Breast conservation in the 21st century

Immediate Effects of Intraoperative Evaluation of Surgical Margins over the Treatment of Early Infiltrating Breast Carcinoma

Aims and Background

Local recurrences in patients submitted to conservative breast treatment for early infiltrating breast carcinomas occur in 5–10% of the cases and are caused mainly by inadequate local resection and remaining residual malignant tissue. The present study was carried out to analyze the effect of intraoperative evaluation of surgical margins and its influence on the immediate surgical management of patients with early breast carcinomas (T1–T2) scheduled to undergo quadrantectomy.

Methods

A total of 102 cases were studied. After a classical quadrantectomy, intraoperative evaluation of surgical margins was done by means of macroscopic, cytological and histopathologic analysis. The margins of the resected tissue were examined to assure they were clear or to orient a wider resection.

Results

In 64 cases (62.7%), the extent of the quadrant resection was considered adequate and the margins were clear. In 38 cases (37.3%), surgical margins were considered inadequate. An enlarged quadrantectomy was immediately performed in 33 patients (32.4%) and mastectomies in 5 (4.9%).

Conclusions

Intraoperative evaluation of surgical margins frequently modifies the surgical management of patients who were initially prepared to be submitted to a quadrantectomy, indicating the need for further resection in the form of an enlarged quadrantectomy or mastectomy.

Outcome Analysis of Patients with Early Infiltrating Breast Carcinoma Treated by Surgery with Intraoperative Evaluation of Surgical Margins

Aim

The purpose of this study was to determine the effect of intraoperative evaluation of surgical margins (IESM) on the local recurrence rate, the occurrence of distant metastases and survival in invasive breast carcinoma (T1-2).

Methods

Two groups of patients were compared: a control group of 149 patients treated by classical quadrantectomy without IESM, and an IESM study group of 102 patients submitted to surgical treatment guided by this procedure. In the IESM group 64 quandrantectomies, 33 enlarged quadrantectomies and five mastectomies were performed.

Results

In the control group 17 local recurrences (11.4%), 49 distant metastases (39.2%) and 43 deaths (31.5%) occurred; in the IESM group there were no local recurrences, nine distant metastases occurred (8.8%) and three patients died (2%). Adjuvant treatment was the same in both groups. The survival curves were estimated by the Kaplan-Meier method and compared with the log-rank test. The curves were censored at 99 months of follow-up for adequate comparison because the follow-up period was different in the two groups. Significant differences in local recurrence-free survival and distant metastasis-free survival curves (P = 0.001) in favor of the study group were observed. The overall survival curve of the IESM group was also superior, but statistical analysis revealed only a strong tendency without significance (P = 0.06).

Conclusion

Treatment of early infiltrating breast carcinoma guided by IESM results in a better prognosis.

Prognostic Effects of Local Recurrence after Conservative Treatment for Early Infiltrating Breast Carcinoma

Aim

A study was carried out to determine whether local recurrence after quadrantectomy, axillary dissection and radiotherapy (QUART) affects the oncologic prognosis of patients with early infiltrating breast carcinoma.

Methods

A total of 149 patients were submitted to QUART between 1981 and 1990 and followed by an average period of 120.9 months (range, 16–213). Local recurrence was not observed in 132 cases (group 1) but was detected in 17 patients (group 2).

Results

In group 1, 39 cases (29.5%) presented distant metastases and 34 (25.8%) evolved to death. In group 2, 10 (51.8%) distant metastases and 9 deaths (52.9%) were verified. The survival curves estimated by the Kaplan-Meier method and analyzed by the logrank test were statistically different for distant metastases-free survival (P = 0.03) and for overall survival (P = 0.01). The relative risk in patients with post-QUART local recurrence for distant metastases was 2.09 and for death 2.34.

Conclusions

It was concluded that post-QUART local recurrences are a poor prognostic factor in patients with early infiltrating breast carcinoma.

Spatiotemporally photoradiation-controlled intratumoral depot for combination of brachytherapy and photodynamic therapy for solid tumor

In an attempt to spatiotemporally control both tumor retention and the coverage of anticancer agents, we developed a photoradiation-controlled intratumoral depot (PRCITD) driven by convection enhanced delivery (CED). This intratumoral depot consists of recombinant elastin-like polypeptide (ELP) containing periodic cysteine residues and is conjugated with a photosensitizer, chlorin-e6 (Ce6) at the N-terminus of the ELP. We hypothesized that this cysteine-containing ELP (cELP) can be readily crosslinked through disulfide bonds upon exposure to oxidative agents, specifically the singlet oxygen produced during photodynamic stimulation. Upon intratumoral injection, CED drives the distribution of the soluble polypeptide freely throughout the tumor interstitium. Formation and retention of the depot was monitored using fluorescence molecular tomography imaging. When imaging shows that the polypeptide has distributed throughout the entire tumor, 660-nm light is applied externally at the tumor site. This photo-radiation wavelength excites Ce6 and generates reactive oxygen species (ROS) in the presence of oxygen. The ROS induce in situ disulfide crosslinking of the cysteine thiols, stabilizing the ELP biopolymer into a stable therapeutic depot. Our results demonstrate that this ELP design effectively forms a hydrogel both in vitro and in vivo. These depots exhibit high stability in subcutaneous tumor xenografts in nude mice and significantly improved intratumoral retention compared to controls without crosslinking, as seen by fluorescent imaging and iodine-125 radiotracer studies. The photodynamic therapy provided by the PRCITD was found to cause significant tumor inhibition in a Ce6 dose dependent manner. Additionally, the combination of PDT and intratumoral radionuclide therapy co-delivered by PRCITD provided a greater antitumor effect than either monotherapy alone. These results suggest that the PRCITD could provide a stable platform for delivering synergistic, anti-cancer drug depots.

Management of the axilla

The development and wide acceptance of sentinel lymph node biopsy (SLNB) has profoundly affected the management of breast cancer. SLNB has spared the additional morbidity of axillary lymph node dissection (ALND) without compromising diagnostic accuracy and prognostic information in patients with clinically node-negative early-stage breast cancer. It has become an invaluable tool to clinicians to guide decisions regarding adjuvant treatment. The management of breast cancer continues to advance to more minimally invasive approaches, and the role of ALND is likely to become less important in the future.

Late morbidity after treatment of breast cancer in relation to daily activities and quality of life: a systematic review

AIMS

Breast cancer treatment may result in long-term upper limb morbidity: reduced range of motion of the shoulder, muscle weakness of the arm and hand, lymph edema, pain and numbness. Relationship of this late morbidity with activities of daily life (ADL) and quality of life (QOL) is infrequently described and the strength of this relationship is not clear.

METHODS

A systematic review was performed to evaluate the results of studies, analyzing late morbidity of breast cancer treatment in relationship with ADL and/or QOL. A literature search over the last 20 years (1980-2000) was performed in the databases MEDLINE, EMBASE, PSYCHLIT and CANCERLIT. Methodological quality of selected articles was assessed and additional, aspects of treatment related late morbidity and the relationship to ADL and/or QOL were summarized.

RESULTS

From the 1642 yielded articles 15 fulfilled our primary selection criteria. Only six articles could be selected due to the inappropriate methodological quality. There was high variation in prevalence of pain (12-51%), impairments in range of motion (2-51%), edema (6-43%) and decreased muscle strength (17-33%). Four articles reported significant relationships between late morbidity of the upper limb and perceived disabilities in ADL/QOL. The strength of these relationships was rather low.

CONCLUSIONS

Few studies investigated the relationship between late morbidity of the upper limb after treatment of early breast cancer and ADL/QOL. Significant relationship between late morbidity and restrictions of daily activities and poorer QOL was reported, however, the strength of this relationship was rather low.

Early response of lung in breast cancer irradiation: radiologic density changes measured by CT and symptomatic radiation pneumonitis

PURPOSE

To quantify radiologic changes in the lung with CT after radiotherapy (RT) for breast cancer (BC) and to study their association with treatment techniques and symptomatic radiation pneumonitis (RP).

METHODS AND MATERIALS

CT scans of the lungs were performed before and 4 months after RT in 121 BC patients treated with four different RT techniques. The changes in mean density (MDCs) were analyzed at two lung levels (i.e., the central and apical CT slice). The central CT slice was also analyzed with respect to the MDCs in the anterior third and anterior half of the ipsilateral lung area. In mastectomized patients who received chest wall RT with an en-face electron beam, the maximal depths for a range of isodose curves were measured. The occurrence of mild/moderate symptomatic RP was assessed prospectively 1, 4, and 7 months after RT. Data on covariates with potential confounding effect on RT-induced lung toxicity were also collected prospectively.

RESULTS

In the entire study population, an association between the MDCs in the anterior third of the central CT slice and treatment technique (p <0.001) and symptomatic RP (p <0.001) was found. Among patients with chest wall treatment consisting of an en-face electron beam, the MDCs of the anterior third of the central CT slice correlated with the 35% isodose curve (16-30 Gy) (p = 0.046) and age (p <0.001). No association between post-RT lung density changes and pre-RT chemotherapy, concurrent tamoxifen intake, or smoking habits was found. Among patients treated with locoregional RT, an association was found between the MDCs in the anterior third of the central CT slice and the incidence of RP. MDCs in the apical CT slice, however, were not associated with RP.

CONCLUSION

The results imply that short-term post-RT lung density changes and symptomatic RP were associated with RT techniques, total doses as low as 16-30 Gy, and increasing age. Structural changes in the central part of lung appeared to be more important for the development of RP than changes in the apex.

MR imaging: breast cancer staging and screening

This review describes the current knowledge and challenges of breast cancer staging and screening with MRI of the breast. Assessment of local disease extent, including tumor size, multicentricity, and chest wall invasion, can be obtained more accurately with MRI than with mammography. Moreover, international experts have established standardized reporting of MRI staging results, taking into account tumor size measurements and the number of breast quadrants involved. Results from MRI assessment of the axilla and skin are promising, but need further refinement. Preliminary results of the use of breast MRI in patients at high risk for breast cancer demonstrated a superiority of breast MRI over the combined use of mammography and high-frequency ultrasound. The role of MRI in this subset of patients may be confirmed by ongoing larger multicenter trials. Strict protocol conditions are mandatory to maintain a high standard of quality. Confirming the nature of "MRI-only" lesions with MRI-guided biopsy systems will allow changes in treatment planning. More accurate tumor diagnosis and tumor volume evaluation may allow minimally invasive treatment strategies.