The presence of proliferative breast disease with atypia does not significantly influence outcome in early-stage invasive breast cancer treated with conservative surgery and radiation

Impact of Atypical Hyperplasia at Surgical Margins on breast cancer outcomes in patients treated with neoadjuvant chemotherapy

Background

Women with atypical hyperplasia (AH) is associated with a higher risk of future breast cancer. However, whether AH found at margins in patients with breast-conserving surgery (BCS) after neoadjuvant chemotherapy (NAC) needs re-excision is not well-defined. The aim of the present study was to evaluate the impact of AH at the surgical margins on the local recurrence and survival outcomes in breast cancer patients treated with NAC and BCS.

Methods

A retrospective analysis comparing patients who treated with NAC and BCS with AH at the margins to those without AH was performed.

Results

598 patients were included in this study. The 5-year rates of ipsilateral breast tumor recurrence (IBTR) were 4.6% and 6.2% in patients with and without AH, respectively. No significant differences were observed among the two groups in terms of IBTR, DMFS, or OS. HER2 overexpressing breast cancer patients with severe AH at margins have a significantly higher risk of IBTR compared to those without severe AH.

Conclusion

Our study suggests that the presence of AH at the surgical margins of BCS in patients who received NAC does not appear to increase the risk of ipsilateral breast cancer. Therefore, there is no need for surgeons to routinely perform additional re-excision of AH found at the margins of BCS in these patients. However, selective re-excision should be considered in certain cases, particularly in patients with HER2 overexpression.

Breast Specimen Processing and Reporting With an Emphasis on Margin Evaluation: A College of American Pathologists Survey of 866 Laboratories

CONTEXT

- The College of American Pathologists (CAP) developed protocols for reporting pathologic characteristics of breast cancer specimens, including margin status. The Society of Surgical Oncology (SSO) and the American Society for Radiation Oncology (ASTRO) published treatment guidelines regarding margins in patients with invasive cancer; and SSO, ASTRO, and the American Society of Clinical Oncology (ASCO) recently published guidelines for patients with ductal carcinoma in situ.

OBJECTIVE

- To assess current practices among pathologists with regard to the processing/reporting of breast specimens, assess compliance with CAP cancer protocols, and assess alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines.

DESIGN

- A survey concerning breast specimen processing/reporting was distributed to pathologists enrolled in the CAP Performance Improvement Program in Surgical Pathology.

RESULTS

- Ninety-four percent (716 of 764 respondents) and 91% (699 of 769 respondents) define positive margins as "tumor on ink" for invasive cancer and ductal carcinoma in situ, respectively, in compliance with CAP cancer protocols and with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. Of 791 respondents who provided details regarding methods for margin evaluation, 608 (77%) exclusively examine perpendicular margins, facilitating guideline compliance. However, 183 of 791 respondents (23%) examine en face margins in at least a subset of specimens, which may preclude guideline compliance in some cases. When separate cavity (shave) margins are examined, while 517 of 586 respondents (88%) ink these specimens, 69 of 586 (12%) do not, and this may also preclude guideline compliance in some cases.

CONCLUSIONS

- A substantial proportion of survey participants report margin status for breast cancer specimens in a manner consistent with CAP cancer protocols, and in alignment with SSO/ASTRO and SSO/ASTRO/ASCO guidelines. However, there are opportunities for some laboratories to modify procedures in order to facilitate more complete adherence to guidelines.

Impact of atypical hyperplasia at margins of breast-conserving surgery on the recurrence of breast cancer

PURPOSE

Atypical hyperplasia (AH) is associated with a relatively higher risk of subsequent development of cancer. It remains controversial whether it is necessary to re-excise AH found at surgical margins during breast-conserving surgery (BCS). The aim of this study was to determine the impact of atypical ductal/lobular hyperplasia found at the margins during BCS on the prognosis of early-stage breast cancer patients.

METHODS

A retrospective analysis comparing patients with AH and receiving no further surgical treatment (n = 233) to those without AH at the margins during BCS (n = 158) was performed.

RESULTS

At a median follow-up of 76 months, the 5- and 8-year rates of ipsilateral breast tumor recurrence (IBTR) were 3.26 and 8.79% for women with AH and 2.56 and 8.95% for women without AH, respectively. There were no significant differences between the two groups in terms of IBTR (p = 0.803), distant-metastasis-free survival (DMFS) (p = 0.749), or overall survival (OS) (p = 0.165). Moreover, no significant differences were found in IBTR, DMFS, or OS between patients with severe atypical hyperplasia (n = 86) and those without AH (n = 158) (p = 0.81, 0.82, and 0.78, respectively). Additionally, young women or those with ductal carcinoma in situ or triple-negative breast cancer with AH involving margins did not have a higher IBTR rate when compared to similar patients without AH.

CONCLUSIONS

This study suggests that AH found at the margins during BCS does not increase the risk of subsequently developing an IBTR. There is not enough evidence for re-excision of AH found at the margins during BCS in patients with early-stage breast cancer.

Atypical Ductal Hyperplasia at the Margin of Lumpectomy Performed for Early Stage Breast Cancer: Is there Enough Evidence to Formulate Guidelines?

Background. Negative margins are associated with a reduced risk of ipsilateral breast tumor recurrence (IBTR) in women with early stage breast cancer treated with breast conserving surgery (BCS). Not infrequently, atypical ductal hyperplasia (ADH) is reported as involving the margin of a BCS specimen, and there is no consensus among surgeons or pathologists on how to approach this diagnosis resulting in varied reexcision practices among breast surgeons. The purpose of this paper is to establish a reasonable approach to guide the treatment of ADH involving the margin after BCS for early stage breast cancer. Methods. the published literature was reviewed using the PubMed site from the US National Library of Medicine. Conclusions. ADH at the margin of a BCS specimen performed for early stage breast cancer is a controversial pathological diagnosis subject to large interobserver variability. There is not enough data evaluating this diagnosis to change current practice patterns; however, it is reasonable to consider reexcision for ADH involving a surgical margin, especially if it coexists with low grade DCIS. Further studies with longer followup and closer attention to ADH at the margin are needed to formulate treatment guidelines.

Rates of atypical ductal hyperplasia have declined with less use of postmenopausal hormone treatment: findings from the Breast Cancer Surveillance Consortium

AIM

To examine risk factors and rates of atypical ductal hyperplasia (ADH) with and without associated breast cancer over time and tumor characteristics of breast cancer with and without associated ADH in women previously screened with mammography.

METHODS

Data on screening mammograms done between 1996 and 2005 were collected from mammography registries that participate in the Breast Cancer Surveillance Consortium. Associations between age, family history of breast cancer, postmenopausal hormone treatment (HT), and final pathology result (ADH or cancer with or without ADH in the same breast) were examined. Rates of different outcomes were calculated per exam year. Tumor characteristics of cancers with and without associated ADH were compared.

RESULTS

A total of 2,453,483 screening mammograms were associated with 1,064 biopsies with ADH, 833 breast cancers with ADH, and 8,161 cancers with no ADH. Postmenopausal HT use decreased significantly from 35% to 11% during the study period. Rates of ADH decreased from a peak of 5.5/10,000 mammograms in 1999 to 2.4/10,000 in 2005. Rates of cancer with ADH decreased from a peak of 4.3/10,000 mammograms in 2003 to 3.3/10,000 in 2005. ADH and breast cancer were significantly associated with use of postmenopausal HT. Cancer associated with ADH was of lower grade and stage and more estrogen receptor positive than cancer with no ADH.

SUMMARY

Postmenopausal HT is associated with an increased risk of ADH with or without cancer. Rates of ADH have decreased over the past decade, which may be partially explained by the significant reduction in use of postmenopausal HT.

A review of current practices in breast conservation surgery in the UK

INTRODUCTION

The aim of this study was to assess whether surgeons in the UK were practising wide excision consistent with current guidelines and current evidence.

PATIENTS AND METHODS

Questionnaires were sent to 200 breast surgeons throughout the UK to determine current practices in breast conserving surgery.

RESULTS

When performing a wide excision for invasive cancer, 61% of respondents always remove full thickness of breast tissue and 37% usually do. Of surgeons, 60% rarely use specimen X-ray for palpable lesions. However, 91% always take specimen X-rays in impalpable lesions, but 9% do not always take specimen X-rays for impalpable lesions. In 93% of units, the pathologist always reports the distance to the nearest margin. For both invasive and in situ cancer, there is a wide variation in what is considered an adequate radial margin. There is wide variation in the practice of re-excision. Of surgeons, 50% indicated that they wish wider margins in the presence of an extensive in situ component and 39% wish wider margins in younger women.

CONCLUSIONS

The results show a large variation in practice with many surgeons not treating patients in accordance with current guidelines and evidence.

Impact of concurrent proliferative high-risk lesions on the risk of ipsilateral breast carcinoma recurrence and contralateral breast carcinoma development in patients with ductal carcinoma in situ treated with breast-conserving therapy

BACKGROUND

The purpose of the study was to determine the risk of ipsilateral breast carcinoma recurrence (IBCR) and contralateral breast carcinoma (CBC) development in patients with a concurrent diagnosis of ductal carcinoma in situ (DCIS) with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS).

METHODS

Records of all 307 patients with DCIS treated with breast-conserving treatment (BCT) from 1968 to 1998 were analyzed. Initial pathology reports and all slides available were re-reviewed for evidence of ADH, ALH, or LCIS. Actuarial local recurrence rates were calculated.

RESULTS

Fifty-five cases of DCIS were associated with ADH, 11 with ALH or LCIS, and 14 with both ADH and ALH or LCIS. Overall, IBCR occurred in 14% and no significant difference in the IBCR rate was identified for patients with proliferative lesions compared with patients without these lesions (P = 0.38). Development of CBC in patients with concurrent DCIS and ADH was 4.4 times (95% confidence interval [CI], 1.44-13.63) that in patients with DCIS alone (P < 0.01). The 15-year cumulative rate of CBC development was 22.7% in patients with ALH or LCIS compared with 6.5% in patients without these lesions (P = 0.30) and 19% in patients with ADH compared with 4.1% in patients with DCIS alone (P < 0.01).

CONCLUSION

The risk of CBC development is higher with concurrent ADH than in patients with DCIS alone, and these patients may therefore be appropriate candidates for additional chemoprevention strategies. Concurrent ADH, ALH, or LCIS with DCIS is not a contraindication to BCT.