Recent Progress in Breast Conserving Therapy: From Experiences in Japan

Survey on pamphlet use explaining breast cancer operations in Japan

BACKGROUND

The burden on hospitals to provide information has been increasing. This study examined the demands of surgeons and patients using a pamphlet explaining breast cancer operation procedures.

METHODS

A questionnaire with an eight-page pamphlet was sent to 367 hospitals with surgery departments in Aichi and Gifu prefectures in Japan. The same pamphlet and a self-administered anonymous questionnaire were also sent to 173 members of a breast cancer patient association, who had undergone breast cancer operations and lived in the same prefectures.

RESULTS

Responses to the questionnaire from 196 hospitals (53%) and 122 patients (71%) were analyzed. Breast cancer operations were conducted at 8 departments of 5 university hospitals, 37 governmental hospitals, 25 non-profit hospitals, and 66 private hospitals, a total of 1 36 hospitals. Among them, 34 hospitals participated in clinical trials. Fourteen hospitals had already used pamphlets as a tool for the explanation of breast cancer operation procedures. Hospitals having experienced special discussion with patients regarding the operation procedure were few, and only two hospitals reported claims or lawsuits concerning the operation procedure. About 60% of the hospitals wished to use the pamphlet, while 86% of the patients answered that it would have been useful if handed out before the operation. These patients stated that hospitals should provide this kind of pamphlet to breast cancer patients before operations.

CONCLUSIONS

It was clearly demonstrated that the great majority of hospitals in Japan lacked the basic tools for information provision on breast cancer operation procedures, while patients want enough information for self-determination.

Outcome of breast-conserving therapy in the Tokyo women’s medical university breast cancer society experience

BACKGROUND

The results of BCT in Japanese women have not been fully evaluated. The Tokyo Women's Medical University Breast Cancer Society initiated BCT protocols in 1987. Here, we present a retrospective analysis of BCT outcomes and identify prognostic factors.

METHODS

The study population comprised 348 patients (353 breasts) with UICC clinical stage 0,I or II breast cancer, for whom wide excision (n= 294), quadrantectomy (n= 56) and tumorectomy (n= 3) were performed. The final pathological margin states were positive in 102 breasts (cancer cells remained within 5 mm of the surgical margin). The whole breast was irradiated to a total dose with 44 Gy/20 fractions or 46 Gy/23 fractions in the patients with negative surgical margins. The patients with positive or close margins received 48.4 Gy/22 fractions or 50 Gy/25 fractions irradiation to the whole breast. All but 2 patients received a radiation boost to the tumor bed and all tumor beds were irradiated to more than 53 Gy. Adjuvant therapy was administered in 240 cases. The median follow-up time was 4.3 years.

RESULTS

The 5-year overall, cause-specific and disease-free survival rates were 95.8%, 97.3% and 92.5%, respectively. Recurrence was observed in 29 patients including 11 patients with loco-regional recurrence. Local recurrence was observed in 6 patients, 5 of whom were premenopausal. The 5-year local control and loco-regional control rates were 98.9% and 96.6%, respectively. T status (T1 to T2) was the only significant prognostic factor for disease-free survival. No severe morbidity has been observed. Cosmetic results were excellent or good in 73% of patients.

CONCLUSION

Our BCT protocols provide a high rate of local control and good cosmetic outcome. Pathologic margin status was not a major prognostic factor for local recurrence. Long term follow-up is required to reach a definite conclusion on optimal BCT protocols.

Video-assisted total glandectomy and immediate reconstruction for breast cancer

This paper describes a new surgical technique and our clinical experience with video-assisted endoscopic total glandectomy via a middle axillary incision followed by immediate reconstruction with latissimus dorsi muscle flap (LDMF) performed in 17 patients with bigger, multiple tumors or extensive ductal spread of breast cancer. The novel techniques in this procedure are as follows: (1) By securing patients in a semi-lateral position and suspending the upper extremity, either supine or semi-lateral position can be easily achieved by simply rotating the operating table, resulting in a wider working space from the axillary to hip area. (2) By applying a retractor for skin flap traction, endoscopic glandectomy and reconstruction become safe and reliable. As a result, the mean number and size of tumors were 1.2 and 4.12 cm, respectively. Surgical margins of all the cases were pathologically negative and there were no recurrences observed during 14 months follow-up to date. Esthetic results have been satisfactory and the surgical wounds were not visible from the front in any case. Compared to mastectomy, this procedure shows the same therapeutic results, but offers a greater esthetic and psychological advantage to all the patients.

Long-term results of breast conserving surgery for stages I and II breast cancer: experiences at Osaka Medical Center for Cancer and Cardiovascular Diseases

PURPOSE

The purpose of this study is to summarize the long-term results of breast conserving surgery (BCS) for Japanese patients with stage I and II breast cancer at a single institute and to identify risk factors for local recurrence after BCS.

PATIENTS AND METHODS

Between October 1986 and June 2000, 979 women underwent BCS with or without radiation therapy (RT). Overall survival, disease free survival and local recurrence rates were calculated by the Kaplan-Meier method. Risk factors for local recurrence were examined by multivariate analysis using the Cox proportional regression model.

RESULTS

The 10-year overall survival rates were 90.9% for the surgery and radiation therapy (RT group) and 89.3% for the surgery only group with a median follow-up time of 46 months. The 10-year disease free survival rates were 85.1% in the RT group and 69.2% in the surgery only group (p=0.0001). The positive margin rate was 14.1% (138/979). The 10-year overall survival rate of the patients with positive margins was 87.9%, compared with 90.8% for patients with negative margins (N.S.). The cumulative incidence of local recurrence at 10 years was significantly lower in the RT group (7.2% ) than in the surgery only group (27.5% ) (p<0.0001). Multivariate analysis showed that positive margins and lack of post-operative irradiation or adjuvant endocrine therapy were risk factors for non-inflammatory local recurrence.

CONCLUSIONS

Our study indicates that BCS can be performed for Japanese women with early breast cancer. The margin status and post-operative irradiation had no influence on overall survival while but were significantly related to local recurrence.

Early results of an endoscope-assisted subcutaneous mastectomy and reconstruction for breast cancer

BACKGROUND

Subcutaneous mastectomy and reconstruction (SMR) is well established; however, most incisions are made directly on the breast, and the majority of patients care about visible scars even if they are satisfied with the reconstructed breast.

METHODS

From August 1998 to March 2001, a total of 46 patients (including 2 bilateral cases) with breast cancer underwent SMR using a saline-filled prosthesis by lateral axillary incision. There were 25 patients who received previous SMR without endoscopic assistance (group A) and 21 patients who underwent an endoscope-assisted SMR (E-SMR) (group B). These 2 groups were compared for curability, morbidity, and cosmesis.

RESULTS

The median follow-up period was 19.2 + 9.8 months (range, 5.8 - 35.2 months). No significant difference was found in clinicopathologic data between the 2 groups. The operation time was 176 minutes in group A and 237 minutes in group B, and the estimated blood loss was 189 mL vs 356 mL, respectively. No critical complications were seen in either group. The average length of incision was 10 cm in group A and 5.7 cm in group B. As for the patients' satisfaction, the incidence of "excellent" plus "good" ratings was 76% in group A and 90.4% in group B.

CONCLUSIONS

E-SMR is a new option that can provide an improved operative view and better cosmetic results for the treatment of breast cancer than with SMR. The operation time is longer than for SMR, but the incision is drastically shorter, resulting in better cosmesis and increased patient satisfaction.

Local Recurrence after Conservative Surgery without Postoperative Radiation for Pure Tubular Carcinoma of the Breast:A Case Report with Reference to Multifocality of Tubular Carcinoma

A 49-year-old premenopausal woman with stage I breast carcinoma underwent left quadrantectomy with axillary dissection in 1992. The tumor was 0.7x0.5 cm Histopathologically, this was a pure tubular carcinoma without lymph node metastasis or lymphatic or vascular invasion. Although the surgical margin was pathologically negative, atypical ductal hyperplasia was present close to the cut margin's edge. Neither adjuvant chemotherapy nor radiotherapy had been given after the operation. Approximately 5 years after the first surgery, she had a local recurrence in the vicinity of the operative wound. There was no clinical evidence of distant metastasis. A salvage mastectomy was performed. Histopathological examination revealed that the second tumor was an invasive ductal carcinoma, histological grade 2, with extensive intraductal component. It was difficult to determine whether this was a true in-breast recurrence or a second primary cancer. Overexpression of p53 and c-erbB-2 was observed in the second tumor. Estrogen receptor and progesterone receptor were both negative. No postoperative chemotherapy was given. Multifocality and atypical ductal hyperplasia were observed in 7(87.5%)and 6(75%) of 8 patients, respectively, with tubular carcinoma between 1991and 1997 at the National Cancer Center Hospital. Coexisting disease associated with tubular carcinoma suggests that radiotherapy may be an important component of breast conservation treatment to prevent local recurrence in this type of tumor.

The Roles and Controversies of Radiation Therapy in Breast Conserving Therapy for Breast Cancer

Breast conserving therapy (BCT) is defined as a combination of conservative surgery for resection of the primary tumor, followed by radiation therapy (RT) for the eradication of residual microscopic disease in the breast. At NIH Consensus Development Conference in 1990, BCT was recognized as the preferred treatment for the majority of women with Stage I and II breast cancer. RT is a potent locoregional treament and its role in BCT in reducing local recurrence is already established. On the other hand, the influence of RT on survival outcome has not yet been closely demonstrated so far. RT appears to be useful as neoadjuvant therapy, and also as exclusive local treatment for patients achieving complete regression (CR) after neoadjuvant chemotherapy. The other possible role of RT is to use it as an alternative to axillary dissection in patients with clinically uninvolved nodes. The question of the appropriateness of using RT in all BCT cases is raised. Since the subgroup of patients who would not deserve any benefit by RT has not yet identified, RT should be delivered as standard treatment following breast conserving surgery for early stage breast cancer.