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

Breast-conserving surgery without radiation in elderly women with early breast cancer

BACKGROUND AND OBJECTIVES

Irradiation after breast-conserving surgery (BCS) decreases the incidence of ipsilateral breast tumor recurrence (IBTR) and breast cancer-related death. However, daily radiation treatments are burdensome to elderly patients, whose risk of IBTR is relatively low. Since 2001, we have offered BCS without radiation to patients meeting our selection criteria. This study assessed the prognosis of the patients who chose this option.

METHODS

Between 2001 and 2014, 203 patients met the selection criteria: aged ≥60 years; pathologically node-negative, hormone-positive breast cancer; a negative surgical margin; and no lymphovascular invasion. Among these patients, 84 and 119 underwent BCS with or without radiation, respectively. IBTR, overall survival (OS), and breast cancer-specific survival (BCSS) were evaluated.

RESULTS

The median follow-up duration was 6.2 years. There were no significant differences in tumor size or the number of patients with adjuvant therapy between the groups. The 5-year IBTR rates were 0.9% and 1.6% in the non-irradiated and irradiated groups, respectively (p = 0.308). The 5-year OS rates were 94.1% and 98.7% (p = 0.391). Similarly, the 5-year BCSS rates were 97.2% and 98.7% (p = 0.812).

CONCLUSION

It is suggested that the omission of irradiation could be an option for elderly breast cancer patients who satisfy our criteria.

Efficacy of intraoperative entire-circumferential frozen section analysis of lumpectomy margins during breast-conserving surgery for breast cancer

BACKGROUND

Intraoperative frozen section analysis of the surgical margins during breast-conserving surgery (BCS) for breast cancer can reliably achieve clear surgical margins and prevent re-operations. The aim of this study was to assess intraoperative entire-circumferential frozen section analysis (IEFSA) of the lumpectomy margins during BCS.

METHODS

A total of 1029 patients who underwent BCS with IEFSA between June 2007 and July 2013 were available for assessment. The inner surfaces of the shaved lumpectomy margins were examined as frozen sections during BCS. The margins were defined as positive when the cancer cells were present within 5 mm from the edge of the outermost margins of the specimens.

RESULTS

Out of 1029 patients, 312 patients (30.3 %) had positive margins after the initial lumpectomy and underwent additional resections during BCS. Fourteen patients (1.4 %) underwent mastectomy following the results of additional resections during the first surgery. Of 1015 patients who completed BCS, 60 patients (5.9 %) were found to have positive margins in the final pathology. One patient (0.1 %) underwent re-operation after BCS while the residual diseases of the other 59 patients were judged to be minimal. Of the 312 patients who were judged to have positive margins after the initial lumpectomy with IEFSA, 53 patients (16.9 %) were found to have negative margins in the final pathology. At a median follow-up time of 54.1 months, one patient (0.1 %) had a recurrence of breast cancer in the preserved breast.

CONCLUSION

IEFSA is useful for preventing the need for re-operation and local recurrence after BCS.

The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis

PURPOSE

There is no consensus on what constitutes adequate negative margins in breast-conserving therapy (BCT). We systematically review the evidence on surgical margins in BCT for invasive breast cancer to support the development of clinical guidelines.

METHODS

Study-level meta-analysis of studies reporting local recurrence (LR) data relative to final microscopic margin status and the threshold distance for negative margins. LR proportion was modeled using random-effects logistic meta-regression.

RESULTS

Based on 33 studies (LR in 1,506 of 28,162), the odds of LR were associated with margin status [model 1: odds ratio (OR) 1.96 for positive/close vs negative; model 2: OR 1.74 for close vs. negative, 2.44 for positive vs. negative; (P < 0.001 both models)] but not with margin distance [model 1: >0 mm vs. 1 mm (referent) vs. 2 mm vs. 5 mm (P = 0.12); and model 2: 1 mm (referent) vs. 2 mm vs. 5 mm (P = 0.90)], adjusting for study median follow-up time. There was little to no statistical evidence that the odds of LR decreased as the distance for declaring negative margins increased, adjusting for follow-up time [model 1: 1 mm (OR 1.0, referent), 2 mm (OR 0.95), 5 mm (OR 0.65), P = 0.21 for trend; and model 2: 1 mm (OR 1.0, referent), 2 mm (OR 0.91), 5 mm (OR 0.77), P = 0.58 for trend]. Adjustment for covariates, such as use of endocrine therapy or median-year of recruitment, did not change the findings.

CONCLUSIONS

Meta-analysis confirms that negative margins reduce the odds of LR; however, increasing the distance for defining negative margins is not significantly associated with reduced odds of LR, allowing for follow-up time. Adoption of wider relative to narrower margin widths to declare negative margins is unlikely to have a substantial additional benefit for long-term local control in BCT.

Preoperative localization and surgical margins in conservative breast surgery

Breast-conserving surgery (BCS) is the treatment of choice for early breast cancer. The adequacy of surgical margins (SM) is a crucial issue for adjusting the volume of excision and for avoiding local recurrences, although the precise definition of an adequate margins width remains controversial. Moreover, other factors such as the biological behaviour of the tumor and subsequent proper systemic therapies may influence the local recurrence rate (LRR). However, a successful BCS requires preoperative localization techniques or margin assessment techniques. Carbon marking, wire-guided, biopsy clips, radio-guided, ultrasound-guided, frozen section analysis, imprint cytology, and cavity shave margins are commonly used, but from the literature review, no single technique proved to be better among the various ones. Thus, an association of two or more methods could result in a decrease in rates of involved margins. Each institute should adopt its most congenial techniques, based on the senologic equipe experience, skills, and technologies.

Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy

PURPOSE

There is no consensus on what constitutes adequate negative margins in breast-conserving therapy (BCT). We review the evidence on surgical margins in BCT for early-stage invasive breast cancer.

METHODS

Meta-analysis of studies reporting local recurrence (LR) relative to quantified final microscopic margin status and the threshold distance for negative margins. The proportion of LR was modelled using random effects logistic meta-regression.

RESULTS

Based on 21 studies (LR in 1,026 of 14,571 subjects) the odds of LR were associated with margin status [model 1: odds ratio (OR) = 2.02 for positive/close versus negative; model 2: OR = 1.80 for close versus negative, 2.42 for positive versus negative (P<0.001 both models)] but not with margin distance [1mm versus 2mm versus 5mm (P > 0.10 both models)], adjusting for median follow-up time. However, there was weak evidence in both models that the odds of LR decreased as the threshold distance for declaring negative margins increased. This bordered significance in model 2 [OR for 1mm, 2mm, 5mm: 1.0, 0.75, 0.51 (P = 0.097 for trend)], and was not significant in model 1 [OR for 1mm, 2mm, 5mm: 1.0, 0.85, 0.58 (P = 0.11 for trend)] but was evident when one study (of women ≤ 40 years) was excluded from this model [OR for 1mm, 2mm, 5mm: 1.0, 0.72, 0.52 (P = 0.058 for trend)]: this trend was rendered insignificant by adjustment for the proportion of subjects receiving a radiation boost or the proportion of subjects receiving endocrine therapy.

CONCLUSIONS

Margin status has a prognostic effect in all women treated for invasive breast cancer; increasing the threshold distance for declaring negative margins is weakly associated with reduced odds of LR, however adjustment for covariates (adjuvant therapy) removes the significance of this effect. Adoption of wider margins, relative to narrower widths, for declaring negative margins is unlikely to a have substantial additional benefit for long-term local control in BCT.

MRI-guided interventions of the breast

MRI has proven to be a very reliable diagnostic tool in the detection and differential diagnosis of breast lesions. Some lesions are, even in retrospect, not detectable in x-ray or ultrasound images but MRI is able to detect lesions at a much smaller size than the average size of lesions depicted by x-ray and ultrasound. The aim in the future is to develop combined procedures where imaging, biopsy, and interventional therapies are combined in a single outpatient procedure. As a step toward this goal different interventional procedures are useful that include interstitial laser therapy (ILT), radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), microwave ablation therapy, and cryotherapy. In this overview the main features and initial results of these procedures are described and discussed.

Comparison of 4 MV photon surface dose among Varian, Siemens, and Elekta linear accelerators for tangential breast treatment: a phantom study

PURPOSE

We have compared the differences in a 4-MV photon surface dose among Varian, Siemens, and Elekta linear accelerators (linacs) with wedges for tangential breast treatment.

MATERIALS AND METHODS

The wedge factor and the surface dose were measured using a solid water phantom and an ion chamber for each linear accelerator with various field sizes and wedge angles. A tangential treatment plan was applied to an elliptical hollow cylinder water phantom with a radiochromic film placed thereon. A dose was delivered to a simulated target in the phantom, and the resulting dose distribution was analyzed using a film scanner.

RESULTS

Varian's wedges resulted in the highest wedge factors, ranging from 0.37 to 0.75 depending on the wedge angles. Varian's wedges led to the highest normalized skin doses, ranging between 0.40 and 0.73 depending on the wedge angles and field sizes. In the cylinder phantom test with two tangential beams, the Varian linac provided a nearly 20% higher maximum dose than the Siemens and Elekta linacs.

CONCLUSION

The Varian linac resulted in the highest surface doses, and the Elekta linac led to the lowest for nearly all the measurement conditions we employed, including open beams.

Ultrasound-guided, percutaneous cryotherapy of small (< or = 15 mm) breast cancers

RATIONALE AND OBJECTIVE

The purpose of this study was to investigate the feasibility, efficacy, and safety of ultrasound-guided percutaneous cryotherapy of stage T1 breast cancers.

MATERIALS AND METHODS

Thirty patients with biopsy-confirmed breast cancers with tumor diameters of 15 mm or smaller (range, 5-15 mm; median, 12 mm) underwent cryotherapy. After local anesthesia, a 3-mm cryo probe was placed into the tumor under ultrasound guidance. All tumors were subjected to 2 freeze cycles with an interposing thawing cycle. The size of the ice-balls, their distance to the skin, and the temperature at the tip of the probe were closely monitored during the procedure. The patients underwent surgery within 6 weeks and the specimens were evaluated histologically.

RESULTS

The median minimum temperature reached -146 degrees C (range, -117 degrees C to -167 degrees C). In 5 of 29 patients, remnant ductal carcinoma in situ was detectable histologically after cryotherapy beyond the margin of the cryosite in the specimens after open surgery. In 24 patients, no viable tumor cells were found. No severe side effects occurred. In one patient, the cryo procedure was not performed completely because of technical problems.

DISCUSSION

Percutaneous cryotherapy is a feasible and safe procedure in minimally invasive therapy for small breast cancers. Residual ductal carcinoma in situ may be attributable to the beginning of a learning curve or by false-negative detection in pre-interventional imaging. Magnetic resonance mammography might aid in treatment planning and for therapy monitoring to better define target tissue and to correlate the tumor margin with the ice-ball.