrantectomies and 345 lumpectomies. No differences in distant metastases and survival were observed in the two groups. However, lumpectomy patients had a much higher frequency of local recurrences (7.0 vs. 2.2%). Since a local recurrence needs a second operation and creates severe psychological distress to the patient, conservative surgical procedures should include generous excision of normal tissue around the primary carcinoma plus intensive postoperative radiotherapy.