Loco-regional recurrences after mastectomy in breast cancer: prognostic factors and implications for postoperative irradiation

Adherence to guideline recommendations for follow-up in patients with DCIS at a large teaching hospital in the Netherlands

PURPOSE

Ductal-carcinoma in situ (DCIS) is a pre-invasive form of breast cancer with good prognosis. Follow-up guidelines in the Netherlands are currently the same as for invasive breast cancer. Due to fear of invasive breast cancer or recurrence, it is hypothesized that follow-up for DCIS after treatment is more intense in practice resulting in potentially unnecessary high costs. This study investigates the follow-up in practice for patients with DCIS compared to the recommendations in order to inform clinicians and policy makers how to utilize these guidelines.

METHODS

Patients diagnosed with pure DCIS between 2004 and 2014 were followed up until 2018. Information on duration and frequency of follow-up visits, reasons and decision makers for shortening, and prolonging follow-up was collected. Prolonged follow-up was defined as deviation from the Dutch guideline: more than 5 years of follow-up and older than 60 years.

RESULTS

Of the 227 patients the mean number of visits per year was 1.4 and mean years of follow-up was 6.0. Thirty-three percent had prolonged follow-up and 26% shorter follow-up than recommended. A majority (78%) of decision for prolonged follow-up was being made by clinicians.

CONCLUSION

Follow-up duration is in almost half of patients with DCIS according to guidelines and with most prolonged follow-up only up to a year longer than recommended. In most cases suspicious findings and the timing of the population screening program appeared to cause prolonged follow-up. If accepted by patients and clinicians, future DCIS specific guidelines should address these reasons and tailor to the individual risks.

The use of bolus in postmastectomy radiation therapy for breast cancer: A systematic review

PURPOSE

Post mastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and breast cancer mortality for selected patients. Bolus overcomes the skin-sparing effect of external-beam radiotherapy, ensuring adequate dose to superficial regions at risk of local recurrence (LR). This systematic review summarizes the current evidence regarding the impact of bolus on LR and acute toxicity in the setting of PMRT.

RESULTS

27 studies were included. The use of bolus led to higher rates of acute grade 3 radiation dermatitis (pooled rates of 9.6% with bolus vs. 1.2% without). Pooled crude LR rates from thirteen studies (n = 3756) were similar with (3.5%) and without (3.6%) bolus.

CONCLUSIONS

Bolus may be indicated in cases with a high risk of LR in the skin, but seems not to be necessary for all patients. Further work is needed to define the role of bolus in PMRT.

Power Doppler Ultrasonography and Shear Wave Elastography as Complementary Imaging Methods for Suspected Local Breast Cancer Recurrence

OBJECTIVES

To prospectively investigate the diagnostic accuracy and clinical consequences of power Doppler morphologic criteria and shear wave elastography (SWE) as complementary imaging methods for evaluation of suspected local breast cancer recurrence in the ipsilateral breast or chest wall.

METHODS

Thirty-two breast masses with a suspicion of local breast cancer recurrence on B-mode ultrasonography underwent complementary power Doppler and SWE evaluations. Power Doppler morphologic criteria were classified as avascular, hypovascular, or hypervascular. Shear wave elastography was classified according to a 5-point scale (SWE score) and SWE maximum elasticity. Diagnostic accuracy was assessed by the sensitivity, specificity, and area under the curve. A decision curve analysis assessed clinical consequences of each method. The reference standard for diagnosis was defined as core needle or excisional biopsy.

RESULTS

Histopathologic examinations revealed 9 (28.2%) benign and 23 (71.8%) malignant cases. Power Doppler ultrasonography (US) had sensitivity of 34.8% (95% confidence interval [CI], 6.6%-62.9%) and specificity of 45.4% (95% CI, 19.3%-71.5%). The SWE score (≥3) had sensitivity of 87.0% (95% CI, 66.4%-97.2%) and specificity of 44.4% (95% CI, 13.7%-78.8%). The SWE maximum elasticity (velocity > 6.5cm/s) had sensitivity of 87% (95% CI, 66.4%-97.2%) and specificity of 77.8% (95% CI, 40.0% to 97.2%). The areas under the curves for the SWE score and SWE maximum elasticity were 0.71 (95% CI, 0.53-0.87) and 0.82 (95% CI, 0.64-0.93), respectively (P = .32).

CONCLUSIONS

Power Doppler US is unsuitable for discrimination between local breast cancer recurrence and fibrosis. Although the SWE score and SWE maximum elasticity can make this discrimination, the use of these methods to determine biopsy may lead to poorer clinical outcomes than the current practice of performing biopsies of all suspicious masses.

Molecular Subtypes and Local-Regional Control of Breast Cancer

In the era of personalized medicine, there has been significant progress regarding the molecular analysis of breast cancer subtypes. Research efforts have focused on how classification of subtypes could provide information on prognosis and influence treatment planning. Although much is known about the impact of different molecular subtypes on disease-specific survival, more recent studies have investigated the role of the different molecular subtypes on local-regional recurrence. This is an area of active study, and in recent years there has been significant progress. This article describes outcomes among disease subtypes to aid in optimal surgical decision-making to improve local-regional control.

Evaluation of Local Oncologic Safety in Nipple-Areola Complex-sparing Mastectomy After Primary Chemotherapy: A Propensity Score-matched Study

BACKGROUND

Nipple-areola complex-sparing mastectomy (NSM), extending the concept of skin-sparing mastectomy, allows for the provision of a better cosmetic result. Large operable T2-T3 breast cancer might theoretically appear suitable for this surgical option as an alternative to conventional mastectomy or breast-conserving surgery, when a good response to primary chemotherapy has been achieved.

PATIENTS AND METHODS

From January 2009 to May 2013, 422 patients with invasive breast cancer were progressively accrued to NSM. Of the 422 patients, 361 underwent NSM as first-line treatment (NSM group), and 61 underwent surgery after primary chemotherapy (NSM-PC group). A total of 151 breast cancer patients, who had undergone PC and conventional total mastectomy (TM-PC group) from 2004 to 2009 were evaluated as comparative group with respect to the NSM-PC group. Using propensity score matching, local disease-free survival (LDFS) was evaluated comparatively.

RESULTS

The rate of nipple-areola involvement in the NSM and NSM-PC groups was 13.3% and 9.8%, respectively (P = .539). The nipple-areola involvement in the NSM and NSM-PC groups was significantly associated with the tumor size (odds ratio [OR], 1.48; 95% confidence interval [CI], 1.13-1.95; P = .004), plurifocal or pluricentric tumor (OR, 3.18; 95% CI, 1.72-5.89; P < .001), and the presence of an intraductal component (OR, 2.38; 95% CI, 1.22-4.64; P = .011). The LDFS in the NSM-PC and TM-PC matched cohorts did not show a significant difference, with a 4-year LDFS of 0.89 (95% CI, 0.77-0.95) and 0.93 (95% CI, 0.83-0.97), respectively (hazard ratio [HR], 1.31; 95% CI, 0.40-4.35; P = .655). The NSM-PC cohort was also compared with the NSM cohort in terms of LDFS using 2 different matching criteria, with the tumor size before and after neoadjuvant chemotherapy as the balancing covariate. In the first of the 2 comparisons, the hazards of local relapse were comparable between the 2 matched groups (HR, 1.23; 95% CI, 0.37-4.04; P = .739). In the second comparison, the NSM-PC patients showed a significant greater hazard of local relapse than did the NSM patients (HR, 3.60; 95% CI, 1.10-11.80; P = .035).

CONCLUSION

NSM might be a valuable option for large breast cancer treated by primary chemotherapy. The rate of local relapse seemed to be related to the disease stage, and no significant association with the type of surgery was detected.

Post-mastectomy radiotherapy benefits subgroups of breast cancer patients with T1-2 tumor and 1-3 axillary lymph node(s) metastasis

Background

To determine the role of postmastectomy radiotherapy (PMRT) in breast cancer patients with T1–2 and N1 disease.

Patients and methods.

A total of 207 postmastectomy women were enrolled. The 5-year Kaplan-Meier estimates of locoregional recurrence rate (LRR), distant recurrence rate (DRR) and overall survival (OS) were analyzed by different tumor characteristics. Multivariate analyses were performed using Cox proportional hazards modeling.

Results

With median follow-up 59.5 months, the 5-year LRR, DRR and OS were 9.1%, 20.3% and 84.4%, respectively. On univariate analysis, age < 40 years old (p = 0.003) and Her-2/neu over-expression (p = 0.016) were associated with higher LRR, whereas presence of LVI significantly predicted higher DRR (p = 0.026). Negative estrogen status (p = 0.033), Her-2/neu overexpression (p = 0.001) and LVI (p = 0.01) were significantly correlated with worse OS. PMRT didn’t prove to reduce 5-year LRR (p = 0.107), as well as 5-year OS (p = 0.918). In subgroup analysis, PMRT showed significant benefits of improvement LRR and OS in patients with positive LVI.

Conclusions

For patients with T1–2 and N1 stage breast cancer, PMRT can decrease locoregional recurrence and increase overall survival only in patients with lymphovascular invasion.

Follow-up care in breast cancer

Improved early diagnosis and treatment of breast cancer has resulted in a significant decrease in breast cancer-related mortality in many countries. Breast cancer survivors live longer. As a consequence, the prevalence of breast cancer survivors will rise and will put an increasing burden on follow-up oncology clinics. Follow-up of breast cancer patients should be aimed at the detection of curable disease and must comply with the needs of the patient. Regular physical examination may be useful for timely discovery of locoregional relapse, and screening mammography for the early detection of a second primary breast cancer or breast relapse after breast-conserving therapy. Onerous searching for distant metastases by routine investigations will not improve life expectancy of the patient and may even be harmful because of false-positive findings and false expectations and reassurance. Patients seek emotional support, information, physical and cosmetic recovery and prompt access to the oncologist in case of worrying complaints, signs or symptoms. Support, information and screening for relatively healthy patients can be provided by breast care nurse practitioners or family practitioners. For more complex issues, such as debilitating functional treatment regimens, estrogen deprivation symptoms, pregnancy after breast cancer or symptoms suspicious for a relapse, an experienced oncologist should be at hand.

Irradiation after surgery for breast cancer patients with primary tumours and one to three positive axillary lymph nodes: yes or no?

OBJECTIVE AND METHODS

We retrospectively analyzed clinicopathologic features and survival in breast cancer patients who had T1 or T2 primary tumours and 1-3 histologically involved axillary lymph nodes and who were treated with modified radical mastectomy without adjuvant radiotherapy (rt). We also explored prognosis to find the high- and low-risk groups.

RESULTS

From May 2001 to April 2005, 368 patients treated at Tianjin Tumor Hospital met the study criteria. The 5- and 8-year rates were 7.2% and 10.7% for locoregional recurrence (lrr), 85.1% and 77.7% for disease-free survival (dfs), and 92.8% and 89.3% for overall survival (os). Multivariate Cox regression analysis showed that age, tumour size, estrogen receptor (er) status, and lymphovascular invasion (lvi) were independent prognostic factors for lrr and dfs. Based on 4 patient-related factors that indicate poor prognosis (age < 40 years, tumour > 3 cm, er negativity, and lvi), the high-risk group (patients with 3 or 4 factors, accounting for 12.5% of the cohort) had 5- and 8-year rates of 24.3% and 36.9% for lrr, 57.2% and 39.2% for dfs, and 74.8% and 43.8% for os compared with 5.0% and 7.1% for lrr, 88.9% and 83.1% for dfs, 91.6% and 83.4% for os in the low-risk group (patients with 0-2 factors, accounting for 87.5% of the cohort; p < 0.001).

CONCLUSIONS

Our study identified several risk factors that correlated independently with a greater incidence of lrr and distant metastasis in patients with T1 and T2 breast cancer and 1-3 positive nodes. Patients with 0-2 risk factors may not be likely to benefit from post-mastectomy rt, but patients with 3-4 risk factors may need rt to optimize locoregional control and improve survival.

Is extracapsular tumour spread a prognostic factor in patients with early breast cancer?

BACKGROUND

This study searched for extra capsular tumour spread (ECS) as a prognostic factor for recurrence in terms of Disease Free Survival (DFS) and Overall Survival (OS).

PATIENTS AND METHODS

For this study, from a retrospective database of the Doubs cancer registry, 823 eligible women with node positive breast cancer treated from February 1984 to November 2000 were identified. The following factors were evaluated: ECS, numbers of involved nodes, histological tumour grade, tumour size, status of estrogen and progesterone receptors, and age of patient. A Cox proportional hazards method was used to search for significant factors related to OS and DFS length.

RESULTS

In the multivariate analysis, factors related to DFS length were found to be: tumour grade (aHR 0.76, 95 % CI 0.61-0.96, p = 0.02), ECS status (aHR 0.7, 95 % CI 0.49-0.96, p = 0.03), progesterone (PgR) status (aHR 0.63, 95 % CI 0.44-0.85 p = 0.008), number of nodes involved (aHR 0.75, 95 % CI 0.56-1, p = 0.05). The multivariate analysis for OS found as significant factors: tumour grade (aHR 0.76, 95 % CI 0.61-0.95; p = 0.02) and PgR status (aHR 0.8, 95 % CI 0.56-0.99, p = 0.02).

CONCLUSIONS

This study might suggest taking into account ECS status in the adjuvant decision-making process.

Are mastectomy resection margins of clinical relevance? A systematic review

Although some guidelines support the use of post-mastectomy radiotherapy where the resection margin is involved or close, the scientific basis of this practice is not established. This systematic review explores the relationship between margin status and subsequent relapse. Pooled data from 22 studies (18,863 women) identified an involved post-mastectomy margin in 2.5%, a close margin in 8.0% and muscle or fascia invasion in 7.2% of patients. In a meta-analysis of five studies of non-inflammatory breast cancer without radiotherapy, local recurrence was increased by an involved or close margin (relative risk 2.6; P<0.00001). The effect of muscle or fascia invasion was of borderline significance (relative risk 1.7; P=0.04). In two separate meta-analyses, risk of relapse was related to margin status in women with inflammatory breast cancer (relative risk 3.1; P<0.0001) but not in those undergoing skin-sparing mastectomy (relative risk 2.1; P=0.16).

Radiotherapy to the chest wall following mastectomy for node-negative breast cancer: a systematic review

BACKGROUND

Although nodal status is the major determinant of risk of locoregional relapse (LRR), other factors also contribute, and these assume a greater significance for those with node-negative breast cancer. Previous reviews of post-mastectomy radiotherapy have included studies using radiotherapy techniques or doses no longer considered clinically appropriate.

OBJECTIVES

To determine the effectiveness of post-mastectomy radiotherapy in women with node-negative breast cancer with particular reference to those patient and tumour factors which contribute to an increased risk of LRR.

METHODS

A systematic literature review was conducted. Trials using inadequate or orthovoltage radiotherapy were excluded. Data linking potential risk factors, either individually or in combination, to the occurrence of LRR were handled qualitatively. Data from randomised trials of post-mastectomy radiotherapy were included in a meta-analysis.

RESULTS

Baseline risk of LRR is increased in the presence of lymphovascular invasion, a grade 3 tumour, tumours greater than 2 cm or a close resection margin and in patients who are pre-menopausal or aged less than 50. Those with no risk factors have a baseline risk of LRR of approximately 5% or less rising to a risk of 15% or more for those with two or more risk factors. In the meta-analysis of three randomised trials of mastectomy and axillary clearance (667 patients), the addition of radiotherapy resulted in an 83% reduction in the risk of LRR (P < 0.00001) and in a 14% improvement in survival (P = 0.16).

CONCLUSION

The use of post-mastectomy radiotherapy for women with node-negative breast cancer requires re-evaluation. Radiotherapy should be considered for those with two or more risk factors.

Locoregional recurrence in breast carcinoma patients

AIMS

To assess the risk of locoregional recurrence (LRR) after mastectomy and to identify predictive and treatment factors that affect the risk of LRR.

METHODS

The primary endpoint was local recurrence. Univariate and multivariate Cox regression analyses were carried out in the data from 1217 patients.

RESULTS

The median follow-up was 74 months, and 63 (5.2%) patients experienced a LRR in their follow-up period. In the multivariate analysis, age group (< or =35 years vs. >35 years, p<0.0001; Hazard Ratio [HR], 5.0; 95% Confidence Interval [95% CI], 3.0-8.3), tumour size (>2 cm vs. < or =2 cm, p=0.03; HR, 2.2; 95% CI, 1.2-4.7) and LVI (yes vs. no, p<0.0001; HR, 3.2; 95% CI,1.9-5.2) were the independent prognostic factors for LRR. This analysis, in the final model, indicated that adjuvant radiotherapy and adjuvant tamoxifen were associated with a reduced risk of LRR by 90% and 75%, respectively, across the follow-up period, whereas age group remained as an important risk factor (p=0.002; HR, 3.0; 95% CI, 1.5-6.2).

CONCLUSIONS

Although adjuvant therapies reduce the risk of LRR, young age is an independent risk factor for LRR.

Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer

BACKGROUND

Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence.

PATIENTS AND METHODS

International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years.

RESULTS

In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied.

CONCLUSIONS

Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.

Can a subgroup of node-negative breast carcinoma patients with T1-2 tumor who may benefit from postmastectomy radiotherapy be identified?

PURPOSE

To determine a subgroup of T1-2N0 breast carcinoma patients at high risk for local recurrence.

METHODS AND MATERIALS

In this retrospective study, univariate and multivariate prognostic factor analyses for local recurrence and distant recurrence were carried out in 502 patients.

RESULTS

During the median observation time of 77 months (range, 24-191 months), 14 patients (2.8%) had local recurrence and 55 (11.0%) had distant recurrence. Tumor size (continuous, p = 0.03; hazard ratio [HR] 1.2; 95% confidence interval [CI], 1.1-1.7), grade (p = 0.01; HR, 2.4; 95% CI, 1.2-5.0), lymphatic vascular invasion (LVI) (p = 0.01; HR, 10.0; 95% CI, 2.4-17.3), estrogen receptor status (p = 0.01; HR, 6.3; 95% CI, 2.0-23.0) and cErbB2 status (p = 0.01; HR, 10.0; 95% CI 1.8-87.5) were strongly associated with distant recurrence. Tumor size (< or =2 cm vs. >2 cm; p = 0.05; HR, 5.4; 95% CI, 1.2-28.0) and LVI (p = 0.004; HR, 9.0; 95% CI, 2.0-41.0) in patients aged < or =40 years, and tumor size (< or =3 cm vs. >3 cm; p = 0.05; HR 8.6; 95% CI 1.3-75.0), LVI (p = 0.007; HR, 18.0; 95% CI, 2.1-153.0), and grade (p = 0.05; HR, 7.0; 95% CI, 1.2-63.0) in patients aged >40 years were the most important predictive factors for local recurrence.

CONCLUSIONS

Among breast carcinoma patients, young patients with tumor size >2 cm and LVI and older patients with tumor size >3 cm, LVI, and high-grade tumor had a high risk of local recurrence.

Local recurrence in breast carcinoma patients with T1–2 and 1–3 positive nodes: Indications for radiotherapy

AIMS

To investigate the relationship between local recurrence (LR) and distant recurrence (DR) and to determine a subgroup of patients who could benefit from radiotherapy among breast carcinoma patients with T(1-2) and N(1a).

METHODS

Univariate and multivariate Cox regression analyses were carried out in the retrospective data of 326 eligible patients.

RESULTS

Fourteen (4.3%) patients had LR and 46 (14.1%) patients suffered DR, in their follow-up periods. The multivariate time-dependent Cox model for DR showed that ratio of positive nodes (PN) (p=0.004; hazard ratio (HR), 1.05; 95% confidence interval (CI), 1.02-1.09) and LR (p=0.05; HR, dependent on time) were strongly associated with DR. In the multivariate Cox analysis for LR, age (<or=35 years vs >35 years; p<0.0001; HR, 6.8; CI, 2.3-19.9), lymphatic vascular invasion (LVI) (yes vs no; p=0.03; HR, 3.3; CI, 1.2-9.8), and a ratio of PN (>15% vs <or=15%; p<0.0001; HR, 13.0; CI, 3.9-42.0) were the most important prognostic factors. Whereas patients with 2 or 3 risk factors were accepted as the high risk group for LR, those with no or 1 risk factor were considered as the low risk group. These groups had a 23% LR rate and a 2.7% LR rate, respectively (p<0.0001).

CONCLUSIONS

This report confirmed the importance of local recurrence for distant recurrence. Age, ratio of PN and LVI were the most important prognostic factors for LR. The T(1-2) and N(1a) patients who had 2 or 3 risk factors might benefit from radiotherapy.

Lymph Node Ratio is More Valuable than Level III Involvement for Prediction of Outcome in Node-Positive Breast Carcinoma Patients

BACKGROUND

We examined the relationship between different expressions of positive axillary lymph nodes (PN) and the outcomes of node-positive breast carcinoma patients to determine the best predictor(s) among these expressions and to assess whether anatomic high level involvement is an independent prognostic factor.

STUDY DESIGN

In this retrospective study, the primary endpoints were distant recurrence (DR), locoregional recurrences (LRR), and disease-free survival (DFS). Univariate and multivariate prognostic factor analyses were carried out using survival and regression methods in the data of 704 patients with PN.

RESULTS

In multivariate analysis, the number of PN, ratio of PN, log odds of PN, and level III (L-III) involvement, separately, were significant factors for DR in addition to age, tumor size, and lymphovascular invasion (LVI). In the final model including all expressions of nodal involvement, age (continuous P = 0.001; hazard ratio [HR]: 0.98; 95% confidence Interval [95% CI]: 0.96-0.99), tumor size (continuous: P < 0.0001; HR: 1.3; 95% CI, 1.2-1.5), LVI (yes vs. no: P = 0.005; HR: 1.6; 95% CI, 1.2-2.2), and ratio of PN (continuous: P = 0.02; HR: 1.03; 95% CI, 1.01-1.06) were the independent prognostic factors for DR. For LRR, ratio of PN (continuous: P = 0.001; HR: 1.02; 95% CI, 1.01-1.03) was the most important factor in addition to age (continuous: P = 0.02; HR: 0.98; 95% CI, 0.97-0.99) and tumor size (continuous: P = 0.04; HR: 1.3; 95% CI, 1.1-1.6). When patients were stratified by number categories of PN (1-3 vs. 4-9 vs. >/= 10), there was no difference between DFSs of patients with and without L-III involvement. In contrast, when patients were stratified by L-III involvement, DFSs according to the number categories were statistically different.

CONCLUSIONS

Ratio of PN was more valuable than number of PN for predicting outcome in node-positive breast carcinoma patients. Level III involvement was not an independent prognostic indicator either for locoregional or for distant recurrences.

Disease-specific and event-free survival in breast cancer patients: a hospital-based study between 1990 and 2001

BACKGROUND

In France, as in other countries, breast cancer care has changed due to therapeutic advances and organized screening programs. Can the effect of new therapeutic procedures over time be measured by health care institutions considering these changes? The present study used data from a hospital-based cancer registry to analyze changes in 5-year disease-specific and event-free survival among women with primary breast cancer over three time periods (1990-1993, 1994-1997, and 1998-2001).

METHODS

All cases of primary invasive breast carcinomas, initially treated in a French Comprehensive Cancer Center between 1990 and 2001, were included. In situ breast carcinoma and male breast cancer were excluded. Cox proportional hazards models were used to analyze disease-specific and event-free survival (DSS and EFS) rates over the three time periods (1990-1993, 1994-1997, and 1998-2001).

RESULTS

During the 1990-2001 period, 4,165 primary breast cancers were initially treated at the Comprehensive Cancer Center. Out of 1,012 deaths overall, 74.6% were due specifically to primary breast cancer (respectively 98% from cancer itself and 2% from treatment side effects); the cause was unknown for only 3.3% of deaths. Out of 3,810 complete remissions, 18.2% presented local, regional or metastatic relapse and 3.8% presented a second primary breast cancer. Comparison of DSS and EFS rates in a recent reporting period (1998-2001) with those in earlier time periods (1994-1997 and 1990-1993) indicated that substantial survival gains were achieved with respectively 88.4% (95% CI: 86.4-90.5), 83.2% (95% CI: 81.3-85.2), and 79.8% (95% CI: 77.4-82.2) (p<0.01) for 5-year Disease-Specific Survival, and respectively 78.3% (95% CI: 75.7-81.0), 73.9% (95% CI: 71.6-76.3), and 70.1% (95% CI: 67.4-72.8) (p<0.01) for 5-year Event-Free Survival. After adjustment for prognostic factors, period was identified as an independent predictor of survival.

CONCLUSION

Survival improvement is likely to be due to changes in routine clinical practice such as an increased use of systemic adjuvant therapy over the study periods, dose modification of epirubicin in adjuvant chemotherapy for node-positive breast cancer since 1994, and organized screening programs since 1997. However the effect of possible early diagnosis and over-diagnosis biases due to screening cannot be assessed.

Prognostic value of extracapsular tumor spread for locoregional control in premenopausal patients with node-positive breast cancer treated with classical cyclophosphamide, methotrexate, and fluorouracil: long-term observations from International Breast Cancer Study Group Trial VI

PURPOSE

We sought to determine retrospectively whether extracapsular spread (ECS) might identify a subgroup that could benefit from radiotherapy after mastectomy, especially patients with 1 to 3 positive lymph nodes (LN1-3+).

PATIENTS AND METHODS

We randomized 1,475 premenopausal women with node-positive breast cancer to three, six, or nine courses of "classical" CMF (cyclophosphamide, methotrexate, and fluorouracil). After a review of all pathology forms, 933 patients (63%) had information on the presence or absence of ECS. ECS was present in 49.5%. The median follow-up was 10 years.

RESULTS

In univariate analyses, ECS was associated with worse disease-free survival (DFS) and overall survival (OS). In multivariate analyses adjusting for tumor size, vessel invasion, surgery type, and age group, ECS remained significant (DFS: hazard ratio, 1.61; 95% CI, 1.34 to 1.93; P < .0001; OS: 1.67; 95% CI, 1.34 to 2.08; P < .0001). However, ECS was not significant when the number of positive nodes was added. The locoregional failure rate +/- distant failure (LRF +/- distant failure) within 10 years was estimated at 19% (+/- 2%) without ECS, versus 27% (+/- 2%) with ECS. The difference was statistically significant in univariate analyses, but not after adjusting for the number of positive nodes. No independent effect of ECS on DFS, OS, or LRF could be confirmed within the subgroup of 382 patients with LN1-3+ treated with mastectomy without radiotherapy.

CONCLUSION

Our results do not support an independent prognostic value of ECS, nor its use as an indication for irradiation in premenopausal patients with LN1-3+ treated with classical CMF. However, we could not examine whether extensive ECS is of prognostic importance.

The pattern of lymphatic metastasis of breast cancer and its influence on the delineation of radiation fields

PURPOSE

The delineation of radiation fields should cover the clinical target volume (CTV) and minimally irradiate the surrounding normal tissues and organs. This study was designed to explore the pattern of lymphatic metastasis of breast cancer and indications for radiotherapy after radical or modified radical mastectomy and to discuss the rational delineation of radiation fields.

METHODS AND MATERIALS

Between September 1980 and December 2003, 78 breast cancer patients receiving extended radical mastectomy in the Margottini model and 61 cases with complete data were analyzed to investigate the internal mammary lymphatic metastatic status. Between March 1988 and December 1988, 46 patients with clinical negative supraclavicular nodes received radical mastectomy plus supraclavicular lymph node dissection. The supraclavicular lymph nodes and axillary lymph nodes were labeled as S and levels I, II, or III, respectively, and examined pathologically. Between January 1996 and April 1999, 412 patients who had radical or modified radical mastectomy underwent the pathologic examination of axillary or levels I, II, or III nodes.

RESULTS

The incidence of internal mammary lymph node metastasis was 24.6%. It was 36.7% for the patients with positive axillary lymph nodes and 12.9% for the patients with negative axillary lymph nodes. All the metastatic internal mammary lymph nodes were located at the first, second, and third intercostal spaces. Skipping metastasis of the supraclavicular and axillary lymph nodes was observed in 3.8% and 8.1% of patients, respectively.

CONCLUSIONS

According to our data, we suggest that the radiation field for internal mammary lymph nodes should exclude the fourth and fifth intercostal spaces, which may help to reduce the radiation damage to heart. It is unnecessary to irradiate the supraclavicular lymph nodes for the patients with negative axillary level III nodes, even with positive level I and level II nodes.

Radiotherapy for invasive breast cancer in North America and Europe: Results of a survey

PURPOSE

To document and explain the current radiotherapeutic management of invasive breast cancer in North America and Europe. We also identified a number of areas of agreement, as well as controversy, toward which additional clinical research should be directed.

METHODS AND MATERIALS

An original survey questionnaire was developed to assess radiation oncologists' self-reported management of breast cancer. The questionnaire was administered to physician members of the American Society for Therapeutic Radiology and Oncology and the European Society for Therapeutic Radiology and Oncology. We present the results of the comparative analysis of 702 responses from North America and 435 responses from Europe.

RESULTS

Several areas of national and international controversy were identified, including the selection of appropriate candidates for postmastectomy radiation therapy (RT) and the appropriate management of the regional lymph nodes after mastectomy, as well as after lumpectomy. Only 40.7% and 36.1% of respondents would use postmastectomy RT in patients with 1-3 positive lymph nodes in North America and Europe, respectively. Sentinel lymph node biopsy was offered more frequently by North American than European respondents (p <0.0001) and more frequently by academic than nonacademic respondents in North America (p < 0.05). The average radiation fraction size was larger in Europe than in North America (p < 0.01). European respondents offered RT to the internal mammary chain more often than did the North American respondents (p < 0.001). North American respondents were more likely to offer RT to the supraclavicular fossa (p < 0.001) and axilla (p < 0.01).

CONCLUSION

Marked differences were found in physician opinions regarding the management of breast cancer, with statistically significant international differences in patterns of care. This survey highlighted areas of controversy, providing support for international randomized trials to optimize the RT management of invasive breast cancer.

T1-T2 Breast Cancer with Four or More Positive Axillary Lymph Nodes: Adjuvant Locoregional Radiotherapy with High-Dose or Standard-Dose Chemotherapy. Results of an Observational Study

Aim and background

The aim of this study was to investigate the efficacy of postoperative locoregional radiotherapy in patients with T1-T2 breast cancer and four or more positive axillary lymph nodes submitted to mastectomy or breast-conserving surgery followed by standard-dose or high-dose adjuvant chemotherapy. The incidence of locoregional relapses and the survival correlated with the number of positive nodes were recorded for each treatment arm.

Patients and methods

From August 1992 to August 1999 86 breast cancer patients (median age, 54 years, T1-T2, N+ >4) submitted to surgery were treated. Sixty-three patients received standard-dose chemotherapy while 23 patients with 10 or more positive nodes received high-dose chemotherapy. After four courses of standard-dose anthracycline-based chemotherapy peripheral blood stem cells were mobilized with cyclophosphamide (7g/m2) and G-CSF (10-16 μg/kg/day/sc). High-dose chemotherapy consisted of etoposide 1000 mg/m2, thiotepa 500 mg/m2 and carboplatin 800 mg/m2. Hormone receptor-positive patients underwent hormone therapy. Following chemotherapy all 86 patients were given conventional radiotherapy to the breast or the chest wall and the supraclavicular fossa. The high-dose subgroup received radiotherapy to the internal mammary nodes ± axilla. Results: The median follow-up from the start of radiotherapy was 36.5 months. Locoregional relapses occurred in nine patients (10.4%); in four of them they were isolated (4.6%). Local relapses were four (4.6%) and regional relapses six (6.9%). Twenty-five patients (29%) had distant metastases. The five-year and eight-year overall actuarial survival rates were 82.6% ± 4.8 and 60.1% ± 8.8, respectively. No statistical differences were found when the number of positive nodes or the type of treatment of N+ 10 patients was included in the analysis.

Conclusions

Breast cancer patients with four or more positive axillary lymph nodes are at high risk of developing locoregional and distant relapses. The results reported here demonstrate the efficacy of radiotherapy in the reduction of locoregional failure; no differences in survival and locoregional control in relation to treatment arm and number of positive nodes were found.

Locoregional failure of postmastectomy patients with 1-3 positive axillary lymph nodes without adjuvant radiotherapy

PURPOSE

To analyze the incidence and risk factors for locoregional recurrence (LRR) in patients with breast cancer who had T1 or T2 primary tumor and 1-3 histologically involved axillary lymph nodes treated with modified radical mastectomy without adjuvant radiotherapy (RT).

MATERIALS AND METHODS

Between April 1991 and December 1998, 125 patients with invasive breast cancer were treated with modified radical mastectomy and were found to have 1-3 positive axillary nodes. The median number of nodes examined was 17 (range 7-33). Of the 125 patients, 110, who had no adjuvant RT and had a minimum follow-up of 25 months, were included in this study. Sixty-nine patients received adjuvant chemotherapy and 84 received adjuvant hormonal therapy with tamoxifen. Patient-related characteristics (age, menopausal status, medial/lateral quadrant of tumor location, T stage, tumor size, estrogen/progesterone receptor protein status, nuclear grade, extracapsular extension, lymphovascular invasion, and number of involved axillary nodes) and treatment-related factors (chemotherapy and hormonal therapy) were analyzed for their impact on LRR. The median follow-up was 54 months.

RESULTS

Of 110 patients without RT, 17 had LRR during follow-up. The 4-year LRR rate was 16.1% (95% confidence interval [CI] 9.1-23.1%). All but one LRR were isolated LRR without preceding or simultaneous distant metastasis. According to univariate analysis, age <40 years (p = 0.006), T2 classification (p = 0.04), tumor size >==3 cm (p = 0.002), negative estrogen receptor protein status (p = 0.02), presence of lymphovascular invasion (p = 0.02), and no tamoxifen therapy (p = 0.0006) were associated with a significantly higher rate of LRR. Tumor size (p = 0.006) was the only risk factor for LRR with statistical significance in the multivariate analysis. On the basis of the 4 patient-related factors (age <40 years, tumor >==3 cm, negative estrogen receptor protein, and lymphovascular invasion), the high-risk group (with 3 or 4 factors) had a 4-year LRR rate of 66.7% (95% CI 42.8-90.5%) compared with 7.8% (95% CI 2.2-13.3%) for the low-risk group (with 0-2 factors; p = 0.0001). For the 110 patients who received no adjuvant RT, LRR was associated with a 4-year distant metastasis rate of 49.0% (9 of 17, 95% CI 24.6-73.4%). For patients without LRR, it was 13.3% (15 of 93, 95% CI 6.3-20.3%; p = 0.0001). The 4-year survival rate for patients with and without LRR was 75.1% (95% CI 53.8-96.4%) and 88.7% (95% CI 82.1-95.4%; p = 0.049), respectively. LRR was independently associated with a higher risk of distant metastasis and worse survival in multivariate analysis.

CONCLUSION

LRR after mastectomy is not only a substantial clinical problem, but has a significant impact on the outcome of patients with T1 or T2 primary tumor and 1-3 positive axillary nodes. Patients with risk factors for LRR may need adjuvant RT. Randomized trials are warranted to determine the potential benefit of postmastectomy RT on the survival of patients with a T1 or T2 primary tumor and 1-3 positive nodes.

[Postmastectomy locoregional radiotherapy for breast cancer: literature review]

Postoperative radiotherapy is controversial after radical mastectomy. Recent clinical trials have shown an increase in survival with this irradiation and conclusions of previous meta-analyses should be reconsidered. The results of a large number of randomized clinical trials in which women received post-mastectomy radiotherapy or not have been reviewed. These trials showed a decrease in locoregional failure with the use of postoperative radiotherapy but survival advantages have not been clearly identified. A larger number of randomized clinical trials compared postoperative radiotherapy alone, chemotherapy alone and the association of the two treatments. They showed that chemotherapy was less active locally than radiotherapy and that radiotherapy and chemotherapy significantly increased both disease-free and overall survival rates in the groups which received postoperative radiotherapy. These favourable results were, however, obtained with optimal radiotherapy techniques and a relative sparing of lung tissue and cardiac muscle. Many retrospective clinical analyses concluded that results obtained in locoregional failure rate were poor and that these failures led to an increase in future risks. Both radiotherapy and systemic treatment should be delivered after mastectomy, reserved for patients with a high risk of locoregional relapses, particularly of nodes and/or tumors with a diameter > or = 5 cm. However, radiotherapy could produce secondary effects, and techniques of radiotherapy should be optimal.