1
|
Get It Off Your Chest: A Narrative Review of Breast Ulcers. Adv Skin Wound Care 2022; 35:306-313. [PMID: 35703852 DOI: 10.1097/01.asw.0000826864.20824.b5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
GENERAL PURPOSE To provide comprehensive information about breast ulcers to facilitate accurate diagnosis and treatment of these lesions. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant will:1. Differentiate common wound complications after mastectomy.2. Identify the clinical manifestations of various types of breast ulcers.3. Explain appropriate pharmacologic and nonpharmacologic treatment options for various types of breast ulcers.
Collapse
|
2
|
Sharma A, Mahajan S, Agrawal SK, Ahmed R, Dey D. Assessment of skin response in T4b breast carcinoma patients post-neoadjuvant chemotherapy. Ecancermedicalscience 2021; 15:1271. [PMID: 34567256 PMCID: PMC8426019 DOI: 10.3332/ecancer.2021.1271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Indexed: 12/09/2022] Open
Abstract
Background Breast cancer patients with skin ulcerations, satellite nodules or Peau d'orange at presentation are classified with stage 4 breast cancer (T4b). Neoadjuvant chemotherapy (NACT), followed by mastectomy, is the commonly accepted treatment in such patients for fear of adverse outcomes with breast conservation surgery (BCS) and uncertainty over sparing initially involved skin irrespective of the response to chemotherapy. Identifying patients with skin resolution post-NACT can help surgeons in decision-making. Aim To assess skin response in T4b breast cancer patients post-NACT and find the correlation between various clinical and pathological factors associated with no skin involvement on final histology. Methodology Records of breast cancer patients managed at the Tata Medical Center, Kolkata, with NACT for T4b breast carcinoma patients who underwent mastectomy were reviewed between January 2014 and December 2018. Final histology was checked for dermal involvement with the tumour. The Mann-Whitney U test was used for continuous variables for descriptive data, and Pearson's chi-squared and Fischer's exact tests were applied for categorical data. p-value < 0.05 was taken as significant. Results A total of 285 records mentioning skin involvement were reviewed, out of which 111 patients fulfilled the AJCC criterion. The median age at diagnosis of T4b breast cancer was 50 years. The median clinical size pre-chemotherapy was 7 cm. Residual median tumour size on final histology was reported as 1 cm. 78/111 patients showed a post-NACT response of 50% or more, and 43/111 showed a response of more than 90%. 57 (51.4%) patients showed skin involvement on final histopathology, while 54 (48.6%) patients did not.ER negative tumours were more likely to show no dermal involvement (p = 0.006). Residual tumour size of less than 1 cm on final histology (p < 0.05) and nodal stage were significant predictors of dermal response. Conclusion Approximately half of the T4b breast cancer patients showed resolution of dermal skin involvement post-NACT. ER negative and those with residual tumour size less than 1 cm post-NACT are more likely to show dermal resolution. This can help surgeons plan a BCS or skin sparing mastectomy for such patients who usually end up having a mastectomy.
Collapse
Affiliation(s)
- Abhishek Sharma
- Department of Breast Oncosurgery, Tata Medical Center, Kolkata 700156, India
| | - Shagun Mahajan
- Department of Breast Oncosurgery, Tata Medical Center, Kolkata 700156, India
| | | | - Rosina Ahmed
- Department of Breast Oncosurgery, Tata Medical Center, Kolkata 700156, India
| | - Debdeep Dey
- Department of Pathology, Tata Medical Center, Kolkata 700156, India
| |
Collapse
|
3
|
Anwar SL, Avanti WS, Nugroho AC, Choridah L, Dwianingsih EK, Harahap WA, Aryandono T, Wulaningsih W. Risk factors of distant metastasis after surgery among different breast cancer subtypes: a hospital-based study in Indonesia. World J Surg Oncol 2020; 18:117. [PMID: 32473643 PMCID: PMC7261382 DOI: 10.1186/s12957-020-01893-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 05/21/2020] [Indexed: 12/24/2022] Open
Abstract
Background More than one third of breast cancer patients including those that are diagnosed in early stages will develop distant metastasis. Patterns of distant metastasis and the associated risks according to the molecular subtypes are not completely revealed particularly in populations of patients with delayed diagnosis and advanced stages. Methods Breast cancer patients (n = 1304) admitted to our institute (2014–2017) were evaluated to identify the metastatic patterns and the associated risks. Metastatic breast cancers at diagnosis were found in 245 patients (18.7%), and 1059 patients were then grouped into non-metastatic and metastatic groups after a median follow-up of 3.8 years. Results Infiltration of the tumor to the skin and chest wall prevailed as the most powerful predictor for distant metastasis (OR 2.115, 95% CI 1.544–2.898) particularly in the luminal A-like subtype (OR 2.685, 95% CI 1.649–4.371). Nodal involvement was also significantly associated with the risk of distant metastasis (OR 1.855, 95% CI 1.319–2.611), and the risk was higher in the Luminal A-like subtype (OR 2.572, 95% CI 1.547–4.278). Luminal A-like subtype had a significant higher risk of bone metastasis (OR 1.601, 95% CI 1.106–2.358). In respect to treatment, a combination of anthracyclines and taxanes-based chemotherapy was significantly associated with lower distant organ spread in comparison with anthracycline-based chemotherapy (OR 0.510, 95% CI 0.355–0.766) and the effect was stronger in Luminal A-like subtype (OR 0.417, 95% CI 0.226–0.769). Classification into Luminal and non-Luminal subtypes revealed significant higher risks of bone metastasis in the Luminal subtype (OR 1.793, 95% CI 1.209–2.660) and pulmonary metastasis in non-Luminal breast cancer (OR 1.445, 95% CI 1.003–2.083). Conclusion In addition to guiding the treatment plan, a comprehensive analysis of clinicopathological variables including the molecular subtypes could assist in the determination of distant metastasis risks of breast cancer patients. Our study offers new perspectives concerning the risks of distant metastasis in breast cancer subtypes in order to plan intensive surveillance or escalation of treatment particularly in a setting where patients are predominantly diagnosed in late stages.
Collapse
Affiliation(s)
- Sumadi Lukman Anwar
- Division of Surgical Oncology, Department of Surgery, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl Kesehatan No. 1, Yogyakarta, 55281, Indonesia.
| | - Widya Surya Avanti
- Department of Radiology, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Andreas Cahyo Nugroho
- Division of Surgical Oncology, Department of Surgery, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl Kesehatan No. 1, Yogyakarta, 55281, Indonesia
| | - Lina Choridah
- Department of Radiology, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Ery Kus Dwianingsih
- Department of Anatomical Pathology, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Yogyakarta, 55281, Indonesia
| | - Wirsma Arif Harahap
- Division of Surgical Oncology, Department of Surgery, Dr M Jamil Hospital/Faculty of Medicine, Universitas Andalas, Padang, 25127, Indonesia
| | - Teguh Aryandono
- Division of Surgical Oncology, Department of Surgery, Dr Sardjito Hospital/Faculty of Medicine, Public Health, and Nursing, Universitas Gadjah Mada, Jl Kesehatan No. 1, Yogyakarta, 55281, Indonesia
| | - Wahyu Wulaningsih
- MRC Unit for Lifelong Health and Ageing, University College London, Place London, Bedford 33, London, WC1B 5JU, UK
| |
Collapse
|
4
|
Mateo AM, Mazor AM, DeMora L, Sigurdson ER, Handorf EA, Daly JM, Aggon AA, Obeid E, Hayes SB, Bleicher RJ. Patterns of Care and Efficacy of Chemotherapy and Radiotherapy in Skin-Involved Breast Cancers of All Sizes. Clin Breast Cancer 2019; 19:292-303. [PMID: 30871966 DOI: 10.1016/j.clbc.2019.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/22/2018] [Accepted: 02/09/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND The management of small skin-involved (SI) invasive breast cancers is controversial because although they are considered unresectable, their prognosis is far better than their stage III classification. This study was undertaken to determine how SI lesions are treated in the United States and to discern the benefit of systemic therapy. PATIENTS AND METHODS Data of patients diagnosed with stage I-III breast cancer in the National Cancer Data Base between 2004 and 2011 were reviewed. Treatment patterns were examined and overall survival assessed. RESULTS A total of 3485 patients had SI and 456,287 patients had non-SI breast cancers. Chemotherapy was administered to 68.5% of SI and 45.9% of non-SI tumors (P < .001), including 77.2% of SI and 33% of non-SI tumors < 2 cm (P < .001). After adjusting for patient and tumor characteristics, SI patients were 19.4% more likely to receive chemotherapy than non-SI patients. Radiotherapy was provided to 61.1% of SI and 64.3% of non-SI tumors (P < .001), including 65.5% of SI and 66.5% non-SI tumors < 2 cm (P = .711). After adjusting for patient and tumor characteristics, SI patients were 76.6% more likely to receive radiotherapy than non-SI patients. Chemotherapy and radiotherapy provided an overall survival benefit for stage II and III SI and non-SI tumors. CONCLUSION Despite controversy regarding staging and prognosis of SI tumors, the majority of patients are provided systemic therapy and radiotherapy. Varied patterns of chemotherapy administration for SI tumors suggests that further treatment guidance and standardization are required, especially because chemotherapy and radiotherapy are equally efficacious in SI and non-SI tumors alike.
Collapse
Affiliation(s)
- Alina M Mateo
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Anna M Mazor
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Lyudmila DeMora
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | | | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Elias Obeid
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Shelly B Hayes
- Department of Radiation Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| |
Collapse
|
5
|
Khoury T, Gaudioso C, Fang YV, Sanati S, Opyrchal M, Desouki MM, Karabakhtsian RG, Li Z, Wang D, Yan L, Jacobson R. The role of skin ulceration in breast carcinoma staging and outcome. Breast J 2018; 24:41-50. [PMID: 28597587 PMCID: PMC5722717 DOI: 10.1111/tbj.12830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/14/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Abstract
Breast carcinoma with skin ulceration (SU) is considered a locally advanced disease. The purpose of the study is to investigate if SU is an independent adverse factor. Breast carcinoma patients with SU (n=111) were included in the study. A subset (n=38, study cohort) was matched with cases that had no SU (n=38, matched cohort); the survival analyses were compared between these groups. Then, cases (n=80) were staged independent from SU into stage I, II or III. Disease free survival (DFS) and overall survival (OS) were analyzed. Patients with larger tumors tended to present with distant metastases more often than patients with smaller tumors (P=.004). In the matched cases, the 5-year DFS probability was 53% for the study cohort and 58% for the matched cohort; and for OS 75% for the study cohort and 84% for the matched cohort with no statistical significant difference. However, there was a trend towards worse DFS for the patients whose tumors had SU. When the cases were staged based on tumor size and node status (I, II or III), the OS was statistically significant (P=.047) but not the DFS (P=.195). Relatively small tumors with SU had an extent of disease similar to that observed in patients with early stages disease. The survival analysis suggests that SU may not be an adverse factor. However, more cases are needed to further examine this finding.
Collapse
Affiliation(s)
- Thaer Khoury
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Carmelo Gaudioso
- Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY
| | - Yisheng V Fang
- Department of Pathology, University of Texas Southwestern Medical Center at Dallas, Dallas TX
| | - Souzan Sanati
- Department of Pathology, Washington University, Saint Louis, MO
| | - Mateusz Opyrchal
- Department of Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY
| | | | - Rouzan G Karabakhtsian
- Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Zaibo Li
- Department of Pathology, Ohio State University, Columbus, OH
| | - Dan Wang
- Department of Biostatistics, Roswell Park Cancer Institute; Roswell Park Cancer Institute, Buffalo, NY
| | - Li Yan
- Department of Biostatistics, Roswell Park Cancer Institute; Roswell Park Cancer Institute, Buffalo, NY
| | - Rebecca Jacobson
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA
| |
Collapse
|
6
|
Mahmood H, Faheem M, Mahmood S, Sadiq M, Irfan J. Impact of Age, Tumor Size, Lymph Node Metastasis, Stage, Receptor Status and Menopausal Status on Overall Survival of Breast Cancer Patients in Pakistan. Asian Pac J Cancer Prev 2015; 16:1019-24. [DOI: 10.7314/apjcp.2015.16.3.1019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
7
|
Histopathological characterization of ulcerated breast cancer and comparison to their non-ulcerated counterparts. Tumour Biol 2014; 36:3423-8. [DOI: 10.1007/s13277-014-2977-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 12/11/2014] [Indexed: 10/24/2022] Open
|
8
|
Silverman D, Ruth K, Sigurdson ER, Egleston BL, Goldstein LJ, Wong YN, Boraas M, Bleicher RJ. Skin involvement and breast cancer: are T4b lesions of all sizes created equal? J Am Coll Surg 2014; 219:534-44. [PMID: 25026875 PMCID: PMC4143438 DOI: 10.1016/j.jamcollsurg.2014.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 03/15/2014] [Accepted: 04/14/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Nonmetastatic, noninflammatory, invasive breast cancers with skin involvement (SI) are classified as T4b, regardless of size. This study evaluated disease-specific survival (DSS) to determine whether size should be considered for these lesions rather than grouping them all into stage III. STUDY DESIGN Surveillance, Epidemiology, and End Results data linked to Medicare claims were reviewed. Skin involved and non-SI tumors were reclassified using the American Joint Committee on Cancer, 7(th) edition groupings using tumor size and nodal involvement alone without considering SI (neostage). Disease-specific survival was adjusted for demographics, histology, and treatment using competing risk methods with propensity score-based weighting and bootstrap standard errors. RESULTS Among 924 SI patients diagnosed between 1992 and 2005, tumors were 0.1 to 2.0 cm, 2.1 to 5.0 cm, and >5.0 cm in 11.6%, 51.1%, and 37.3% of patients, respectively. There were no nodal metastases in 22.3%, 1 to 3 positive nodes in 31.7%, 4 to 9 positive in 28.6%, and ≥10 positive in 17.4% of patients. For SI patients, adjusted 5-year DSS was 95.8% (95% CI, 95.6-96.0) for neostage I, declining progressively to 36.4% (95% CI, 33.8-39.2) for neostage IIIC patients. Adjusted 5-year DSS for SI and non-SI tumors (n = 66,185) was similar for neostage I, IIA, and IIB, and markedly lower for IIIA and IIIC. Adjusted DSS for SI IIIA was similar to non-SI IIIC. CONCLUSIONS Noninflammatory SI breast cancers have widely varied DSS that differs by tumor size and nodal involvement and therefore should not all be stage III. Skin involvement should be subordinate to T and N groupings to classify SI with non-SI lesions having similar prognoses.
Collapse
Affiliation(s)
- Diana Silverman
- Department of Surgery, Saint Francis Hospital and Health Center, Poughkeepsie, NY
| | - Karen Ruth
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Brian L Egleston
- Department of Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
| | - Lori J Goldstein
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Yu-Ning Wong
- Department of Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Marcia Boraas
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA.
| |
Collapse
|
9
|
Güth U, Huang DJ, Schötzau A, Dirnhofer S, Wight E, Singer G. Breast cancer with non-inflammatory skin involvement: current data on an underreported entity and its problematic classification. Breast 2009; 19:59-64. [PMID: 20015652 DOI: 10.1016/j.breast.2009.11.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 09/17/2009] [Accepted: 11/25/2009] [Indexed: 12/01/2022] Open
Abstract
We evaluated 166 breast cancer cases with non-inflammatory skin involvement (NISI), which were classified in the TNM classification as T4b. The distribution of tumour sizes and stages was: < or =3 cm:24.1%, 3.1-5 cm:21.7%, 5.1-10 cm:33.1%, >10 cm:21.1%; stages:I/II:21.0%, III:43.4%, IV:35.6%. To assess the impact of NISI on axillary lymph node involvement (ALNI), we analyzed a sub-group of 50 patients with tumours < or =5 cm and compared them with a matched control group. NISI was found to be associated with increased ALNI (HR, 2.66; 95%CI, 1.59-4.63; p<0.0001). According to the inherent rules of tumour classification, only tumours with similar morphologic extent and prognostic significance should be combined. Since there is a high grade of heterogeneity, this basic tenet is clearly violated regarding breast cancer with NISI. Our proposal is to eliminate these tumours from the T4 category and to classify them simply by size (T1-3). Due to its prognostic significance, NISI should be indicated by an optional descriptor (e.g. S1).
Collapse
Affiliation(s)
- Uwe Güth
- University Hospital Basel, Department of Gynecology and Obstetrics, Spitalstrasse 21, Basel, Switzerland.
| | | | | | | | | | | |
Collapse
|
10
|
Martella S, Caliskan M, Brenelli FP, Rossetto F, Aparecida De Oliveira H, De Brito Lima LN, Chifu C, Rodriguez-Fernandez J, Petit JY, Luini A. Surgical Closure of Chest Wall in Noninflammatory Locally Advanced Breast Carcinoma with Ulceration of the Skin1. Breast J 2008; 14:345-52. [DOI: 10.1111/j.1524-4741.2008.00596.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
11
|
Abstract
PURPOSE OF REVIEW Inflammatory breast cancer is a highly aggressive variant of locally advanced breast cancer that carries a significantly worse prognosis. The purpose of this review is to highlight recent advances in the molecular modus operandi of this particular form of breast cancer. RECENT FINDINGS Studies on tumor cell emboli, E-cadherin, chemokine receptors, steroid hormone receptor, angiogenesis, lymphangiogenesis and gene expression all suggest significant differences with noninflammatory breast cancer and are clearly in line with a different pathogenesis of the condition. SUMMARY This comprehensive review will hopefully allow for better treatment modalities with targeted approaches as suggested by the early data on anti-vascular endothelial growth factor treatment in inflammatory breast cancer.
Collapse
Affiliation(s)
- Luc Y Dirix
- Oncology Center, Multidisciplinary Breast Clinic, AZ (Algemeen Ziekenhuis) Sint-Augustinus, Antwerp, Belgium.
| | | | | | | |
Collapse
|
12
|
Harms K, Wittekind C. Prognosis of women with pT4b breast cancer: the significance of this category in the TNM system. Eur J Surg Oncol 2008; 35:38-42. [PMID: 18215492 DOI: 10.1016/j.ejso.2007.11.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 11/28/2007] [Indexed: 11/24/2022] Open
Abstract
AIMS The T4b/pT4b category of the TNM System for breast cancer is discussed controversially. For a more detailed analysis, we explored the prognosis of patients with breast cancer strictly fulfilling the criteria for T4b/pT4b tumors according to the TNM System. METHODS Retrospectively analysed data from patients with pT4b breast tumors diagnosed between January 1994 and December 2004 were collected. Reclassification was undertaken according to the TNM System criteria establishing a study group including only "correctly" classified T4b/pT4b tumors. A control group with pT1-3 carcinomas was used for analysing the prognostic value of criteria for T4b/pT4b tumors. RESULTS Eighty-six patients with pT4b carcinomas were found. After reclassification, 65 remained as pT4b fulfilling the strict criteria. The study group showed a 60% three-year Disease Specific Survival (DSS). Age (p<0.01) and regional lymph node status (p<0.01) were significantly related to prognosis. Compared to the control group, the DSS in the study group of patients with a tumor size >2 cm to 5 cm was significantly worse (three-year survival: 82% vs. 51%, p<0.01). For tumors >5 cm, the DSS was not significantly different between both groups (three-year survival: 68% vs. 72%, p=0.7). CONCLUSIONS The criteria for T4b/pT4b breast cancer are associated with a poorer prognosis in patients with a tumor size >2 cm to 5 cm. For tumors >5 cm, prognosis is independent of T4b/pT4b criteria. These findings do not justify the demanded deletion of the T4b/pT4b category. The missing uniformity in applying the correct criteria of T4b/pT4b tumors queries the practicability of this category.
Collapse
Affiliation(s)
- K Harms
- Institute of Pathology, University Hospital of Leipzig, Leipzig, Germany
| | | |
Collapse
|
13
|
Güth U, Jane Huang D, Holzgreve W, Wight E, Singer G. T4 breast cancer under closer inspection: A case for revision of the TNM classification. Breast 2007; 16:625-36. [PMID: 17604172 DOI: 10.1016/j.breast.2007.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2007] [Accepted: 05/13/2007] [Indexed: 01/27/2023] Open
Abstract
The presence of skin involvement in breast cancer results in the classification of the tumor into the highest tumor category, and accordingly into the highest non-metastatic disease stage (current TNM classification: T4/stage III). This traditional view is no longer justifiable, as tumors that show non-inflammatory skin involvement (T4b) make up a considerably heterogeneous group with a high percentage of small-sized tumors. Classifying all lesions demonstrating this feature together results in the combination of tumors with widely differing prognostic and therapeutic implications into a single group. This violates the basic principle of the TNM concept in that only tumors exhibiting similar extension and prognosis should be grouped into one category/stage. Furthermore, the currently valid definitions of non-inflammatory skin involvement are misconceived for the substantial group of small tumors which often have ambiguous morphologic findings: the clinical classification depends on the subjective perception of the individual observer, and the pathologic staging considers histologic criteria that are not justifiable from a functional-morphological point of view. For these reasons, we strongly feel that there is a need to revise the current T4 category. We recommend that breast carcinomas currently classified as T4a-c should be eliminated from the T4 category and classified simply according to their tumor size (T1-3). The prognostically very unfavorable inflammatory carcinoma (T4d) should be maintained as the only clinicopathologic entity in the T4 category. This proposal, which will also lead to a revision of the stage III group, adheres more closely to the goals and principles of the TNM classification than do the current classification guidelines. Through the revision of the T4 category, the definitions and guidelines of inflammatory breast carcinoma should be adapted to the internationally accepted nomenclature.
Collapse
Affiliation(s)
- Uwe Güth
- University Hospital Basel, Department of Gynecology and Obstetrics, Spitalstrasse 21, CH-4031 Basel, Switzerland.
| | | | | | | | | |
Collapse
|
14
|
Gueth U, Wight E, Schoetzau A, Langer I, Dieterich H, Rochlitz C, Herberich L, Holzgreve W, Singer G. Non-inflammatory skin involvement in breast cancer, histologically proven but without the clinical and histological T4 category features. J Surg Oncol 2007; 95:291-7. [PMID: 17326124 DOI: 10.1002/jso.20660] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The study evaluates characteristics and prognostic significance of breast cancer with histologically proven non-inflammatory skin involvement but without the clinical and histological features that are mandatory for inclusion in the T4 category. METHODS We compared retrospectively the clinical course of 55 patients with this clinico-pathologic entity to the outcome of a control group of 309 consecutive patients with tumors of the same size but without skin involvement. The median follow-up time was 6.6 years in the study and 8.4 years in the control group. Two subsets were analyzed: (A) 1.1-2.0 cm (T1c); (B) 2.1-5.0 cm (T2). RESULTS The distribution of TNM stages within Study Group A was: Stage I: 28.6%, Stage II: 61.9%, Stage III: 9.5%. The distribution within Study Group B was: Stage II: 67.7%, Stage III: 23.5%, and Stage IV: 8.8%. Differences in disease-specific survival (DSS) between study and control groups were not significant. In multivariate analysis, skin involvement was not a significant variable, while lymph node involvement was found to be significant for worse outcome (Group A: HR=3.99 [1.33-12.05], P=0.014; Group B: HR=2.37 [1.37-4.08], P=0.002). CONCLUSION Breast carcinomas with histologically proven skin involvement without the clinical and histological correlate are a heterogeneous group of cases, but the majority of the patients have Stage I/II disease. While lymph node involvement had a most significant effect on DSS, skin involvement was not a significant prognostic factor. Physicians must be aware of this clinico-pathologic entity in order not to misclassify these cases as T4 and consider them falsely as being locally advanced breast cancer.
Collapse
Affiliation(s)
- Uwe Gueth
- Department of Gynecology and Obstetrics, University Hospital Basel (UHB), Spitalstrasse, Basel, Switzerland.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Güth U, Singer G, Langer I, Schötzau A, Herberich L, Holzgreve W, Wight E. T4 category revision enhances the accuracy and significance of stage III breast cancer. Cancer 2006; 106:2569-75. [PMID: 16688772 DOI: 10.1002/cncr.21920] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Because of the considerable heterogeneity in breast carcinoma with noninflammatory skin involvement (T4b/Stage IIIB), a revision was proposed of the TNM staging system that would classify these tumors exclusively based on their tumor size and lymph node status. In the current study, the authors evaluated how implementation of this proposal will affect Stage III noninflammatory breast cancer. METHODS Two hundred seven patients who were classified with noninflammatory Stage III breast cancer were treated consecutively between 1990 and 1999 at the University Hospital Basel, Switzerland. To assess the extent of T4b/Stage IIIB tumors independent of the clinicopathologic feature of skin involvement, the reclassification was undertaken. RESULTS Of 68 patients who had nonmetastatic T4b breast cancer, 37 patients (54.4%) had a tumor extent in accordance with Stage I/II and had improved disease-specific survival (DSS) compared with patients who had Stage III breast cancer (P = .008). Excluding those patients from Stage III led to a 17.9% reduction of the number of patients in this group (n = 170 patients). The 10-year DSS declined from 48.5% to 42.9%. CONCLUSIONS Considerable numbers of patients who are classified with noninflammatory Stage IIIB breast cancer show only a limited disease extent. Through a revision of the T4 category, these low-risk patients were excluded from the highest nonmetastatic TNM stage, and overstaging could be avoided. This procedure decreased the degree of heterogeneity of the entire Stage III group and may result in a more precise assessment of this disease entity.
Collapse
Affiliation(s)
- Uwe Güth
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland.
| | | | | | | | | | | | | |
Collapse
|