251
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Joslyn SA. Ductal Carcinoma in Situ: Trends in Geographic, Temporal, and Demographic Patterns of Care and Survival. Breast J 2006; 12:20-7. [PMID: 16409583 DOI: 10.1111/j.1075-122x.2006.00182.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
While long-term prognosis is excellent, treatment of ductal carcinoma in situ (DCIS) remains controversial and inconsistent. The purpose of this study was to track geographic and temporal patterns of care for women diagnosed with DCIS, and analyze subsequent cancer-specific risk of mortality. Subjects for this study were 41,245 women diagnosed with primary DCIS in the National Surveillance, Epidemiology, and End Results (SEER) program from 1973 through 2000. Variables analyzed included patient age, year of diagnosis, SEER site of residence at the time of diagnosis, treatment (surgery, radiation), race, age, and hormone (estrogen and progesterone) receptor status. The percentage of women diagnosed with DCIS out of the total number of women diagnosed with breast cancer increased steadily between 1973 and 2000, with the largest increase occurring around 1985. Breast conserving surgery (BCS) utilization increased over time for each SEER site to the current proportions, ranging from 49.5% in Utah to 76.9% in Connecticut. Younger women were significantly more likely to receive mastectomy and had significantly lower risk of death. Women receiving BCS who also had radiation therapy (RT) had a significantly lower risk of death, although those receiving mastectomy had the lowest risk of death. Black women and Asian/Pacific island women were significantly more likely to receive BCS, although black women were less likely to receive follow-up RT and had a significantly increased risk of death. Racial and age differences in the treatment of DCIS resulted in significantly disparate rates of survival, which should be considered in public health programming. Mastectomy utilization resulted in improved survival, although additional studies may elucidate the interaction of treatment with patient age.
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Affiliation(s)
- Sue A Joslyn
- University of Northern Iowa, Cedar Falls, Iowa 50614-0135, USA.
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252
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White V, Pruden M, Giles G, Kitchen P, Collins J, Inglis G, Hill D. CHANGES IN THE MANAGEMENT OF DUCTAL CARCINOMA IN SITU BEFORE THE RELEASE OF CLINICAL PRACTICE RECOMMENDATIONS IN AUSTRALIA: THE CASE IN VICTORIA. ANZ J Surg 2006; 76:28-34. [PMID: 16483292 DOI: 10.1111/j.1445-2197.2006.03640.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study examines changes in the management of ductal carcinoma in situ between 1995 and 1999 in the Australian State of Victoria. This period was before the release of Australian treatment recommendations. METHODS All new cases of ductal carcinoma in situ diagnosed between 1 April and 30 September in 1995 and 1999 were identified from the population cancer registry. Treating surgeons completed a questionnaire on the presentation and management of each case. In 1995, 64 out of 70 surgeons returned questionnaires for 137 cases (case response, 94%). In 1999, 68 surgeons treated 159 registered cases and 141 completed surveys were returned (case response, 89%). RESULTS More cases underwent an image-guided biopsy in 1999 (54%) than in 1995 (34%). Breast-conserving surgery (BCS) was used to treat 69% of cases in 1999 and 63% in 1995. The use of axillary procedures (clearance or sampling) for women treated by mastectomy decreased from 61% in 1995 to 30% in 1999. More patients treated with BCS had margins simply described as "clear" in 1995 (49%) than in 1999 (21%). In 1995, only 7% of cases treated with BCS had radiotherapy, and this was 25% in 1999. CONCLUSION In both 1999 and 1995, the majority of patients were treated by BCS, but only a minority received radiotherapy.
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MESH Headings
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Combined Modality Therapy
- Female
- Humans
- Lymph Node Excision
- Mastectomy, Segmental
- Middle Aged
- Multivariate Analysis
- Practice Patterns, Physicians'/trends
- Victoria
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Affiliation(s)
- Victoria White
- Centre for Behavioural Research in Cancer, Cancer Control Research Institute, The Cancer Council Victoria, 1 Rathdowne Street, Carlton, Victoria 3053, Australia.
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253
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Souchon R, Budach W, Classen J. Radiooncological Aspects Regarding Multimodal Primary Treatment of Breast Cancer – a Review. Breast Care (Basel) 2006. [DOI: 10.1159/000097931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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254
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Vapiwala N, Harris E, Hwang WT, Solin LJ. Long-Term Outcome for Mammographically Detected Ductal Carcinoma In Situ Managed with Breast Conservation Treatment. Cancer J 2006; 12:25-32. [PMID: 16613659 DOI: 10.1097/00130404-200601000-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The importance of negative final resection margins for optimal local control has been established for women with ductal carcinoma in situ (intraductal carcinoma) undergoing breast conservation treatment. This study evaluated long-term outcome after breast conservation treatment and whether reexcision or the presence of residual tumor in the reexcision specimen predicted for local recurrence in patients with ductal carcinoma in situ with negative margins. METHODS The study cohort consisted of 192 women with ductal carcinoma in situ treated with breast conservation treatment at the University of Pennsylvania from 1978 to 2000. Analysis was performed for unilateral, mammographically detected, intraductal breast carcinomas. Study endpoints of interest included rates of local recurrence, overall survival, and cause-specific survival. The median follow-up was 6.2 years (mean, 7 years; range, 0.1-21.4 years). RESULTS The 10-year overall survival and 10-year cause-specific survival rates were 87% and 99%, respectively. There were 11 local failures (6%) in the treated breast, with a 10-year actuarial local failure rate of 10% and a median time to local failure of 7.4 years (mean, 6.6 years; range, 1.6-10.2 years). Among the subset of 124 patients with negative final resection margins, there was no statistically significant difference in the 8-year actuarial local recurrence rates among patients who underwent single excision (7%), reexcision with residual tumor (8%), or reexcision with no residual tumor (0%). DISCUSSION The use of breast conservation treatment in patients with ductal carcinoma in situ remains an effective and durable treatment approach. The need for reexcision to achieve negative margins and the presence of residual ductal carcinoma in situ in the reexcision specimen do not negatively impact local recurrence rates in the current study. These findings suggest that requiring more than one surgery to obtain clear resection margins is not an adverse prognostic factor for local failure.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Cohort Studies
- Female
- Follow-Up Studies
- Humans
- Mammography
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local
- Neoplasm, Residual
- Prognosis
- Radiotherapy
- Reoperation
- Survival Analysis
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Neha Vapiwala
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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255
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Adepoju LJ, Symmans WF, Babiera GV, Singletary SE, Arun B, Sneige N, Pusztai L, Buchholz TA, Sahin A, Hunt KK, Meric-Bernstam F, Ross MI, Ames FC, Kuerer HM. Impact of concurrent proliferative high-risk lesions on the risk of ipsilateral breast carcinoma recurrence and contralateral breast carcinoma development in patients with ductal carcinoma in situ treated with breast-conserving therapy. Cancer 2006; 106:42-50. [PMID: 16333852 DOI: 10.1002/cncr.21571] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The purpose of the study was to determine the risk of ipsilateral breast carcinoma recurrence (IBCR) and contralateral breast carcinoma (CBC) development in patients with a concurrent diagnosis of ductal carcinoma in situ (DCIS) with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). METHODS Records of all 307 patients with DCIS treated with breast-conserving treatment (BCT) from 1968 to 1998 were analyzed. Initial pathology reports and all slides available were re-reviewed for evidence of ADH, ALH, or LCIS. Actuarial local recurrence rates were calculated. RESULTS Fifty-five cases of DCIS were associated with ADH, 11 with ALH or LCIS, and 14 with both ADH and ALH or LCIS. Overall, IBCR occurred in 14% and no significant difference in the IBCR rate was identified for patients with proliferative lesions compared with patients without these lesions (P = 0.38). Development of CBC in patients with concurrent DCIS and ADH was 4.4 times (95% confidence interval [CI], 1.44-13.63) that in patients with DCIS alone (P < 0.01). The 15-year cumulative rate of CBC development was 22.7% in patients with ALH or LCIS compared with 6.5% in patients without these lesions (P = 0.30) and 19% in patients with ADH compared with 4.1% in patients with DCIS alone (P < 0.01). CONCLUSION The risk of CBC development is higher with concurrent ADH than in patients with DCIS alone, and these patients may therefore be appropriate candidates for additional chemoprevention strategies. Concurrent ADH, ALH, or LCIS with DCIS is not a contraindication to BCT.
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MESH Headings
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma in Situ/mortality
- Carcinoma in Situ/pathology
- Carcinoma in Situ/therapy
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/therapy
- Carcinoma, Lobular/mortality
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/therapy
- Female
- Follow-Up Studies
- Humans
- Hyperplasia
- Mastectomy, Segmental
- Middle Aged
- Neoplasm Recurrence, Local/pathology
- Neoplasm Recurrence, Local/prevention & control
- Neoplasms, Multiple Primary/pathology
- Neoplasms, Multiple Primary/prevention & control
- Precancerous Conditions/pathology
- Precancerous Conditions/therapy
- Radiotherapy, Adjuvant
- Risk Assessment
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Affiliation(s)
- Linda J Adepoju
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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256
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de Koning HJ, Draisma G, Fracheboud J, de Bruijn A. Overdiagnosis and overtreatment of breast cancer: microsimulation modelling estimates based on observed screen and clinical data. Breast Cancer Res 2005; 8:202. [PMID: 16524452 PMCID: PMC1413979 DOI: 10.1186/bcr1369] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
There is a delicate balance between the favourable and unfavourable side-effects of screening in general. Overdiagnosis, the detection of breast cancers by screening that would otherwise never have been clinically diagnosed but are now consequently treated, is such an unfavourable side effect. To correctly model the natural history of breast cancer, one has to estimate mean durations of the different pre-clinical phases, transition probabilities to clinical cancer stages, and sensitivity of the applied test based on observed screen and clinical data. The Dutch data clearly show an increase in screen-detected cases in the 50 to 74 year old age group since the introduction of screening, and a decline in incidence around age 80 years. We had estimated that 3% of total incidence would otherwise not have been diagnosed clinically. This magnitude is no reason not to offer screening for women aged 50 to 74 years. The increases in ductal carcinoma in situ (DCIS) are primarily due to mammography screening, but DCIS still remains a relatively small proportion of the total breast cancer problem.
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Affiliation(s)
- Harry J de Koning
- Erasmus MC, Department of Public Health, PO Box 1738, 3000 DR Rotterdam, The Netherlands.
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257
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Vargas C, Kestin L, Go N, Krauss D, Chen P, Goldstein N, Martinez A, Vicini FA. Factors associated with local recurrence and cause-specific survival in patients with ductal carcinoma in situ of the breast treated with breast-conserving therapy or mastectomy. Int J Radiat Oncol Biol Phys 2005; 63:1514-21. [PMID: 16005576 DOI: 10.1016/j.ijrobp.2005.04.045] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2005] [Revised: 04/19/2005] [Accepted: 04/20/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE We reviewed our institution's experience treating patients with ductal carcinoma in situ (DCIS) of the breast to determine risk factors for ipsilateral breast tumor recurrence (IBTR) and cause-specific survival (CSS) after breast-conserving therapy (BCT) or mastectomy. MATERIALS AND METHODS Between 1981 and 1999, 410 cases of DCIS (405 patients) were treated at our institution; 367 were managed with breast-conserving surgery (54 with lumpectomy alone and 313 with adjuvant radiation therapy (RT) [median dose, 45 Gy]). Of these 313 patients, 298 received also a supplemental boost of RT to the lumpectomy cavity (median dose, 16 Gy). Forty-three patients underwent mastectomy; 2 (5%) received adjuvant RT to the chest wall. A true recurrence/marginal miss (TR/MM) IBTR was defined as failure within or adjacent to the tumor bed in patients undergoing BCT. Median follow-up for all patients was 7 years (mean: 6.1 years). RESULTS Thirty patients (8.2%) experienced an IBTR after BCT (25 [8%] after RT, 5 [9.3%] after no RT), and 2 patients (4.7%) developed a chest wall recurrence after mastectomy. Of the 32 local failures, 20 (63%) were invasive (18/30 [60%] after BCT and 2/2 [100%] after mastectomy), and 37% were DCIS alone. Twenty-four (80%) of the IBTRs were classified as TR/MM. The 10-year freedom from local failure, CSS, and overall survival after BCT or mastectomy were 89% vs. 90% (p = 0.4), 98% vs. 100% (p = 0.7), and 89% vs. 100% (p = 0.3), respectively. Factors associated with IBTR on Cox multivariate analysis were younger age (p = 0.02, hazard ratio [HR] 1.06 per year), electron boost energy < or = 9 MeV (p = 0.03, HR 1.41), final margins < or = 2 mm (p = 0.007; HR, 3.65), and no breast radiation (p = 0.002, HR 5.56). On Cox univariate analysis for BCT patients, IBTR, TR/MM failures, and predominant nuclear Grade 3 were associated with an increased risk of distant metastases and a reduced CSS. CONCLUSIONS After treatment for DCIS, 10-year rates of local control, CSS, and overall survival were similar after mastectomy and BCT. Young age (<45 years), close/positive margins (< or = 2 mm), no breast radiation, and lower electron boost energies (< or = 9 MeV) were associated with IBTR. Local failure and predominant nuclear Grade 3 were found to have a small (4%-12%) but statistically significantly negative impact on the rates of distant metastasis and CSS. These results suggest that optimizing local therapy (surgery and radiation) is crucial to improve local control and CSS in patients treated with DCIS.
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Affiliation(s)
- Carlos Vargas
- Department of Radiation Oncology, William Beaumont Hospital, Beaumont Cancer Institute, Royal Oak, MI 48073, USA
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258
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Jang JY, Ryu MR, Kim SW, Kay CS, Kim YS, Oh YK, Kwon HC, Yoon SC, Park WC, Song BJ, Oh SJ, Jung SS, Won JM, Kim SN, Chung SM. Clinical experience of patients with ductal carcinoma in situ of the breast treated with breast-conserving surgery plus radiotherapy: a preliminary report. Cancer Res Treat 2005; 37:344-8. [PMID: 19956370 DOI: 10.4143/crt.2005.37.6.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 12/28/2005] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Breast-conserving therapy (BCT) is a practical alternative to mastectomy for treating ductal carcinoma in situ (DCIS). We reviewed our experience for treating patients with DCIS of the breast to evaluate the outcome after performing breast-conserving surgery plus radiotherapy (BCS-RT). MATERIALS AND METHODS Between January 1983 and December 2002, 25 patients with clinically or mammographically detected DCIS were treated by BCS-RT. One patient was diagnosed with bilateral DCIS. Thirteen cases (50%) had symptomatic lesions at presentation. All 26 cases of 25 patients underwent BCS such as lumpectomy, partial mastectomy or quadrantectomy. All of them received whole breast irradiation to a median dose of 50.4 Gy. Twenty-four cases (92.3%) received a boost to the tumor bed for a median total dose of 59.4 Gy. The median follow up period was 67 months (range: 38 to 149 months). RESULTS Two cases (7.7%) experienced ipsilateral breast tumor recurrence (IBTR) after BCS-RT. The histology results at the time of IBTR showed invasive ductal carcinoma (IDC), and the median time to IBTR was 25.5 months. On the univariate analysis, there were no significant factors associated with IBTR in the DCIS patients. The three-year local recurrence free survival rate was 96.0% and the overall survival rate was 96.3%. CONCLUSION After the treatment for DCIS, the IBTR rate in our study was similar to other previous studies. Considering that we included patients who had many symptomatic lesions, close or positive margins and less that complete early data, our result is comparable to the previous studies. We could not find the prognostic significant factors associated with IBTR after BCS-RT. A longer follow up period with more patients would be required to evaluate the role of any predictive factors and to confirm these short-term results.
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Affiliation(s)
- Ji-Young Jang
- Department of Radiation Oncology, Chosun University Hospital, Gwangju, Korea
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259
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Warren JL, Weaver DL, Bocklage T, Key CR, Platz CE, Cronin KA, Ballard-Barbash R, Willey SC, Harlan LC. The frequency of ipsilateral second tumors after breast-conserving surgery for DCIS. Cancer 2005; 104:1840-8. [PMID: 16136599 DOI: 10.1002/cncr.21406] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The diagnosis of ductal carcinoma in situ (DCIS) is increasing, although to the authors' knowledge there is no consensus regarding optimal treatment. This analysis of women treated with breast-conserving surgery (BCS) evaluated the impact of radiation therapy (RT) in patient outcomes. METHODS The current study included a population-based sample of 1103 women residing in selected Surveillance, Epidemiology, and End Results (SEER) registries who were diagnosed with DCIS between 1991-1992. Data were obtained from the registry, physician follow-up, and pathology reports. Physicians were contacted in 1999 to determine whether the patient had developed a second event in the ipsilateral breast. For second events, pathology reports were reviewed to determine the presence of in situ or invasive disease. Registry data through 2001 were used to assess death rates and cause of death. Cox proportional hazards and logistic regression models were used to evaluate the rates of second events and breast carcinoma deaths between women treated with and without RT. RESULTS Over an average of 91 months, 13.2% of women developed a second event. Rates of second events were 11% for women treated with BCS and RT compared with 15% for women treated with BCS only (adjusted hazards ratio, 0.64; 95% confidence interval, 0.44-0.92). Women receiving RT were significantly less likely to develop invasive breast carcinoma in the ipsilateral breast (adjusted odds ratio, 0.40). By 2001, the rate of death from breast carcinoma was 2.7%; in the group of women treated with BCS only compared with 0.8% in the group of women treated with BCS with RT. CONCLUSIONS Among a population-based cohort, RT was found to significantly reduce the risk of second events in the ipsilateral breast, particularly invasive tumors, although not to the extent reported in clinical trials.
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Affiliation(s)
- Joan L Warren
- Health Services and Economics Branch/Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland 20892-7344, USA.
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260
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Hanley KY, Beckman A, Hayne M. Advances in treating early breast cancer. JAAPA 2005; 18:54, 56, 59-62. [PMID: 16315500 DOI: 10.1097/01720610-200511000-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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261
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Solin LJ, Fourquet A, Vicini FA, Taylor M, Haffty B, Strom EA, Wai E, Pierce LJ, Marks LB, Bartelink H, Campana F, McNeese MD, Jhingran A, Olivotto IA, Bijker N, Hwang WT. Salvage treatment for local or local-regional recurrence after initial breast conservation treatment with radiation for ductal carcinoma in situ. Eur J Cancer 2005; 41:1715-23. [PMID: 16043350 DOI: 10.1016/j.ejca.2005.03.028] [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: 01/08/2005] [Revised: 02/15/2005] [Accepted: 03/04/2005] [Indexed: 10/25/2022]
Abstract
The present study evaluated the outcome of salvage treatment for women with local or local-regional recurrence after initial breast conservation treatment with radiation for mammographically detected ductal carcinoma in situ (DCIS; intraductal carcinoma) of the breast. The study cohort consisted of 90 women with local only first failure (n=85) or local-regional only first failure (n=5). The histology at the time of recurrence was invasive carcinoma for 53 patients (59%), non-invasive carcinoma for 34 patients (38%), angiosarcoma for one patient (1%), and unknown for two patients (2%). The median follow-up after salvage treatment was 5.5 years (mean=5.8 years; range=0.2-14.2 years). The 10-year rates of overall survival, cause-specific survival, and freedom from distant metastases after salvage treatment were 83%, 95%, and 91%, respectively. Adverse prognostic factors for the development of subsequent distant metastases after salvage treatment were invasive histology of the local recurrence and pathologically positive axillary lymph nodes. These results demonstrate that local and local-regional recurrences can be salvaged with high rates of survival and freedom from distant metastases. Close follow-up after initial breast conservation treatment with radiation is warranted for the early detection of potentially salvageable local and local-regional recurrences.
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Affiliation(s)
- Lawrence J Solin
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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262
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Goldberg H, Prosnitz RG, Olson JA, Marks LB. Definition of postlumpectomy tumor bed for radiotherapy boost field planning: CT versus surgical clips. Int J Radiat Oncol Biol Phys 2005; 63:209-13. [PMID: 16111591 DOI: 10.1016/j.ijrobp.2005.01.044] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2004] [Revised: 01/13/2005] [Accepted: 01/20/2005] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the location and extent of the tumor bed as defined by surgical clips and computed tomography (CT) scans, after lumpectomy, for electron boost planning as part of breast radiotherapy. METHODS AND MATERIALS Planning CT images of 31 operated breasts in 30 patients who underwent lumpectomy were reviewed. One or more clips were placed in the lumpectomy cavity. Serial CT images were used to measure the depth and transverse and longitudinal dimensions. The area and geometric center of the tumor bed were defined by the clips and CT. RESULTS The CT and clip measurements were identical for the maximal tumor depth in 27 of 30 patients. The CT bed extended beyond the clips by 0-7 mm medially in the transverse/longitudinal extent (multiclip patients). The median distance between the geometric centers in the coronal plane for the tumor bed center was larger for patients with single clips than for those with multiple clips (p < 0.025). Tumor bed areas in the coronal plane defined by both methods correlated strongly. However, the CT-defined area was larger by 13.9 mm2. The CT bed was more readily visible in patients with a shorter interval between surgery and radiotherapy. CONCLUSION The maximal depth of the tumor bed was similar using the two methods. The extent and centers of the clip-and CT-determined beds differed significantly. This may indicate an underestimation of the tumor bed as defined by clips only and justifies integration of CT information in boost field planning.
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MESH Headings
- Adult
- Aged
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma in Situ/diagnostic imaging
- Carcinoma in Situ/radiotherapy
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Electrons/therapeutic use
- Female
- Humans
- Mastectomy, Segmental
- Middle Aged
- Radiotherapy Planning, Computer-Assisted
- Radiotherapy, Adjuvant
- Surgical Instruments
- Tomography, X-Ray Computed
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263
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264
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MacDonald HR, Silverstein MJ, Mabry H, Moorthy B, Ye W, Epstein MS, Holmes D, Silberman H, Lagios M. Local control in ductal carcinoma in situ treated by excision alone: incremental benefit of larger margins. Am J Surg 2005; 190:521-5. [PMID: 16164913 DOI: 10.1016/j.amjsurg.2005.06.005] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2005] [Revised: 06/10/2005] [Accepted: 06/10/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Margin width has been shown previously to be the most important predictor of local treatment failure after breast conservation for ductal carcinoma in situ (DCIS). METHODS Five variables thought to be associated with local recurrence were evaluated by univariate and multivariate analysis in 455 nonrandomized patients with DCIS treated with excision alone. RESULTS Multivariate analysis showed that margin width, age, nuclear grade, and tumor size all were independent predictors of local recurrence, with margin width as the single most important predictor. After adjusting for all other predictors the likelihood of local recurrence for patients with margins less than 10 mm was 5.39 times as much as that for patients with margins of 10 mm or more (95% confidence interval, 2.68-10.64). CONCLUSIONS Margin width, the distance between DCIS and the closest inked margin, was the single most important predictor of local recurrence. As margin width increases, the risk for local recurrence decreases.
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Affiliation(s)
- Heather R MacDonald
- USC Norris Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave., Room 7415, Los Angeles, CA 90033-0800, USA
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265
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Fourquet A, Bollet MA, Kirova Y, Dendale R, Campana F. Optimal management of breast cancer with locoregional radiotherapy. EJC Suppl 2005. [DOI: 10.1016/s1359-6349(05)80271-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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266
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Intra M, Trifirò G, Viale G, Rotmensz N, Gentilini OD, Soteldo J, Galimberti V, Veronesi P, Luini A, Paganelli G, Veronesi U. Second Biopsy of Axillary Sentinel Lymph Node for Reappearing Breast Cancer After Previous Sentinel Lymph Node Biopsy. Ann Surg Oncol 2005; 12:895-9. [PMID: 16195833 DOI: 10.1245/aso.2005.10.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2004] [Accepted: 06/28/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is a safe and accurate axillary staging procedure for patients with primary operable breast cancer. An increasing proportion of these patients undergo breast-conserving surgery, and 5% to 15% will develop local relapses that necessitate reoperation. Although a previous SLNB is often considered a contraindication for a subsequent SLNB, few data support this concern. METHODS Between January 2000 and June 2004, 79 patients who were previously treated at our institution with breast-conserving surgery and who had a negative SLNB for early breast cancer developed, during follow-up, local recurrence that was amenable to reoperation. Eighteen of these patients were offered a second SLNB because of a clinically negative axillary status an average of 26.1 months after the primary event. RESULTS In all 18 patients (7 with ductal carcinoma-in-situ and 11 with invasive recurrences), preoperative lymphoscintigraphy showed an axillary sentinel lymph node, with a preoperative identification rate of 100%, and 1 or more SLNs (an average of 1.3 per patient) were surgically removed. Sentinel lymph node metastases were detected in two patients with invasive recurrence, and a complete axillary dissection followed. At a median follow up of 12.7 months, no axillary recurrences have occurred in patients who did not undergo axillary dissection. CONCLUSIONS Second SLNB after previous SLNB is technically feasible and likely effective in selected breast cancer patients. A larger population and longer follow-up are necessary to confirm these preliminary data.
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Affiliation(s)
- Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy.
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267
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Nofech-Mozes S, Spayne J, Rakovitch E, Hanna W. Prognostic and predictive molecular markers in DCIS: a review. Adv Anat Pathol 2005; 12:256-64. [PMID: 16210921 DOI: 10.1097/01.pap.0000184177.65919.5e] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Eighteen percent of all new breast cancers detected on screening mammography are ductal carcinoma in situ (DCIS), a preinvasive lesion that is highly curable. However, some women with DCIS will develop life-threatening invasive breast cancer. Because the determinants of invasive recurrence are unknown, all women with DCIS require the same treatment (usually with surgery and radiation). Therefore, there is a need to identify biologic markers and create a profile that will provide prognostic information that is more accurate than the currently used van Nuys Index to predict invasive recurrence. In the present review, we examined the many biologic markers studied in breast cancer, describe their main biologic role and their expression in DCIS, and review the various studies regarding their ability to serve as prognostic factors in breast cancer with an emphasis on predicting invasive recurrence in patients with DCIS. This review covers established markers, namely, ER, PR and HER2/neu, that are used routinely to make treatment decisions as well as investigative biologic factors involved in cell proliferation, cell cycle regulation, extracellular molecules, factors involved in extracellular matrix degradation, and angiogenesis. However, controversies exist regarding the value of these prognostic factors, their interrelationship, and their advantages over morphologic evaluation.
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Affiliation(s)
- Sharon Nofech-Mozes
- Department of Pathology, Sunnybrook and Women's College Health Sciences Center, Toronto, Ontario, Canada
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268
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Meyners T, Stöckelhuber B, Friedrich M, Noack F, Dunst J. Duktales Carcinoma in situ. ONKOLOGE 2005. [DOI: 10.1007/s00761-005-0952-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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269
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Guinebretière JM, Menet E, Tardivon A, Cherel P, Vanel D. Normal and pathological breast, the histological basis. Eur J Radiol 2005; 54:6-14. [PMID: 15797289 DOI: 10.1016/j.ejrad.2004.11.020] [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: 11/22/2004] [Revised: 11/26/2004] [Accepted: 11/29/2004] [Indexed: 10/25/2022]
Abstract
Breast tissue is heterogeneous, associating connective and glandular structures, which grow and change cyclically under hormonal regulation. Hormones are also thought to be the main determinant of the major benign and malignant pathologies encountered in the breast. Benign lesions are more frequent and fibrocystic changes are by far the most common among them. They usually associate different entities, (adenosis, fibrosis, cysts and hyperplasia) but vary in intensity and extension. Thus, their clinical and radiographic presentation is extremely different from one patient to another. Adenofibroma is the most frequent tumour. It also undergoes modifications according to hormonal conditions. About 90% of malignant tumours are primary carcinoma. The incidence of intra-ductal carcinoma has risen dramatically since the development of screening because of its ability to induce calcification. Two mechanisms could be involved in the formation of calcification: one active (tumour cell secretion of vesicles), the other passive (necrotic cell fragments are released). Invasive carcinoma comprises numerous histological types. Stromal reactions essentially determines their shape: a fibrous reaction commonly found in ductal carcinoma creates a stellate lesion while other stroma, inflammatory (medullary carcinoma), vascular (papillary carcinoma) or mucinous determine nodular lesions whose borders push the surrounding tissue. The histological features which give rise to the radiographic pattern will be emphasised.
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Affiliation(s)
- J M Guinebretière
- Department of Pathology, Centre René-Huguenin, 35 rue Dailly, 92210 Saint Cloud, France.
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270
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Zujewski J, Eng-Wong J. Sentinel Lymph Node Biopsy in the Management of Ductal Carcinoma In Situ. Clin Breast Cancer 2005; 6:216-22. [PMID: 16137431 DOI: 10.3816/cbc.2005.n.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Sentinel lymph node biopsy (SLNB) has been adopted by some physicians in the evaluation of ductal carcinoma in situ (DCIS). In a review of the current literature, we found no convincing data that SLNB is warranted as standard of care in newly diagnosed DCIS. Although lymph node invasion is present in 2% of women with traditional axillary lymph node dissection (ALND), as a result of the excellent prognosis of DCIS, it is not recommended. However, the detailed evaluation of the lymph node(s) with SLNB raises the issue that perhaps patients at risk for recurrence can be identified early and be treated aggressively without the morbidity associated with ALND. Limited data suggest that, with the use of more sensitive methods for detection of cytokeratin-positive cells, the prevalence of positive lymph nodes in pure DCIS is approximately 2%-13%. In high-risk DCIS or DCIS with microinvasion, the prevalence is 8%-20%. Several limited retrospective studies with long-term follow-up have not demonstrated an adverse relapse-free or overall survival effect for women with immunohistochemically (IHC) positive cells in the lymph nodes compared with those with negative IHC results in the lymph nodes. Sentinel lymph node biopsy in DCIS is associated with known risks, and health care benefits, if any, have not been demonstrated. Sentinel lymph node biopsy is not recommended in patients with DCIS.
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271
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Hayman JA, Kabeto MU, Schipper MJ, Bennett JE, Vicini FA, Pierce LJ. Assessing the Benefit of Radiation Therapy After Breast-Conserving Surgery for Ductal Carcinoma-In-Situ. J Clin Oncol 2005; 23:5171-7. [PMID: 16051959 DOI: 10.1200/jco.2005.11.692] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Purpose To assess women's preferences regarding the trade-off between the risks and benefits of treatment with radiation therapy (RT) after breast-conserving surgery (BCS) for ductal carcinoma-in-situ (DCIS). Patients and Methods Utilities were obtained from 120 patients and 210 nonpatients for eight relevant health states using standard gambles. Results Differences in utilities obtained from patient and nonpatient participants between health states were relatively similar. Reduction in the likelihood of local recurrence associated with RT did not result in higher utilities. Utilities for noninvasive recurrence were only lower after initial treatment with RT. Patient and nonpatient participants had the lowest utilities for invasive local recurrence, regardless of initial treatment or manner of salvage therapy. When comparing patient and nonpatient utilities directly, patients had higher utility for being without recurrence after initial RT and lower utility for invasive recurrence salvaged by mastectomy after initial BCS alone. None of the clinical or sociodemographic factors examined explained more than 5% of the variability in the patients' or nonpatients' utilities or their differences. Conclusion The principal benefit associated with adding RT to BCS for DCIS seems to be its ability to reduce invasive recurrences.
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Affiliation(s)
- James A Hayman
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, MI 48109-0010, USA.
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272
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Kaas R, Hart AAM, Rutgers EJT. The impact of the physician on the accrual to randomized clinical trials in patients with primary operable breast cancer. Breast 2005; 14:310-6. [PMID: 16085238 DOI: 10.1016/j.breast.2005.01.004] [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] [Received: 10/07/2004] [Revised: 12/24/2004] [Accepted: 01/27/2005] [Indexed: 11/19/2022] Open
Abstract
Randomized clinical trials (RCT) are the best way to define optimal treatment, but the accrual rates for hardly any trials have been reported. We analyzed retrospectively the participation of patients in eight phase III multicenter RTCs. Out of a total of 738 patients treated in a single institution for operable breast cancer over a 3-year period, 455 patients (62%) were eligible for at least one of the ongoing trials. Overall, 81% of the patients were informed and 47% of the eligible patients consented to participate. The accrual was 100% to a study with an aggressive combined modality treatment arm for patients with a poor prognosis. A low accrual rate was seen in two trials: 6% in the "elderly" trial comparing tamoxifen only with mastectomy and 10% to the "axilla" trial comparing surgery with radiotherapy to the axilla. The clinicians failed to inform most of these patients about the two trials. In the literature seven of the eight trials were reported; two of them (29%) failed to accrue enough patients.
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Affiliation(s)
- R Kaas
- Department of Surgical Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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273
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Fehr MK. [Limitations of sentinel lymph node biopsy in breast cancer]. ACTA ACUST UNITED AC 2005; 45:127-31. [PMID: 15990436 DOI: 10.1159/000085192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Sentinel lymph node biopsy is a widely accepted new surgical procedure in the treatment of early breast cancer. However, not only numerous details of the technique, but also limitations of the method, such as maximal tumor size, multifocal disease, accuracy following neoadjuvant chemotherapy and appropriateness in ductal carcinoma in situ are being debated. Recent multicenter studies could establish the lower morbidity of sentinel lymph node biopsy compared to axillary clearance as well as the false-negative rate which lies between 7 and 9.7%. In unifocal T1 disease with clinically negative axillary lymph nodes, the method is considered to be standard of care. Evidence is growing that it may also be appropriate in larger and multifocal tumors while the method is unreliable after neoadjuvant chemotherapy.
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Affiliation(s)
- Mathias K Fehr
- Klinik für Gynäkologie, Departement für Frauenheilkunde, Universitätsspital, Zürich, Schweiz.
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274
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Sahoo S, Recant WM, Jaskowiak N, Tong L, Heimann R. Defining Negative Margins in DCIS Patients Treated with Breast Conservation Therapy: The University of Chicago Experience. Breast J 2005; 11:242-7. [PMID: 15982389 DOI: 10.1111/j.1075-122x.2005.21617.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Management of ductal carcinoma in situ (DCIS) has been evolving and the majority of women are now being treated with breast-conserving surgery and radiation therapy (i.e. breast conservation therapy [BCT]). Controversies still exist regarding the histologic features and margin status that are associated with local recurrence. The goal of this study was to review our institution's experience in patients diagnosed with DCIS and treated with BCT to determine pathologic features that can predict local recurrence, with particular emphasis on the final surgical margin status. We analyzed 103 consecutive patients with DCIS who were treated with BCT between 1986 and 2000. The slides were reviewed to determine the final margin status, type of DCIS, size of DCIS, nuclear grade, presence of necrosis and calcification, and volume of excised specimen. Margins were considered positive when DCIS touched or was transected at an inked margin. Negative margins were further categorized as close (less than 1 mm), 1--5 mm, and more than 5 mm. The size of the DCIS was determined based on either the maximal dimension on a slide or from the number of consecutive slides containing DCIS. Morphology and immunohistochemical profiles of the recurrent DCIS cases were compared with original DCIS. All patients were treated uniformly with external beam radiation therapy to the entire breast (median dose 46 Gy) with a boost to the tumor bed (median dose 14 Gy). The median follow-up was 63 months (range 7--191 months). The actuarial 5-year local control rate was 89%. The median time to local recurrence was 55 months. There were 13 local recurrences, of which 9 recurred as pure DCIS and 4 as invasive ductal carcinomas. Univariate analysis showed a significant association with local recurrence for positive margin (p=0.008), high nuclear grade (p=0.02), and young age at diagnosis (p=0.03). If margins were negative, the 5-year local control was 93%, as compared to 69% if margins were positive. A multivariate analysis showed that early age at diagnosis, positive margin status, and high nuclear grade were independently associated with local recurrence. The morphology and immunohistochemical stains of all nine recurrent DCIS were similar to those of the original DCIS. Breast conservation can be achieved with excellent local control by obtaining microscopically negative margins as strictly defined by DCIS not touching the inked surgical margins, and postoperative radiation that includes boost therapy to the tumor bed.
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Affiliation(s)
- Sunati Sahoo
- Department of Pathology, University of Chicago, Chicago, Illinois, USA.
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275
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Wu F, Wang ZB, Zhu H, Chen WZ, Zou JZ, Bai J, Li KQ, Jin CB, Xie FL, Su HB. Extracorporeal high intensity focused ultrasound treatment for patients with breast cancer. Breast Cancer Res Treat 2005; 92:51-60. [PMID: 15980991 DOI: 10.1007/s10549-004-5778-7] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE To investigate the safety, efficacy and feasibility of using high-intensity focused ultrasound (HIFU) as a non-invasive treatment for patients with breast cancer. PATIENTS AND METHODS Twenty-two patients with breast cancer were enrolled into this non-randomized prospective trial. Disease TNM stage was classified as stage I in 4 patients, stage II(A) in 9 patients, stage II(B) in 8 patients, and stage IV in 1 patient. Tumor size ranged from 2 to 4.8 cm in diameter (mean 3.4 cm). All patients received chemotherapy, radiation and tamoxifen, following HIFU for the primary lesions. Outcome measures included radiological and pathologic assessment of the treated tumor, cosmesis, and local recurrence. A cumulative survival rate is calculated by using the Kaplan-Meier method. RESULTS No severe complications were encountered after HIFU. Post-operative imaging demonstrated positive response and regression of all treated lesions. Follow-up biopsy revealed coagulation necrosis of target tumor and subsequent replacement by fibroblastic tissue. After a median follow-up of 54.8 months, 1 patient died, 1 was lost to follow-up, and 20 were still alive. Two of 22 patients developed local recurrence. Five-year disease-free survival and recurrence-free survival were 95% and 89%, respectively. Cosmetic result was judged as good to excellent in 94% of patients. CONCLUSIONS HIFU treatment is safe, effective, and feasible for patients with breast cancer. But, large-scale, multiple-center clinical trials will be needed to determine the future role of this novel modality.
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Affiliation(s)
- Feng Wu
- Institute of Ultrasonic Engineering in Medicine, Chongqing University of Medical Sciences, Box 153, 1 Medical College Road, Chongqing 400016, China.
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276
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Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, Deapen D, Salem B, Lakhani I, Morrow M. Patterns and correlates of local therapy for women with ductal carcinoma-in-situ. J Clin Oncol 2005; 23:3001-7. [PMID: 15860856 PMCID: PMC1819396 DOI: 10.1200/jco.2005.04.028] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Concerns have been raised about the quality of treatment for women with ductal carcinoma-in-situ (DCIS) because persistent high rates of mastectomy suggest overtreatment, whereas lower than expected rates of radiation therapy after breast-conserving surgery (BCS) suggest undertreatment. PATIENTS AND METHODS All women with DCIS diagnosed in 2002 and who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries were identified and surveyed shortly after receipt of surgery (response rate, 79.7%; n = 817). Analyses were restricted to patients with DCIS (n = 659) indicated by SEER stage data. RESULTS Only 14.0% of patients at lowest risk of recurrence (based on tumor size and histologic grade) received a mastectomy compared with 22.8% and 52.6% of patients at intermediate and highest risk (P < .001). Only 13.1% of patients who were not influenced or slightly influenced by concerns about recurrence received mastectomy compared with 48.8% of women who were greatly influenced by this concern (P < .001). A between-geographic site difference in receipt of radiation after BCS was observed for the lowest risk group (38.9% in Los Angeles v 70.5% in Detroit) but not for the highest risk group (80.2% in Los Angeles v 85.9% in Detroit, P = .006 for site and risk group differences). Between-site differences in receipt of radiation after BCS were consistent with patient recall of surgeon discussions about treatment. CONCLUSION Surgeons are tailoring their recommendations for local therapy options for DCIS based on important clinical factors. Patient attitudes also play an important role in treatment decisions. The substantial influence of both surgeon opinion and patient attitudes should temper concerns about the quality of treatment for women with DCIS.
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Affiliation(s)
- Steven J Katz
- Department of Medicine and Health Management and Policy, University of Michigan, 300 N Ingalls, Ste 7E12, Box 0429, Ann Arbor, MI 48109-0429, USA.
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277
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Yen TWF, Hunt KK, Ross MI, Mirza NQ, Babiera GV, Meric-Bernstam F, Singletary SE, Symmans WF, Giordano SH, Feig BW, Ames FC, Kuerer HM. Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ. J Am Coll Surg 2005; 200:516-26. [PMID: 15804465 DOI: 10.1016/j.jamcollsurg.2004.11.012] [Citation(s) in RCA: 198] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2004] [Accepted: 11/17/2004] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of sentinel lymph node biopsy (SLNB) in patients with an initial diagnosis of ductal carcinoma in situ (DCIS) has not been well defined. The purpose of our study was to determine when the risk of finding invasive disease on final pathology in patients with an initial diagnosis of DCIS was sufficiently high to justify use of SLNB. STUDY DESIGN The records of 398 consecutive patients from our prospective database with an initial diagnosis of DCIS, treated between July 1999 and December 2002, were analyzed. Associations between clinical and pathologic factors and patient selection for SLNB and outcomes were analyzed for significance using univariate and multivariate analyses. RESULTS Of the 398 patients, 80 (20%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer on final pathology: 55 years of age or younger (odds ratio [OR], 2.19; p = 0.024), diagnosis by core-needle biopsy (OR, 3.76; p = 0.006), mammographic DCIS size of at least 4 cm (OR, 2.92; p = 0.001), and high-grade DCIS (OR, 3.06; p = 0.002). A total of 141 patients (35%) underwent SLNB as a component of their initial operation. Multivariate analysis revealed that the presence of comedonecrosis (OR, 2.69; p = 0.007) and larger mammographic DCIS size (OR, 1.18; p = 0.0002) were independent predictors of patients' undergoing SLNB. Of these 141 patients, 103 (73%) were diagnosed by core-needle biopsy, 42 (30%) had invasive disease on final pathology, and 14 (10%) had a positive sentinel lymph node: 12 (86%) by hematoxylin and eosin staining and 2 by immunohistochemistry. The only independent predictor of a positive SLN was the presence of a palpable tumor (OR, 4.28, p = 0.042). Of these 14 patients with a positive sentinel node, only 11 (79%) had invasive cancer on final pathology. CONCLUSIONS SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. Risks and benefits of SLNB should be discussed with patients who are younger, are diagnosed by core-needle biopsy, or have large or high-grade DCIS.
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Affiliation(s)
- Tina W F Yen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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278
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Horst KC, Smitt MC, Goffinet DR, Carlson RW. Predictors of local recurrence after breast-conservation therapy. Clin Breast Cancer 2005; 5:425-38. [PMID: 15748463 DOI: 10.3816/cbc.2005.n.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.
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Affiliation(s)
- Kathleen C Horst
- Department of Radiation Oncology, Stanford University, CA 94305, USA
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279
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Haynes RB, McKibbon KA, Wilczynski NL, Walter SD, Werre SR. Optimal search strategies for retrieving scientifically strong studies of treatment from Medline: analytical survey. BMJ 2005; 330:1179. [PMID: 15894554 PMCID: PMC558012 DOI: 10.1136/bmj.38446.498542.8f] [Citation(s) in RCA: 337] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To develop and test optimal Medline search strategies for retrieving sound clinical studies on prevention or treatment of health disorders. DESIGN Analytical survey. DATA SOURCES 161 clinical journals indexed in Medline for the year 2000. MAIN OUTCOME MEASURES Sensitivity, specificity, precision, and accuracy of 4862 unique terms in 18 404 combinations. RESULTS Only 1587 (24.2%) of 6568 articles on treatment met criteria for testing clinical interventions. Combinations of search terms reached peak sensitivities of 99.3% (95% confidence interval 98.7% to 99.8%) at a specificity of 70.4% (69.8% to 70.9%). Compared with best single terms, best multiple terms increased sensitivity for sound studies by 4.1% (absolute increase), but with substantial loss of specificity (absolute difference 23.7%) when sensitivity was maximised. When terms were combined to maximise specificity, 97.4% (97.3% to 97.6%) was achieved, about the same as that achieved by the best single term (97.6%, 97.4% to 97.7%). The strategies newly reported in this paper outperformed other validated search strategies except for two strategies that had slightly higher specificity (98.1% and 97.6% v 97.4%) but lower sensitivity (42.0% and 92.8% v 93.1%). CONCLUSION New empirical search strategies have been validated to optimise retrieval from Medline of articles reporting high quality clinical studies on prevention or treatment of health disorders.
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Affiliation(s)
- R Brian Haynes
- Health Information Research Unit, McMaster University, Hamilton, ON, Canada L8N 3Z5.
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280
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Pierce LJ, Griffith KA, Hayman JA, Douglas KR, Lichter AS. Conservative surgery and radiotherapy for stage I/II breast cancer using lung density correction: 10-year and 15-year results. Int J Radiat Oncol Biol Phys 2005; 61:1317-27. [PMID: 15817333 DOI: 10.1016/j.ijrobp.2004.08.004] [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] [Received: 03/23/2004] [Revised: 07/13/2004] [Accepted: 08/09/2004] [Indexed: 11/30/2022]
Abstract
PURPOSE Radiotherapy (RT) planning for breast cancer using lung density correction improves dose homogeneity. Its use obviates the need for a medial wedge, thus reducing scatter to the opposite breast. Although lung density correction is used at many centers in planning for early-stage breast cancer, long-term results of local control and survival have not been reported. Since 1984, we have used lung density correction for dose calculations at the University of Michigan. We now present our 10-year and 15-year results. METHODS AND MATERIALS The records of 867 patients with Stage I/II breast cancer treated with breast-conserving surgery and RT with or without systemic therapy were reviewed. Tangential fields delivering 45-50 Gy to the whole breast calculated using lung density correction were used. A boost was added in 96.8% of patients for a total median dose of 61.8 Gy. RESULTS With a median follow-up of 6.6 years (range, 0.2-18.9 years), 5-, 10-, and 15-year actuarial rates of in-breast tumor recurrence as only first failure were 2.2%, 3.6%, and 5.4%, respectively. With surgical salvage, the 15-year cumulative rate of local control was 99.7%. Factors that significantly predicted for increased rate of local recurrence in multivariate analysis were age </= 35 years, hazard ratio 4.8 (95% confidence interval [CI], 1.6-13.9) p = 0.004; negative progesterone receptor status, hazard ratio 6.8 (95% CI, 2.3-20.3) p = < 0.001; negative estrogen receptor status, hazard ratio 4.0 (95% CI, 1.5-11.1) p = 0.007; and lack of adjuvant tamoxifen therapy, hazard ratio 7.7 (95% CI, 1.7-33.3) p = 0.008. Relapse-free survival rates at 5, 10, and 15 years were 84.6%, 70.8%, and 55.9%, respectively; breast cancer-specific survival rates were 94.4%, 90.5%, and 86.9%, respectively; and corresponding estimates for overall survival were 89.7%, 75.7%, and 61.3%. CONCLUSIONS Use of lung density correction was associated with high rates of local control, relapse-free survival, breast cancer-specific survival, and overall survival compared with other reported series of breast-conserving surgery and RT in early-stage disease. These results will serve as a benchmark against which newer radiation delivery strategies such as intensity-modulated RT and partial breast RT can be compared.
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Affiliation(s)
- Lori J Pierce
- Department of Radiation Oncology, University of Michigan School of Medicine, Ann Arbor, MI, USA.
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281
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Barnes NLP, Boland GP, Davenport A, Knox WF, Bundred NJ. Relationship between hormone receptor status and tumour size, grade and comedo necrosis in ductal carcinoma in situ. Br J Surg 2005; 92:429-34. [PMID: 15736216 DOI: 10.1002/bjs.4878] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Results of the National Surgical Adjuvant Breast Project B-24 trial indicate that adjuvant tamoxifen therapy is of benefit only in oestrogen receptor (ER)- positive ductal carcinoma in situ (DCIS). In the UK, ER status is not routinely determined in DCIS. The aim of this study was to assess the ER status in women with DCIS to determine whether any clinicopathological factors could predict positivity instead of immunohistochemical assessment. METHODS The ER and progesterone receptor (PR) status of consecutive women diagnosed with DCIS during 2001 and 2002 was determined by immunohistochemistry. RESULTS One hundred and nineteen tumours diagnosed between 2001 and 2002 were analysed; 73.0 per cent were ER positive and 61.1 per cent were PR positive. PR positivity was associated with ER positivity (P < 0.001). Increasing tumour grade correlated with a decrease in ER and PR positivity (both P = 0.002). Comedo necrosis was associated with ER negativity (P = 0.026), PR negativity (P = 0.033) and a lower percentage of ER expression in ER-positive tumours (mean(s.d.) 82(27) versus 93(10) per cent; P = 0.021). CONCLUSION Tumour grade and comedo necrosis were not strong enough predictors to be used as surrogates for immunohistochemical assessment. ER status should be determined before commencing endocrine therapy.
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Affiliation(s)
- N L P Barnes
- Department of Academic Surgery, South Manchester University Hospital, Southmoor Road, Manchester M23 9LT, UK
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282
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283
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Wai ES, D'yachkova Y, Olivotto IA, Tyldesley S, Phillips N, Warren LJ, Coldman AJ. Comparison of 1- and 2-year screening intervals for women undergoing screening mammography. Br J Cancer 2005; 92:961-6. [PMID: 15714210 PMCID: PMC2361910 DOI: 10.1038/sj.bjc.6602393] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We compared the long-term impact of 1- and 2-year screening mammography intervals using prognostic, screening, and outcome information for women aged 50–74 years obtained from the Screening Mammography Program of British Columbia in two time periods, prior to 1997 (policy of annual mammography) and after 1997 (biennial mammography). Survival was estimated for both periods using a prognostic model and the expected rate of interval and screen-detected cancers. The likelihood of a screen-detected cancer with annual screening was 2.32 per thousand screens and with biennial screening was 3.32 per thousand screens. The prognostic profile of screen-detected cancers was better than that of interval cancers. Among both screen-detected and interval cancers, the prognostic profiles with annual and biennial screening were similar. The estimated breast cancer-specific survival rates for women undergoing annual and biennial screening mammography were 95.2 and 94.6% at 5 years, and 90.4 and 89.2% at 10 years, respectively. Annual compared to biennial mammography was associated with a 1.2% increase in the estimated 10-year breast cancer-specific survival for women aged 50–74 years, diagnosed with invasive breast cancer after screening programme attendance.
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Affiliation(s)
- E S Wai
- Radiation Therapy Program, BC Cancer Agency, Vancouver Island Centre, 2410 Lee Ave, Victoria, BC, Canada V8R 6V5.
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284
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Huston TL, Simmons RM. Locally recurrent breast cancer after conservation therapy. Am J Surg 2005; 189:229-35. [PMID: 15720997 DOI: 10.1016/j.amjsurg.2004.07.039] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 07/16/2004] [Accepted: 07/16/2004] [Indexed: 11/22/2022]
Abstract
BACKGROUND Today, the majority of small invasive and noninvasive breast cancers are treated with breast conservation therapy (BCT). The incidence of local-regional recurrence (LRR) after BCT for stage 0, I, and II patients ranges between 5% and 22%. METHODS A literature search for BCT, local recurrence, and regional recurrence was performed. Data from over 50 articles pertaining to the characteristics, risk factors, detection, management, and prognosis of these patients with LRR after BCT were collected and analyzed. RESULTS Positive margins, high-grade ductal carcinoma in situ (DCIS), young age, and the absence of radiation therapy after BCT increase the risk for LRR. Prognosis at LRR is impacted by invasive versus noninvasive histology, size and stage, method of detection, and involvement of skin and/or axillary lymph nodes. The standard treatment is salvage mastectomy. CONCLUSIONS The prognosis for LRR after BCT is favorable compared with patients with postmastectomy chest wall recurrence.
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Affiliation(s)
- Tara L Huston
- Department of Surgery, The Weill Medical College of Cornell University, The New York-Presbyterian Hospital, 425 E. 61st St., 8th Floor, New York, NY 10021, USA
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285
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Cutuli B, Fay R, Cohen-Solal-Le Nir C, De Lafontan B, Mignotte H, Servent V, Giard S, Auvray H, Charra-Brunaud C, Gonzague-Casabianca L, Quetin P. Carcinome canalaire in situ du sein. Analyse de 882 cas. IMAGERIE DE LA FEMME 2005. [DOI: 10.1016/s1776-9817(05)80634-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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286
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Rakovitch E, Mihai A, Pignol JP, Hanna W, Kwinter J, Chartier C, Ackerman I, Kim J, Pritchard K, Paszat L. Is expert breast pathology assessment necessary for the management of ductal carcinoma in situ ? Breast Cancer Res Treat 2005; 87:265-72. [PMID: 15528969 DOI: 10.1007/s10549-004-9454-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Current guidelines include a recommendation that a pathologist with expertise in breast disease review all ductal carcinoma in situ (DCIS) specimens due to the presence of significant variability in pathologic reporting of DCIS. The objective of this study was to evaluate the completeness and accuracy of pathologic reporting of DCIS over the past decade and to determine the current impact of expert breast pathology assessment on the management of DCIS. METHODS All patients with a diagnosis of DCIS referred to a single regional cancer centre between 1982 and 2000 have been reviewed. Inter-observer variability between initial and secondary reports has been evaluated using kappa statistics. For each case, the Van Nuys Prognostic Index (VNPI) using pathologic data obtained from the initial and reviewed pathology reports were compared. The impact of expert breast pathology on risk assessment and treatment was determined. RESULTS 481 individuals with DCIS were referred and pathology review was performed on 350 patients (73%). Inter-observer agreement was high for the main pathologic features of DCIS. From 1996 to 2000, secondary pathology assessments lead to a change in the assessment of local recurrence risk in 100 cases (29%) and contributed to a change in treatment recommendation in 93 (43%) cases. CONCLUSION Expert breast pathology assessments continue to be necessary in the management of DCIS.
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Affiliation(s)
- Eileen Rakovitch
- Department of Radiation Oncology, Toronto-Sunnybrook Regional Cancer Centre, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, Ontario, Canada.
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287
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Levi F, Randimbison L, Te VC, La Vecchia C. Invasive breast cancer following ductal and lobular carcinomain situ of the breast. Int J Cancer 2005; 116:820-3. [PMID: 15838829 DOI: 10.1002/ijc.20870] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We considered the risk of subsequent invasive breast cancer in a population-based series of 579 carcinomas in situ (CIS) of the breast (482 ductal, 88 lobular) registered between 1977 and 2002 in the Swiss Canton of Vaud. A total of 55 cases of invasive breast cancer were observed vs. 12.3 expected, corresponding to a standardized incidence ratio (SIR) of 4.5 (95% confidence interval [CI], 3.4-5.8). The SIR was 4.6 after ductal and 4.2 after lobular CIS, was similar with passing time since CIS diagnosis, but was higher (SIR = 5.5) for women aged <55 years. At 20 years following CIS, the cumulative risk of invasive breast cancer was 26%, similar for lobular and for ductal CIS. The incidence of invasive breast cancer following CIS showed no consistent pattern of trends with age, all rates in subsequent age groups ranging between 10 and 18 in 1,000. This is compatible with the occurrence of a single mutational event in a population of susceptible women.
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Affiliation(s)
- Fabio Levi
- Cancer Epidemiology Unit and Cancer Registries of Vaud and Neuchâtel, Institut universitaire de médecine sociale et préventive, Lausanne, Switzerland.
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288
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Solin LJ, Fourquet A, Vicini FA, Taylor M, Olivotto IA, Haffty B, Strom EA, Pierce LJ, Marks LB, Bartelink H, McNeese MD, Jhingran A, Wai E, Bijker N, Campana F, Hwang WT. Long-term outcome after breast-conservation treatment with radiation for mammographically detected ductal carcinoma in situ of the breast. Cancer 2005; 103:1137-46. [PMID: 15674853 DOI: 10.1002/cncr.20886] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) is detected most commonly on routine screening mammography in the asymptomatic patient, and has a long natural history. The objective of the current study was to determine the long-term outcome after breast-conservation surgery followed by definitive breast irradiation for women with mammographically detected DCIS of the breast. METHODS In total, 1003 women with unilateral, mammographically detected DCIS of the breast underwent breast-conserving surgery followed by definitive breast irradiation. These women were treated in 10 institutions in North America and Europe. The median follow-up was 8.5 years (mean, 9.0 years; range, 0.2-24.6 years). RESULTS The 15-year overall survival rate was 89%, and the 15-year cause-specific survival rate was 98%. The 15-year rate of freedom from distant metastases was 97%. In total, there were 100 local failures (10%) in the treated breast. The 15-year rate of any local failure was 19%, and the 15-year rate of local only first failure was 16%. Patient age > or = 50 years at the time of treatment and negative final pathology margins from the primary tumor excision both were associated independently with a lower risk of local failure in univariate analysis (P = 0.00062 and P = 0.024, respectively) and in multivariate analysis (P = 0.00057 and P = 0.0026, respectively). For favorable subgroups of patients age > or = 50 years or with negative resection margins, the 10-year risk of local failure was < or = 8%. CONCLUSIONS The current results support the use of breast-conserving surgery followed by definitive breast irradiation for the treatment of patients with mammographically detected DCIS of the breast. Patient age > or = 50 years at the time of treatment and negative resection margins both were associated independently with a decreased risk of local failure.
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MESH Headings
- Adult
- Age Distribution
- Aged
- Aged, 80 and over
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/mortality
- Breast Neoplasms/therapy
- Carcinoma in Situ/diagnostic imaging
- Carcinoma in Situ/mortality
- Carcinoma in Situ/therapy
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/therapy
- Combined Modality Therapy
- Confidence Intervals
- Female
- Humans
- Incidence
- Mammography/methods
- Mastectomy, Segmental
- Middle Aged
- Multivariate Analysis
- Neoplasm Recurrence, Local/epidemiology
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Proportional Hazards Models
- Radiotherapy Dosage
- Radiotherapy, Adjuvant
- Registries
- Retrospective Studies
- Risk Assessment
- Survival Analysis
- Time Factors
- Treatment Failure
- Treatment Outcome
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Affiliation(s)
- Lawrence J Solin
- Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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289
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Kricker A, Armstrong B. Surgery and outcomes of ductal carcinoma in situ of the breast: a population-based study in Australia. Eur J Cancer 2004; 40:2396-402. [PMID: 15519511 DOI: 10.1016/j.ejca.2004.07.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2004] [Revised: 06/25/2004] [Accepted: 07/13/2004] [Indexed: 11/22/2022]
Abstract
We examined surgery and outcome in a population-based series of 2109 women newly diagnosed with ductal carcinoma in situ (DCIS) in 1995-2000 in New South Wales (NSW), Australia. The sole data source for the study was pathology records in the NSW Cancer Registry. Most DCIS was treated with breast-conserving surgery (BCS); use of breast conservation increased throughout the 6 years of the study. Women who were younger, had higher grade DCIS or had larger lesions were significantly and independently less likely to have BCS than other women. Eighteen percent of women had lymph nodes removed, most often with mastectomy. The NSW Cancer Registry does not collect information about radiotherapy. Based on cancer registrations alone, 97.7% of women were free of ipsilateral invasive cancer after three years; more women who had mastectomy were cancer-free (100%) than women who had breast-conserving surgery (97.2%; P=0.05).
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Affiliation(s)
- Anne Kricker
- School of Public Health, Level 6, Medical Foundation Building K25, University of Sydney, Sydney, NSW 2006, Australia.
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290
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Abstract
The success of the angiogenesis inhibitor bevacizumab, the vascular endothelial growth factor antagonist that was recently shown to significantly improve the survival of patients with metastatic colon cancer when administered in combination with conventional chemotherapy, has provided proof of principle in clinical trials that antiangiogenesis can be an important strategy in the treatment of cancer. This report reviews the contemporary therapeutic approaches for breast cancer, the essential role that angiogenesis plays in the initiation and progression of this disease, and the strategies that should be considered to make antiangiogenic therapy a successful component of breast cancer treatment.
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Affiliation(s)
- Marsha A Moses
- Vascular Biology Program, Children's Hospital, Enders 1009, 320 Longwood Avenue, Boston, MA 02115, USA.
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291
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Ceilley E, Jagsi R, Goldberg S, Kachnic L, Powell S, Taghian A. The management of ductal carcinoma in situ in North America and Europe. Cancer 2004; 101:1958-67. [PMID: 15389481 DOI: 10.1002/cncr.20580] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The goal of the current study was to understand and document contemporary treatment approaches in the management of ductal carcinoma in situ (DCIS). METHODS An original questionnaire was designed to assess radiation oncologists' management of breast carcinoma, including 26 questions specifically addressing DCIS. A postal survey was conducted of members of the American and European Societies of Therapeutic Radiology and Oncology. The results of 702 responses from North America were compared with 435 responses from Europe, to determine treatment recommendations and variability by type of institution and geographic region. RESULTS There were strong correlations between the grade of DCIS and/or the margin status and the use of radiotherapy (RT; P < 0.0001). For Grade 3 DCIS, RT was recommended regardless of the margin status. Opinions were split in the treatment of low-grade DCIS with 10-mm margins. North American respondents were more likely to recommend RT for low-grade DCIS than their European counterparts (P < 0.0001). Within the United States, there were significant regional variations in physician recommendations for tamoxifen (P < 0.001), but not in the tendency to recommend RT. North American academic physicians were less likely to recommend RT for favorable DCIS than nonacademic physicians (P < 0.01). CONCLUSIONS There were marked differences in physician opinions regarding the management of DCIS, with significant international differences in patterns of care. The survey quantified and highlighted areas of agreement and controversy regarding the use of RT and tamoxifen in the management of DCIS. It provided support for large international trials to evaluate the optimal management of DCIS in the areas identified as most controversial.
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Affiliation(s)
- Elizabeth Ceilley
- Department of Radiation Oncology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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292
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Lybeert MLM, Louwman M, Coebergh JWW. Stable overall referral rates of primary radiotherapy for newly diagnosed cancer patients in the ageing population of South-Eastern Netherlands, 1975–1998. Radiother Oncol 2004; 73:101-8. [PMID: 15465153 DOI: 10.1016/j.radonc.2004.07.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2003] [Revised: 06/10/2004] [Accepted: 07/15/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND PURPOSE To determine the primary radiotherapy (RT) consumption in a population of almost one million inhabitants, served by one RT centre. Primary RT was defined as being planned, started or finished within 4-6 months of diagnosis. Application was evaluated according to tumour category, stage and year of diagnosis during three 8-year periods: 1975-1982, 1983 -1990 and 1991-1998. RESULTS Most patients were between 60 and 75 years. The number of patients receiving primary RT increased with 3% annually over the whole studied period, but remained proportionally stable for males at 30% and decreased for females from 36.2 to 34.6%. A decrease of referral rates for patients with gynaecological cancer was observed. The introduction of breast-conserving therapy in 1981 and of population screening for women aged 50-69 years in 1992 led to a considerable increase of primary RT. The eightfold increase in number of irradiated patients with localised prostate cancer rather reflected a higher detection rate than an increased referral rate. Except for an important increase of irradiated patients with rectal cancer, largely due to the shift to preoperative RT since 1994, and of patients with brain cancer, only slight alterations in referral rates were observed for the other cancers. CONCLUSIONS Use of primary RT remained proportionally steady and modest. The marked increase in workload was mainly due to more and earlier detection of breast and prostate cancer and treatment changes in rectal cancer. Decreases were observed for each of the gynecological cancers.
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Affiliation(s)
- Marnix L M Lybeert
- Department of Radiotherapy, Catharina Hospital, P.O. Box 1350, 5602 ZA Eindhoven, The Netherlands
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293
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Abstract
In the treatment of early breast cancer adjuvant irradiation improves local control following both mastectomy and breast-conserving surgery. For women at high risk of relapse it also increases survival. Breast radiotherapy is usually given using simple planning techniques and serious morbidity is unusual. The greatest concern following adjuvant breast irradiation is of an increase in cardiovascular mortality after 15-20 years. New techniques of breast irradiation including conformal radiotherapy and intensity-modulated radiotherapy (IMRT) have been shown to reduce cardiac and lung irradiation. In addition, improved dosimetry within the breast may improve both local control and cosmesis. To replace current radiotherapy techniques with those requiring more complex planning would demand an increase in resources including both machinery and staff. In this review we outline the indications and benefits of breast radiotherapy along with the planning process. Technical advances are discussed within the context of improving outcome at a time of limited national resources.
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Affiliation(s)
- J A Violet
- The Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ, UK
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294
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Romero L, Klein L, Ye W, Holmes D, Soni R, Silberman H, Lagios MD, Silverstein MJ. Outcome after invasive recurrence in patients with ductal carcinoma in situ of the breast. Am J Surg 2004; 188:371-6. [PMID: 15474428 DOI: 10.1016/j.amjsurg.2004.06.034] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Revised: 06/13/2004] [Indexed: 01/02/2023]
Abstract
BACKGROUND Local recurrence is used as a marker of treatment failure for patients with ductal carcinoma in situ (DCIS). As follow-up lengthens, distant recurrence, breast cancer-specific survival (BCSS), and overall survival must be monitored. METHODS A prospective database was used to analyze 1031 patients with DCIS. Patients having invasive recurrence after DCIS treatment were compared with patients having infiltrating ductal carcinoma (IDC). End points included distant recurrence, BCSS, and overall survival. RESULTS Overall, patients with DCIS had a BCSS of 99%. BCSS was 85% for patients with invasive recurrences. DDFS in this group was 80%. Stage I IDC patients had a BCSS of 91%, whereas it was 38% in those with stage I IDC and invasive recurrences. CONCLUSIONS Most patients with DCIS that recur can be salvaged. For the small subgroup of patients who recur with invasive breast cancer, survival is similar to that of patients with stage IIA IDC.
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Affiliation(s)
- Lina Romero
- Breast Service, Department of Surgery and Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, 1441 Eastlake Ave., No. 7415, Los Angeles, CA 90033, USA.
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295
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RESPONSE: Re: Trends in the Treatment of Ductal Carcinoma In Situ of the Breast. J Natl Cancer Inst 2004. [DOI: 10.1093/jnci/djh251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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296
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Hoorntje LE, Schipper MEI, Kaya A, Verkooijen HM, Klinkenbijl JG, Borel Rinkes IHM. Tumour cell displacement after 14G breast biopsy. Eur J Surg Oncol 2004; 30:520-5. [PMID: 15135480 DOI: 10.1016/j.ejso.2004.03.001] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2004] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Seeding of biopsy needle tracks with viable malignant cells was an initial concern with all diagnostic breast needle procedures, including 14G automated needle biopsy. In an attempt to further evaluate this phenomenon, we have addressed the following questions: (1) are the tracks left by the needle biopsy procedure detectable in the surgical excision specimen? (2) Are displaced tumour cells visible along the needle tracks? (3) Is it possible to identify and excise the entire needle track for thorough histopathologic evaluation? METHODS Surgical biopsy specimens of patients previously diagnosed with cancer on stereotactic 14G-needle biopsy were studied to find needle tracks. These are characterised by hemosiderin, scar tissue, foreign body giant cell reaction, fat necrosis, or organizing haemorrhage. Occurrence of displaced tumour cells or groups of cells along the tracks was registered. RESULTS Needle tracks were found in 22/64 excision specimens of patients who underwent 14G-needle biopsy and surgery on the same day. Tumour-cell displacement along the needle track was seen in 11/22 cases (50%). In a prospective study, an attempt was made to excise the entire needle track in 13 consecutive cancer cases after 14G biopsy. Median time interval between core biopsy and first surgical excision was 21 days (range 7-35). Needle tracks could be visualised in 11/13 cases; displaced cells were seen in seven. CONCLUSION Needle tracks can be found in the excision specimens of patients who previously underwent 14G biopsy, and displaced tumour cells can be recognised. Excision of the entire needle track is neither feasible, nor advisable as a routine measure, since radiotherapy is advised for both in situ and invasive carcinoma after conservative surgery.
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Affiliation(s)
- L E Hoorntje
- Department of Surgery, University Medical Centre, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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297
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Goffman TE, Miller M, Laronga C, Oliver S, Wong P. Shielding of the Contralateral Breast During Tangential Irradiation. Am J Clin Oncol 2004; 27:436-9. [PMID: 15289741 DOI: 10.1097/01.coc.0000128720.56101.81] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this study was to investigate both optimal and practical contralateral breast shielding during tangential irradiation in young patients. A shaped sheet of variable thickness of lead was tested on a phantom with rubber breasts, and an optimized shield was created. Testing on 18 consecutive patients 50 years or younger showed shielding consistently reduced contralateral breast dose to at least half, with small additional reduction after removal of the medial wedge. For younger patients in whom radiation exposure is of considerable concern, a simple shield of 2 mm lead thickness proved practical and effective.
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Affiliation(s)
- Thomas E Goffman
- Department of Radiation Oncology, Eastern Virginia Medical School, Norfolk, Virginia, USA.
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298
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Abstract
The incidence of ductal carcinoma in situ (DCIS), a noninvasive form of breast cancer, has increased markedly in recent decades, and DCIS now accounts for approximately 20% of breast cancers diagnosed by mammography. Laboratory and patient data suggest that DCIS is a precursor lesion for invasive cancer. The appropriate classification of DCIS has provoked much debate; a number of classification systems have been developed, but there is a lack of uniformity in the diagnosis and prognostication of this disease. Further investigation of molecular markers should improve the classification of DCIS and our understanding of its relationship to invasive disease. Controversy also exists with regard to the optimal management of DCIS patients. In the past, mastectomy was the primary treatment for patients with DCIS, but as with invasive cancer, breast-conserving surgery has become the standard approach. Three randomized trials have reported a statistically significant decrease in the risk of recurrence with radiation therapy in combination with lumpectomy compared with lumpectomy alone, but there was no survival advantage with the addition of radiotherapy. Two randomized trials have suggested an additional benefit, in terms of recurrence, with the addition of adjuvant tamoxifen therapy, although in one trial the benefit was not statistically significant. Current data suggest that tamoxifen use should be restricted to patients with estrogen receptor-positive DCIS. Neither trial demonstrated a survival benefit with adjuvant tamoxifen. Ongoing and recently completed studies should provide information on outcomes in patients treated with lumpectomy alone and on the effectiveness of aromatase inhibitors as an alternative to tamoxifen.
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MESH Headings
- Antineoplastic Agents, Hormonal/administration & dosage
- Aromatase Inhibitors
- Biomarkers, Tumor/analysis
- Breast Neoplasms/diagnosis
- Breast Neoplasms/drug therapy
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Chemotherapy, Adjuvant
- Clinical Trials as Topic
- Enzyme Inhibitors/pharmacology
- Estrogen Receptor Modulators/administration & dosage
- Female
- Humans
- Lymph Node Excision
- Lymphatic Metastasis
- Magnetic Resonance Imaging
- Mammography
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/prevention & control
- Radiotherapy, Adjuvant
- Receptors, Estrogen/analysis
- Risk Factors
- SEER Program
- Tamoxifen/administration & dosage
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Affiliation(s)
- Gregory D Leonard
- Cancer Therapeutics Branch, National Cancer Institute, Bethesda, MD 20889-5105, USA
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299
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Millis RR, Pinder SE, Ryder K, Howitt R, Lakhani SR. Grade of recurrent in situ and invasive carcinoma following treatment of pure ductal carcinoma in situ of the breast. Br J Cancer 2004; 90:1538-42. [PMID: 15083182 PMCID: PMC2409719 DOI: 10.1038/sj.bjc.6601704] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The grade of recurrent in situ and invasive carcinoma occurring after treatment of pure ductal carcinoma in situ (DCIS) has been compared with the grade of the original DCIS in 122 patients from four different centres (The Royal Marsden Hospitals, London and Sutton, 57 patients; Guy's Hospital, London, 19 patients; Nottingham City Hospital, 31 patients and The Royal Liverpool Hospital, 15 patients). The recurrent carcinoma was pure DCIS in 70 women (57%) and in 52 women (43%) invasive carcinoma was present, which was associated with an in situ element in 43. In all, 19 patients developed a second recurrence (pure DCIS in 11 and invasive with or without an in situ element in eight). The majority of invasive carcinomas followed high-grade DCIS. There was strong agreement between the grade of the original DCIS and that of the recurrent DCIS (kappa=0.679), which was the same in 95 of 113 patients (84%). The grade of the original DCIS showed only fair agreement with the grade of recurrent invasive carcinoma (kappa=0.241), although agreement was stronger with the pleomorphism score of the recurrent carcinoma (kappa=0.396). There was moderate agreement, in recurrent invasive lesions, between the grade of the DCIS and that of the associated invasive element (kappa=0.515). Other features that showed moderate or strong agreement between the original and recurrent DCIS were necrosis and periductal inflammation. The similarity between the histological findings of the original and subsequent DCIS is consistent with the concept that recurrent lesions represent regrowth of residual carcinoma. In addition, although agreement between the grade of the original DCIS and that of any subsequent invasive carcinoma was only fair, there is no suggestion that low-grade DCIS lesions progress to higher grade lesions or to the development of higher grade invasive carcinoma. This is in agreement with immunohistochemical and molecular data indicating that low-grade and high-grade mammary carcinomas are quite different lesions.
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Affiliation(s)
- R R Millis
- Hedley Atkins Cancer Research UK Breast Pathology Laboratory, Guy's Hospital, London SE1 9RT, UK
| | - S E Pinder
- Department of Histopathology, University of Nottingham, Nottingham City Hospital, Hucknal Road, Nottingham NG5 1PB, UK
- Department of Histopathology, University of Nottingham, Nottingham City Hospital, Hucknal Road, Nottingham NG5 1PB, UK. E-mail:
| | - K Ryder
- Academic Oncology Unit, Guy's Hospital, London SE1 9RT, UK
| | - R Howitt
- Department of Cellular Pathology, Southampton General Hospital, Southampton SO16 6YD, UK
| | - S R Lakhani
- The Breakthrough Toby Robins Breast Cancer Research Centre, ICR and the Royal Marsden Hospital, London SW3 6JB, UK
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MESH Headings
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/mortality
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Chemotherapy, Adjuvant
- Combined Modality Therapy
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Female
- Humans
- Mastectomy, Segmental/methods
- Middle Aged
- Neoplasm Staging
- Radiotherapy, Adjuvant
- Randomized Controlled Trials as Topic
- Risk Assessment
- Survival Analysis
- Tamoxifen/therapeutic use
- Treatment Outcome
- United Kingdom
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Affiliation(s)
- Jack Cuzick
- Department of Epidemiology, Mathematics and Statistics, Cancer Research UK, Wolfson Institute of Preventive Medicine, Charterhouse Square, London, EC1M 6BQ, UK.
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